Psychiatry in Limbo: New Ways of Talking

Some things don’t change

 

‘Everyone thinks of changing the world, but no one thinks of changing himself.’ Leo Tolstoy (1828-1910) 

Readers surely must have noticed by now how ‘client’, ‘service user’, ‘customer’, and other business terms have gained momentum in health care settings over the years. Newspeak has insidiously worked its way into all health policy documents. For reasons that escape me, in mental health services particularly, there seems to be an unwritten diktat that hospital personnel use any terminology other than ‘patient’ for those attending for treatment. Anyone who sets foot inside a hospital is now deemed to be a service user even though the word patient (from the Latin, patiens, for ‘one who suffers’) has not changed its meaning for centuries. Yet curiously, management Newspeak is not questioned or discussed openly by medical or nursing staff, perhaps for fear of being labelled old-fashioned, trying to cling on to relics of a bygone era. Subtle, unspoken, ‘nannying’ of health professionals in general, and a casual, perfunctory dismissal of matters medical now seem to be the order of the day.

 

The term ‘patient’ is now viewed sceptically by some in the management hierarchy as depicting an individual dependent on the nurse or doctor, rather than a token of respect for that person’s privacy and dignity. Non-clinical therapists are not obliged to use the term patient. What follows from that however, is the abstruse rationale that it is probably best to describe everyone as a ‘client’, ‘customer’, or ‘service user’ so as not to appear judgemental or create confusion. This apparently avoids ‘inferiority’ labelling and ensures all are ‘treated’ the same. Using the term ‘patient’, implies a rejection by doctors of multi-disciplinary team working, we are led to believe. There is a perceived, albeit unfounded notion, that the medical profession want to dominate those with mental healthproblems in particular by insisting on a biological model of illness and, by inference, pharmacological ‘chemical cosh’ treatments. At the heart of all this mumbo-jumbo lies the social model of care with its aim of ‘demedicalising’ the management of mental illness. This, ironically, seems at odds with medical practice where the emphasis has always been on a holistic approach to patient care. Yet an insistence on a social model of mental illness is as patronising to the patients that hospital managers purport to be caring for, as is the imagined ‘disempowerment’ model they want to dismantle. Some in the health management hierarchy contend that the word ‘patient’ fits poorly with today’s views of ‘users’ taking an ‘active part’ in their own health care.¹  Or does it? One may decide to have the cholecystectomy or the coronary bypass, when the acute cholecystitis and chest pain respectively have settled down, and select the time and date of the procedure, but I doubt whether one has any real ‘choice’ in the matter when the condition becomes critical, or that one will play an active part in the procedure itself. 

 

The concept of empowerment, which has been around for decades, also seems to be enjoying a renaissance, being one of the current buzzwords in ‘modern’ health care. Other buzz phrases, among many, include ‘freedom of choice’, ‘equity’, ‘right to participation’, ‘increased role of the consumer.’ Empowerment, theoretically, enables new customers to stand up for themselves, demand their therapeutic rights and choose their own treatment. Fine when you are well. However, should I develop a serious illness, particularly one in which I have no great expertise, and because I cannot conceivably amass the entire body of medical knowledge before I see the doctor or nurse about my condition, I would prefer the physician/nurse to outline the treatment plan. I do not want to be called a client, customer or punter, because such derisory terms are more apt to make me feel, ironically, ‘disempowered’.

 

 

‘If you want to make enemies, try to change something.’ Woodrow Wilson (1856-1924)

 

What is it about doctors using the word ‘patient’ that health managers and non-medical therapists find so irritating and difficult to accept? Perhaps the answer lies in the doctor-patient relationship, akin to the attorney-client privilege afforded to the legal profession, so loathed by the judicial system. We are being swept along on a current of neutral, incongruous words such as ‘client’ (the most popular at present), ‘service user’ (this applies across the board), ‘consumer’ (Consuming what? I know my rights!), ‘customer’ (Do I get a warranty with this service? May I return the goods if they are unsatisfactory?) Better still, ‘ambulatory health seekers’ (the walking wounded) and ‘punters’ (a day at the races). The general trend it seems is for doctors to name one attending an appointment as ‘patient,’ midwives opt for ‘people’, social workers tend to speak of the ‘service user’, psychologists and occupational therapists prefer ‘client’, and psychoanalysts sometimes use the rather cumbersome description ‘analysand’. What is usually forgotten is that the person waiting in the analyst’s reception is no different from the humble stomach-ache sufferer.²

