Tuesday 20 February 2018

Patient, service user or client- what's in a name?

Mind & meaning

Stock photo
Stock photo

Patricia Casey

The words we use to describe people are important. The 'N' word is no longer used to describe those of Afro-Caribbean descent; those with growth conditions such as achondroplasia are no longer called 'midgets'; and people with mental illness are not described as 'lunatics' or 'basket cases' - except by those ignorant about mental illness. The importance of these terms is that they can create a particular perception of an individual that may be positive and enriching or harmful and stigmatising.

The debate about the best words to describe those who use the services of doctors is a relatively recent one. 'Patient' has been the traditional term. Its origin in the Latin word 'patiens' or 'patior' means to suffer or bear. In a debate in the British Medical Journal in January 1999, Rabbi Julia Neuberg suggested that the word 'patient' conjures up an image of passivity. She was particularly troubled by the implied inequality in the relationship between the parties.

She wrote: "The healthcare professional is the healer, while the recipient of healthcare services is the healed, and does not need to take a part in any decision making or in any thinking about alternatives."

She argued that, at a time when user participation and joint decision-making was coming to the fore, the word 'patient' was no longer fitting. She also pointed out that many people using the services of doctors were not ill, but attending with lifestyle concerns ranging from fertility issues to cosmetic surgery inquiries, or simply for vaccinations against illness.

At that time, there was little information on the designation preferences of those attending doctors. This has subsequently changed and a number of studies have thrown some light on this. For instance, in 2012, a study from a sexual health clinic in Scotland (Loudon et al) found that 61pc of attendees and 59pc of staff had a preference for 'patient', while only 9pc of attendees and 33pc of staff opted for 'client'.

Nowhere is this more prescient than in psychiatry as a result of the long history of stigma endured by those with mental illness. Research into the associated etymology has been more extensive than in other branches of medicine.

While derogatory descriptors such as 'lunatic' are rarely heard anymore, psychiatry as a specialty remains especially sensitive to words and has been grappling with the best term to describe those who use the mental health services.

The diversity in terms is mirrored by the strength of opinion about this. 'Service user' was one of the most popular, while 'client' was also met with approval. Those in the recovery movement emphasised the 'survivor' elements, while 'consumer' was preferred by others.

Other terms include 'attendee', 'customer' and 'recipient'. For years, 'patient' was unacceptable and it seemed as though political correctness had invaded and won.

A fascinating study in 2012 by Geoff Dickens from Kings College London found that the struggle with the multiplicity of terms was an international phenomenon. For example, New Horizons (2009), the UK government's 10-year plan for mental health services, refers variously to 'service user' (23 times), 'patient' (12 times) and 'client' (five times). Australia's fourth national mental health plan (2009) uses 'consumer/s' 94 times; the other terms used, all on fewer than five occasions, are 'patients', 'clients' and 'recipients'.

Meanwhile, Canada's framework for a mental health strategy (2009) uses no single term exclusively. In Ireland's proposal for a national framework (2006), 'service user/s' or 'user/s' are preferred (951 uses) in comparison to 'patient/s' (287 uses). In the US, the Surgeon General's report on mental health (1999) uses 'patient/s' (668 times), 'consumer/s' (289 times) and 'client/s' (104 times).

What do those who use the psychiatric services themselves say?

While there are some caveats with regard to methodology and the terms compared, there is a clear pattern. The largest percentages endorsed 'patient' (over 40pc) and less than 5pc preferred 'service user'. 'Survivor' was endorsed by around 6.5pc and 'client' by 33pc. There were regional differences, with those in the US preferring 'client' while 'patient' won in the UK and Canada (over 60pc support).

In Britain, the Royal College of Psychiatrists passed a resolution in 2013 to use the word 'patient' in all official documents. The College of Psychiatrists of Ireland has no official policy. The thinking behind the UK move was that defining a person by their use of a particular service ('service user') would potentially have the unintended consequence of stigmatising them, while the word 'patient' emphasised the parity between mental and physical health conditions.

In addition, the hallowed tradition of referring to those attending doctors as patients was steeped into our understanding, in phrases such as 'doctor-patient relationship' or even 'patient autonomy'.

Words are indeed important, and now psychiatrists can speak of having 'patients' rather than having our language curtailed at the altar of a new linguistic orthodoxy.

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