Patient, Clients, Consumers: Whom do Mental health clinicians treat?

“But if thought corrupts language, language can also corrupt thought.”
―George Orwell, 1984

Some mental health clinicians call the people they treat, patients; some call them clients; and a few call them consumers. What is going on here?

The word patient comes from the latin verb pati meaning to suffer and implies the presence of an illness that requires medical intervention. The doctor/patient relationship has an ethical dimension: the duty to care for the patient goes beyond a commercial transaction.

Client as it is used in contemporary mental health care derives from the mid twentieth century humanistic, collaborative approach to psychotherapy of Carl Rogers. His theory of Client Centered Therapy was a reaction to the authoritarian approach to psychiatry of that time, an approach he believed blocked self growth and self realization because it did not empower clients to discover solutions for themselves. Many psychologists and other non-medical clinicians use clients in lieu of patients.

The term consumer is also used by some clinicians. The term came in in the 90s. It comes from the field of economics, specifically neoliberal economics. It was an attempt to give more dignity and power to the recipient of services by emphasizing their role as an economic agent.

Calling recipients of care clients to avoid association with the paternalistic medical model made sense 50 years ago when Carl Rogers was active. But it doesn’t anymore. The growing recognition that many medical conditions (diabetes, heart disease, etc) are biopsychosocial in origin (e.g. due to lifestyle issues such as smoking, drinking, obesity, diet, etc) has changed medical practice and made it less paternalistic and more collaborative.

For the majority of clinicians who see a broad range of people and take insurance, patients is probably the most respectful term today because it acknowledges the patient’s suffering as well as the ethical duty of the clinician to care. Arguably, the term client was more respectful when medicine was more paternalistic, but the term’s lack of recognition of suffering and ethical dimension makes it a less appealing choice now. Consumer is appropriate only in the very narrow mercantile sense of making a purchasing “decision.” Using the term more generally diminishes the recipient of care by denying their suffering and the clinician’s duty to care. Indeed, consumer seems a particularly abhorrent term as it implies the commodification of services as patients become customers, healthcare professionals become contracted workers, and healthcare becomes a business like any other.

Patients Fear Psychotherapy Costs, But Should They?

For the more than 30 million US adults who do not receive the mental health services they need, 45% cite cost as a barrier to care. Our data show that the idea that psychotherapy is expensive is a myth. We analyzed some of our 2014 data and here’s what we found:

–For those with insurance who had more than one session, the total average out of pocket cost to a patient for a course of treatment was just $74! The average number of sessions was 6.8, the total insurance reimbursement was $354 and total charges before write off’s was $930.

–Average out of pocket costs of $74 suggests that therapists are under-collecting copays.

However, psychotherapy is expensive if the patient does not have insurance. We found:

–The total cost of and episode of care to a patient without insurance was $306. The average number of sessions was 8.4.

A major difference between insured and uninsured patients was drop out rate. 38% of patients with no insurance dropped out after 1 session, whereas only 14% of insurance patients dropped out. Not having insurance translates into a 270% increase in the likelihood of dropping out of treatment.

What is the import of these data? The word needs to get out that psychotherapy is not, as most people think, expensive. In the last quarter century a number of changes have made psychotherapy affordable, including parity (which reduced copayments), the Affordable Care Act (which extended coverage), and the embrace by the field of the short term treatment model (which reduced the length of an episode of care). These changes have resulted in psychotherapy being highly affordable. The fact is that today psychotherapy for most common psychiatric conditions is the least costly first line treatment option.

That said, cost is a factor for the uninsured and those with high deductible plans. Therapists need to be sensitive to cost and should provide affordable options to the under- or uninsured.