 

To most people ‘service user’ infers someone who uses a train or bus, or brings their car to a garage or petrol station. The term ‘user’ often denotes one who exploits another; it is also synonymous with ‘junkie’ and a myriad of other derogatory terms for those dependent on illegal drugs; ‘client’ has ambiguous overtones, and ‘people’ refers generally to the population or race, not to individuals receiving treatment. For general purposes a ‘client’ could be defined as a person who seeks the services of a solicitor, architect, hairdresser or harlot. There is also talk of ‘health clients’. Someone who goes to the gym perhaps! A customer is a person who purchases goods or services from another; it does not specifically imply an individual patient buying treatment from a clinician. Try to imagine the scenario of being told in your outpatient setting that a client with obsessive compulsive disorder, or a service user who is psychotic, or a customer with schizophrenia, is waiting to be seen. Although it is defies belief, this is how non-medical therapists portray patients. Would a medical doctor describe a person with haemorrhagic pancreatitis as a customer? Picture a physician and psychiatrist talking about the same person as a patient and customer respectively. Patients make appointments with their general practitioners. In psychiatry the terms are an incongruous depiction of the actual clinic setting in that most patients are not consumers or customers in the market sense; indeed many have little wish to buy mental health services; some go to extraordinary lengths to avoid them.³ Those who are regarded as in greatest need vehemently avoid and reject mental health services and have to be coerced into becoming ‘customers’ through the process of the mental health act.

 

What do our medical and surgical colleagues make of all this? Despite Newspeak insidiously weaving its way through other specialties, it does not seem to have permeated medicine or surgery to the same extent. Is psychiatry therefore alienating itself even further from other fields in medicine by aligning itself with this fluent psychobabble? Do cardiologists refer to patients with myocardial infarctions as customers? Does a patient with a pulmonary embolism or sarcoidosis feel more empowered when described as a punter? Changing the name does not address the illness or the factors in its causation. Perhaps one could be forgiven for using terms other than ‘patient’ for someone who wants plastic surgery to enhance their facial appearance, or a ‘tummy tuck’ to rid themselves of fatty tissue induced by overindulgence, or in more deserving cases, successive pregnancies. Readers will have no difficulty adding to the list. Such people are not ill. However, when describing a person with multiple myeloma, acute pulmonary oedema, intravascular disseminated coagulopathy or diabetic ketotic coma, I’m not so sure ‘consumer’ or ‘ambulatory health client,’ fits the profile. After all, a customer usually wants to ‘buy something’ of his/her own choosing. Now this may apply to ‘gastric banding’ or silicone implants, but there is not much choice on offer when one is in a hypoglycaemic coma or bedridden with multiple sclerosis.

 

Despite the above, when people were actually asked how they would prefer to be described by a psychiatrist or by a general practitioner,67% and 75% preferred ‘patient’ respectively.⁴ Another survey revealed a slightly higher preference (77%) for ‘patient’.⁵ One might argue that such results depend on the setting where the surveys were carried out and by whom. However, logic dictates that if I am in the supermarket waiting to be served, I would assume I am a customer; while attending the general practitioner’s surgery for some ailment, I would imagine I am there as a patient. Such surveys are conveniently ignored by service providers. So what does it matter? It matters because the lack of direct contact between managers and patients puts the former at a great disadvantage and leads one to question their competence and credibility when accounting for patient preferences. Perhaps managers should ‘shadow’ physicians and surgeons to fully understand why the people they treat are called patients. Psychiatry is not a good example of normal medical practice since so many of its adherents possess the illusory fantasy of being ‘experts in living’, and not physicians whose aim is to diagnose and treat.

