Abstract
Nandi Siegfried, Psychosis and Substance Use Project, Central Sydney Area Mental Health Services; Joanne Ferguson, Central Sydney Area Drug and Alcohol Services and Mental Health Services; Michelle Cleary, Central Sydney Area Mental Health Services; Garry Walter and Joseph M. Rey, Rivendell Unit and Department of Psychological Medicine, University of Sydney, Sydney, Australia:
It was with interest that we noted the substitution of the word ‘patient’ for ‘client’ in the proofs of a recent article of ours accepted for publication in this Journal [1]; interesting because at no time during the review process had the reviewers or the Editorial Office recommended this change to us. As any author knows, choosing the correct word to capture a desired meaning can be a time-consuming process. When the word itself is heavy with sensitive connotations, collaborating authors may well have debated the merit of the word and its various alternatives. While an editor retains the right to a final decision, that decision must take into account the implicit meaning of the words authors have chosen. As authors, we believe an editor can change the way things are said, rather than what is said. However, we acknowledge that in this particular case there is little consensus regarding terminology for people who access or have accessed mental health services. So, what do we call those whom we treat?
Most readers will agree that the term ‘patient’ implies an ‘inherently unequal relationship with a health professional which is bridged by trust in a context of care’ [1, p.18]. Many will argue that the elements of trust and professional ethics present in the professional-recipient relationship adequately compensate the powerlessness experienced by the recipient. However, others point out that the violation of trust and breaching of ethics once commonplace in psychiatry necessitate a shift in paradigm. Renaming, it is argued, will accentuate the issue and force professionals to confront the inequalities of the past. Only with a shared value base can we move towards a term that is agreeable to both professional and recipient.
What then are the alternatives to patient? ‘Client’ has recently been replaced by ‘consumer’, although it is still widely used, especially among drug and alcohol workers. (Think of a person accessing a needle and syringe exchange service.)
The consumer movement had its beginnings in the managed care marketplace of America, from where it spread quickly to Australia. A flourishing consumer movement in this country has enriched professional practice by focusing on partnership and mutual benefit. The National Mental Health Strategy has led the way through its extensive consumer participation processes and more and more services are recognising the value of consumer consultation. In the marketplace, consumers have choice and providers are accountable for the commodities they sell. Few would contest these ideals as worthy of extending to the public health system. Why then are so many professionals still so uncomfortable with the term consumer? We believe it has less to do with the devolution of professional power and more to do with the metaphorical implications of the term.
To most of us, the marketplace metaphor allows little room for the comforting and caring we expect to provide to others in times of personal need [2]. We are fearful that by replacing ‘patient’ with ‘consumer’, we will lose that implied caring and comforting. The recently proposed alternative, ‘service user’, goes no way to resolving this, merely reflecting a shift from the marketplace metaphor to computer techno-speak.
Given then that no one word fully defines the complexity of the professional-recipient relationship, what term do we use? Is there a need for uniformity, for only one term? To return to our original questions, should authors choose terms they wish to use and accept the consequences of implied biases? Should editors stipulate a preferred term for their journals? After all, they request that we not use pejorative language. Amid all this confusion, we can be certain of only one thing: language is a powerful tool that defines our reality. As words continue to gather additional meanings, we will need to grapple more and more with terminology and associated interpretations. And patients, clients, consumers and service users must all have their say.
Editor's note: The correspondents raise a relevant issue for which there is no straightforward answer; we would welcome readers' views on the best course to adopt.