This series was triggered by a post at Dr. Helen about a bit of Politically Correct behavior by the American Psychological Association. The overt topic had to do with the APA refusing to accredit a conference concerning therapy designed to re-orient homosexuals who were unhappy with their orientation, to heterosexuality. I share Dr. Helen's skepticism that such changes can be brought about (and would point out that there is no single entity known as homosexuality; just as there are a myriad of characterological and constitutional determinants that shape one's heterosexuality, the same is true of homosexuality.) However, my interest was stirred by her causal comment:
Personally, I'm skeptical about turning gay people straight. But shouldn't the client be the one to choose, not the APA? [Emphasis mine-SW]
The use of "client" in this setting, a usage that is ubiquitous in the mental health arena, has important implications, the more so because I do not think it has ever really been systematically explored. Yesterday, two commenters pointed toward the distinction between Patients, Clients, and "Consumers".
sigmund, carl and alfred wrote about laser eye surgery, which over the last few years has gone from a sophisticated medical procedure costing upwards of $2500 per eye to as little as $250. Dymphna commented on the odious nature of terming patients "consumers" and as she is wont to do, made a humorous and subversive suggestion that therapeutic relationships involve more than a simple exchange of money for services.
This morning, EssEm added some comments that get close to the heart of the problem, starting with etymology:
"Patient" comes from "suffer". It is a constant reminder to me that what brings people to my door is their suffering, and that it is my role (and responsibility) to help them find its meaning.
All the comments are illustrative and worth a closer look. S,C & A's provides us with an excellent starting point. He suggested that competition and a free market has allowed the price of laser eye surgery to come down to such an affordable level that a once rare procedure has become extremely common and available. His implicit point was even more important for this discussion.
First, a little history is in order. I have worn glasses since ~6th grade and have always wished that I could see clearly without them. When I first heard of Radial keratotomy, I was intrigued but reasoned that it would be quite some time before the procedure was found to be safe enough for general use. The procedure, which had its roots in the late 1800's, had a brief popularity in Japan in the mid-1950's, and flourished in Russia in the late 1960's, involved making numerous small incisions in the cornea which, when they healed, subtly shifted the curve of the cornea allowing for improved vision. The idea of allowing multiple, tiny cuts to be made in my eye, with uncertain assurances of success and greater uncertainties about long term effects, was enough to dissuade me from the procedure, despite how much I was looking forward to getting rid of my glasses. By the 1990's, American surgeons began to use lasers to more carefully and precisely re-shape the cornea to achieve much better results than the original Russian procedure.
Initially, the procedures were offered for upwards of $5000 an eye by a very limited number of Ophthalmologists. Within a few years however, a great many Ophthalmologists, in responding to the great demand, were trained in the procedure, the computer guided lasers improved almost daily, as all high tech seems to do, and with increased supply, the prices came down. By the time I had the procedure several years ago, the Ophthalmologist was no longer working as a highly trained Physician. Essentially, the Ophthalmologist had become a very well paid technician and insurance policy; on the rare occasion of an infection or other, even rarer, complication, the Ophthalmologist was there to take responsibility for patient care and prevent a complication from turning into a disaster. The crucial point here is that a once highly technical procedure had been routinized by technology such that it no longer required a Doctor's highly trained (and expensive) expertise; all that was required was a technician and sophisticated equipment.
As the procedure changed from a highly technical, inexact, human-mediated surgery into a much more precise, computer controlled procedure, and the Doctors changed from care-givers to providers of a service, the patient underwent a complementary change. Ever since the time refractive lenses were invented and put into eye glasses, surgery for visual acuity has been elective. Patients who were particularly distressed by the need to wear glasses were willing to risk pain, possible poor outcomes, and significant expense in order to alleviate their distress. The primary reason for risking such surgery was that the patient was in pain. In the case of Radial Keratotomy, the pain was emotional. A person who was terribly unhappy with how they looked in glasses could alleviate their pain and distress by having a significant eye operation. Once the surgery turned into a minor procedure with minimal risk and expense, it became available to anyone who wanted it (and whose eyes could tolerate or benefit from it.) At that point, people requesting laser surgery on their eyes were no longer patients motivated by significant distress, but were clients or consumers looking for a better cosmetic outcome.
What is significant about this? The primary differentiation between a patient and a client comes down to the level of distress and dysfunction for the person involved. Returning to EssEm's comment, there is this: when people are suffering, when they are in pain, whether physical or emotional, they become a patient and this makes all the difference.
Part III in this series will explore what effect pain and suffering have on a person that changes them from a client into a patient.
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