You are in distress and seek help. Let’s name certain kinds of distress to help us visualize who you are. Maybe you feel sad or “depressed.” Maybe you feel even darker than that: maybe you’re despairing or suicidal. Maybe you feel anxious. Maybe you believe that you’re suffering from an addiction. Maybe your behaviors are out of control, and you’ve sought out help. Maybe someone else, maybe a parent or the courts, have demanded that you get help. Maybe your distress is of the sort that gets called “serious mental illness”—maybe, for example, you are delusional or “schizophrenic.” Maybe you’re having relationship problems, maybe you feel isolated and lonely. Maybe you feel under tremendous stress at work. Maybe you are having “trouble with life” and want a sympathetic ear and some new strategies and tactics for living.
You want help. But before we can discuss what help is available to you and, in particular, what our human experience specialist might have to offer you, we need to know what to call you. I hope I’ve convinced you that the naming of things is no innocent business. It matters if there really are “mental disorders” or if we are only designating certain thoughts, feelings, and behaviors as such. It matters if there is something sensible to say about “normal” and “abnormal” or if we are using those words inappropriately and primarily to make money. And—this is what we want to examine next—it matters if it is proper to call you a “patient” or if it isn’t.
Why should someone experiencing emotional distress be labeled a “patient”? Shouldn’t we reserve the word “patient” for genuine medical interactions? The current mental health system promotes the idea that mental health service providers “see patients.” This ought to change. The practice is both illegitimate and dangerous. Why dangerous? First of all, “just like that” you have given me license to see you in a certain way: as sick. Patients are not sick people by definition, since you may see a doctor and learn that you are just fine. Yet the word “patient” carries with it the large likelihood that you are, in fact, sick. By accepting that label, you have accepted a certain sort of verdict, one that has not been adjudicated.
If you are a service provider, will you see me as “sick” just by virtue of the label I’m wearing? You quite likely will. Say, for example, that I’m a well-known mental health professional. I tell you, another mental health professional, that the “patient” I’m sending over to you, a person who is completely mentally healthy, “appears neurotic but is really psychotic.” What are the chances that you will agree with my diagnosis in the absence of any actual evidence of “neurosis” or “psychosis”? According to one elegant experiment, 100 percent!
There looks to be a 100 percent chance that, even if I am well, you will see me as sick because a colleague of yours told you that I’m sick. In an experiment performed by Maurice Temerlin and reported in the Journal of Nervous and Mental Disease, Temerlin had an actor memorize a script designed to portray a mentally healthy individual whom we’ll call Harry. Harry was happy, effective at work, self-confident, warm, gracious, happily married, and insightful—as mentally healthy as a person can be.
Harry’s performance, presented as an “intake interview,” was played for a group of mental health professionals. Beforehand, a well-known mental health professional told the gathered group that they were about to listen to an interview with a man who “appears neurotic but is really psychotic.” After listening to Harry, they were told to rate Harry’s mental health based only on the interview; they were explicitly told not to use the information provided by the “prestige associate.”
The results? Virtually every graduate student, clinical psychologist, and psychiatrist rated Harry as either neurotic or psychotic. The psychiatrists were the worst in this regard: 60 percent rated him psychotic and 40 percent rated him neurotic. Having listened to an interview with a healthy man and having been told to confine their ratings to the evidence of that interview, 100 percent of the psychiatrists judged him disordered because a “prestige associate” told them that they ought to.
Multiple experiments have confirmed that when presented with a “patient” or a “prospective patient,” mental health professionals are considerably more likely to “diagnose the presence of a mental disorder.” The very act of walking in somehow confirms that you have a “mental disorder”! An excellent experiment run by Ellen Langer of Harvard and Robert Abelson of Yale and published in the Journal of Consulting and Clinical Psychology further illustrates this point.
