Should we be described as patients or clients?

Whenever I hear a patient called a client I shudder, just as I used to when my teacher caught her nail on the blackboard as she was writing on it with chalk. There is something about the term - it is simultaneously unctuous and euphemistic, as if some unpleasant reality were being concealed by its use. I can't help thinking we will soon hear prisoners referred to as "clients": even the term "con" would be preferable to that.

Patients in psychiatric services are now rarely referred to except as clients and the usage is now nearly universal. Indeed, if one still uses "patient", one can almost feel the disapproval. One is regarded as a reactionary and almost as an enemy of the people.

A paper in the latest Psychiatric Bulletin reports the first (admittedly small) survey of psychiatric patients and terminology: did they prefer to be called patients or clients? Overwhelmingly they preferred patients. Social class didn't matter nor did their diagnosis; in fact there was no identifiable subgroup that preferred to be called clients.

As the authors of the survey - psychiatrists at the Royal Free Hospital in London and at the Royal Park Hospital in Melbourne - point out, the two words have quite different connotations. A patient is a suffering person who either seeks or needs care. A client is a person who buys a service. Patients go to doctors, clients go to lawyers (or prostitutes).

The authors quote Ben Pimlott's introduction to the Penguin edition of Nineteen Eighty-Four: when Orwell noted the eagerness with which truth evaders shy away from well-known words and substitute their own he was observing it as something as relevant to petty bureaucrats as to dictators.

The demand that patients should become clients clearly did not originate with the patients themselves. I have never heard a single one ask to be called a client, though some, who wish to be left alone with their delusions and hallucinations, don't want to be called patients either.

Two questions emerge, one historical and one practical. Why did the change in terminology occur, and what happens next?

Ostensibly, the term client was introduced to equalise the relationship between the provider and recipient of help and attention. A client, after all, actively chooses his adviser and pays him: his payment stands guarantor of his dignity. In the NHS, no one pays his doctor or even chooses him. The patient gets whom he's given.

And a patient is much more passive, even when he does pay. He has things done to him. A patient, but not a client, is worthy of compassion because it is acknowledged that he is, by definition, a sufferer and therefore in need of succour and relief. An involuntary patient is not a contradiction in terms; but an involuntary client is.

The real reason for the change was a power struggle between various factions in the psychiatric services. It had nothing to do with the wishes of patients, or even with increasing professional respect for them.

Some people who worked in the psychiatric services just felt that doctors needed demoting, or putting in their place: and doctors above all see patients, therefore patients had to be turned into clients, whether they wanted it or not. As Humpty Dumpty so acutely remarked: "The question is, which is to be master - that's all."

It is not to be expected, therefore, that practices will change as a result of this survey. The march of the term client will continue, until it has been so widely used for so long that it becomes completely accepted, and no one will even be able to remember a time when it wasn't. A return to using the term patient would be a political defeat, its elimination a victory. In all this, patients (and clients for that matter) are mere pawns.

I suppose one might call the change from patient to client a little piece of linguistic engineering. I find it sinister: but perhaps I'm paranoid. In which case, of course, I need to become a client.

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