 

‘The art of medicine consists in amusing the patient while nature cures the disease.’   Voltaire (1694-1778)

 

It is noticeable that ‘patient’ remains the preferred usage by the media, press, and cabinet ministers, and of course, by medical and surgical teams. The implicit meaning of the word ‘patient’ is that someone is being cared for, and the media at least seem to respect this. Ironically, in the field of mental health, clinicians will often write letters to other professionals referring to an ill person as a ‘patient’ in one paragraph, and a ‘client’ in the next! Doubt and equivocation reign. It is as if the stigma of mental illness will evaporate if we gradually stop talking about sufferers as patients, and ‘empower’ them by describing them as ‘customers.’ There is ambiguity in the terminology itself. The term service user is the most disliked term among those who consult mental health professionals.⁶  The terms are also used interchangeably, with ‘customers’ and ‘service users’ described in the same breath. What do we call a drug-user? - a service user drug-user or a drug-user service user, a customer who uses drugs, or a drug-using customer? How does one accurately describe an individual using alcohol and illegal drugs? Is an infant suffering from respiratory distress syndrome or a child moribund with bacterial meningitis an active participant in his/her health care? In theory, they are service users. What about young people among whom substance misuse is prevalent?⁷ Do we label and stigmatise them as drug clients or drug customers? Will the outpatient and inpatient departments be redesignated as out-service or in-service user clinics? Oxymoronic terms such as ‘health clients’ do not convey any meaning when applied to hospital patients. Doubtless, critics with their customary predictability will lamely and with gloating schadenfreude, accuse the medical profession of bemoaning their loss of hegemony in health care matters, but their arguments are specious, stem from a lingering resentment of the medical profession, and amount to little.

 

In other areas of health some argue that making choices about lifestyle, and seeking advice on matters such as fertility, liposuction, gastric banding, or cosmeticsurgery, do not require one to be called a patient, and rightly so. Such information is freely available at clinics and on the Internet, and therefore does not require the advice of a doctor per se, until the actual procedure is imminent. However, it would be inconceivable for a patient undergoing say, a laparoscopic bypass or sleeve mastectomy for obesity, not to heed the views of the surgeon performing the procedure itself, the success rate, and complications. Whether to have the operation is a different matter. Similarly, individuals who want to engage in psychological therapies such as cognitive or psychoanalytic, or who would rather indulge in an expensive course of ‘emotional healing’, can choose for themselves. Neither does one need to see a nurse practitioner or general practitioner for a mild upper respiratory tract infection. Such people are not suffering from any serious medical illness (an enduring feeling of being physically or mentally unwell) in the true sense of the word.

When all is said and done, most people are unschooled in etymology, and condemning words because of their remote origins is pointless. Words change in meaning over time. Often they take on a new meaning, all too obvious in teenage slang. The word ‘wicked’ used to mean sinful, now it refers to something ‘cool’ (another word that has changed its meaning). Besides, if ‘patient’ really is that offensive, it seems odd that it has retained unchallenged supremacy in the United States,the centre of consumerist medicine, where the patient is quite definitely a partner.⁸

 

Physicians do not want to return to the days of paternalistic and condescending medicine, where deferential, passive patients were at the mercy of the stereotypical omniscient, omnipotent doctor or nurse matron. Likewise, patients do not want to be treated like products in order to achieve targets for the government health police. Patients nowadays are generally more confident and better informed about their conditions, in other words, already empowered, than in days gone by, particularly with the advent of the Internet (alas, here misinformation also abounds) and this is welcome. Therefore, if you are relatively well you can choose a treatment to suit your lifestyle. Unfortunately, not many patients suffering from chronic illnesses, for example, schizophrenia in some cases, or a degenerative condition such as motor neurone disease, feel empowered. I might feel empowered when I can decide to have one therapy or another, say, cognitive as opposed to solution-focussed therapy. I somehow doubt whether I would feel equal in status to, or more empowered than, the surgeon who is performing a splenectomy on me for traumatic splenic rupture.

 

The thrust of all this is that nothing is thought through; everything consists of ‘sound bites’ and ‘catchphrases’, and the sound bites become increasingly absurd the more one scrutinises the terminology. The medical and nursing profession should only be tending to people who are ill or recovering from illness. Of course other staff are directly or indirectly involved in patient care and follow-up. Physiotherapy is a good example. Nonetheless the title patient remains the same. Therefore let us be clear about the definition: those who suffer from an illness are patients; those who are not ill can be called service users, or whatever term takes your fancy.