The experimenters wanted to gauge what therapists would say about a subject who for one set of therapists was called a “job applicant” and who for a second set of therapists was called a “patient.” Would the latter label bias their opinions? It did indeed. Therapists who thought that the subject was a job applicant used words like “candid,” “upstanding,” “innovative,” and “ingenious” to describe him. Therapists who thought that the subject was a patient used words and phrases like “tight,” “defensive,” “frightened of his own aggressive impulses,” “conflicted over homosexuality,” and “passive dependent type” to describe him. The experimenters concluded, “Once an individual enters a therapist’s office for consultation, he has labeled himself ‘patient.’ The therapist’s negative expectations in turn may affect the patient’s own view of the situation, thereby possibly locking the interaction into a self-fulfilling gloomy prophecy.”
If there is a genuine illness present and it is a professional’s job to treat illnesses, it is then fair to call folks “patients” when they walk into that professional’s office. It is fair to call them “patients” even when they aren’t suffering from an illness or disorder, just so long as the professional’s office is truly a medical office and just so long as the professional can actually distinguish between health and illness. But what if the transaction is more of the following sort? Say that you enter a mental health service provider’s office and share that you are worried about your son’s drinking, the impending loss of your job, and your mate’s infidelity, and that these pressures and many other pressures are making you unhappy. If, after I hear this, I say to you that you are “ill” with the “mental disorder of clinical depression,” I have illegitimately labeled you and illegitimately turned you into a patient. You came in wanting to talk about your problems, and you left as a patient with a mental disorder.
Whether a professional’s office carries the shingle of psychiatrist, psychologist, clinical social worker, family therapist, licensed counselor, or some other name sanctioned by the state, that does not give the professional the right to make a patient out of the person who walks into his office. It would be as if you walked into your accountant’s office, told him of your financial troubles, and he replied, “You have the illness of bad debt! And since it is an illness, I can happily accept your medical insurance!”
The label of “patient” should be used appropriately because by its very nature it increases the power of the provider and weakens the person who is suffering. If what is present is emotional distress caused by life’s problems, it is not right to apply the label of “patient.” Should the very act of looking for help and walking into a certain sort of office lead to you being labeled a “patient,” after which you will almost certainly be “diagnosed with a mental disorder”? It should not.
Sufferers who come in looking for mental health services shouldn’t be labeled as patients. First, the transaction isn’t a genuinely medical one, even if so-called “drugs” are often prescribed. Second, nonmedical personnel like psychologists, counselors, clinical social workers, and family therapists shouldn’t have “patients.” Third, the word stigmatizes the individual for no legitimate reason. There are many other good reasons, too, not to bandy about the word “patient.”
But what about that most common alternative word to “patient”: the word “client”? Is that a useful, appropriate word, or is that a word with its own baggage, limitations, and dangers? If we are looking to rethink mental health service provision, it is very important that we get the players in the game appropriately named. The providers should be appropriately named—we are calling them a human experience specialist. But what do we think about the word “client” for the sufferer?
Who has clients? Lawyers, accountants, high-end boutiques, real estate agents, and personal shoppers have clients. Why do plumbers have customers and personal shoppers have clients? Why do auto mechanics have customers and architects have clients? It looks like there is something about economic class built into the word “client.” A bargain basement department store has customers and an expensive boutique has clients. An auto repair shop that caters to everyday cars has customers and a shop that caters to fancy cars has clients. The guests of a motel are customers and the guests of a boutique hotel are clients. If “patient” carries a tangle of meanings having to do with illness, “client” looks to come with a tangle of meanings having to do with economic class.
“Client” also appears connected to the idea of “better service.” We expect that you will get “better service” or “more service” or “more personalized service” in a boutique hotel than at a motel off the highway and at a boutique dress shop rather than in the dress department of a bargain basement department store. A “cook” and a “chef” might do the same work, but from which one do we expect “better food”? By making you my client, I have made myself look better. I have instantly and effortlessly upgraded myself. Isn’t that interesting? It doesn’t matter whether I’ve done anything to merit that upgrading. Language does the trick for me!
Before we try to decide whether it makes sense to ditch such a class-driven word, one that raises the provider’s status simply by how language operates, let’s take a look at some alternative language. What other words exist to describe customers and consumers? Who is the customer of a parish priest? A parishioner. Who is the customer of a Zen master? A student. A cruise ship has passengers, a cab driver fares, social workers cases. None of these words or the many others words we might offer up make for a very interesting or useful alternative to “client.” Are we stuck with “client” by default? Or do we perhaps have to coin some new language?
Before we think about coining any new language, however, let’s look at the following issue: “customer resistance.” Remember that while life is difficult, you are also difficult. We might have it in our heart to frame the relationship of the future as a certain sort of easy collaboration between sufferer and helper and maybe find a word that communicates “collaboration,” but that would imply that sufferers would indeed collaborate. Would they? Let’s think about that for a minute.
We have to factor customer resistance into this discussion. If someone comes in wanting a pill, wanting to blame a spouse, wanting to talk but not listen, wanting insights but not the subsequent work, wanting to get better but not to change, and so on, what sort of collaboration can come from that?
We need to talk frankly. How often are human beings really interested in reducing their emotional distress? Do they always or even often really want to feel better? What if feeling better requires that you change your daily habits, change your habits of mind, change your circumstances, upgrade your personality, and work like the dickens on every aspect of your life? How many people are up for that?
A person may be suffering and may seek out a helping professional hired to help relieve emotional distress. Unfortunately for both, the sufferer may have powerful reasons for not cooperating. Maybe he doesn’t want his drinking, smoking, or eating habits tampered with. Maybe he doesn’t want to change—he wants the people around him to change. Maybe he’s unwilling to reveal what’s going on because he’s embarrassed by his thoughts or his actions. Maybe there would be repercussions—say, if his mate found out about his affairs. Maybe he’s very comfortable with his formed personality and his habits of mind, even though they produce sadness and anxiety.
This would make him entirely human and not very unusual. In fact, virtually all human beings prefer being who they are to being helped or to reducing their emotional distress—if being helped and reducing their distress makes work for them, requires that they change, or forces them to look in the mirror. It is an artifact of evolution that our “selfish genes” cause us to defend ourselves even against useful, life-improving help. It might prove in your best interests to make certain admissions and take a certain amount of responsibility, but most human natures rebel against this approach to life. This reality doesn’t auger well for any helping relationship, present or future.
These are, of course, the sufferer’s issues—but they also become the issues of the helping professional. You are forcing the person you hire to deal with human nature, and who doesn’t get tired and “burn out” on human nature? The current thrust of mental health services in the direction of “diagnosing and treating mental disorders” and “medicating patients” is rooted in large measure in this tiresome transaction, that as a helper I must try to help someone who isn’t helping me or himself. What psychiatrist isn’t happier acting like you “have something” and writing you a prescription rather than trying to arm-wrestle you out of your personality, your habits of mind, and your ways of being? Wouldn’t you be rather likely to do the same in his position?
It may be that you are more unwilling to cooperate because you have secrets to keep, or it may be that you are more unable to cooperate because your chronic sadness has drained you of the energy you need to collaborate. These are different situations, but from a helper’s point of view, they amount to the same problem: you aren’t helping. And that has consequences for you because your lack of cooperation will get factored into the diagnostic label you get and, in turn, will factor into your prognosis and your treatment plan.
Say that you are uncooperative—you may even be loud about it—perhaps because you have some intuitive sense that you are not going to get the help you need. The more difficult you are, the less likely you are to get some “mild” adjustment disorder diagnosis or some mood disorder diagnosis and the more likely you are to get a “severe” personality disorder diagnosis. Just as a judge has a remedy for “difficult and unpleasant” where he works—contempt of court—a therapist-as-judge has his remedy: the ability to diagnose you with a “borderline personality disorder” or an “oppositional defiant personality disorder” or something else that translates as, “Boy, you are difficult!”
This is, of course, a covert and maybe even half-unconscious operation. A psychiatrist would never say to you, “Because you are being uncooperative, I am giving you a harsher label.” Nevertheless, he is likely to provide you with that harsher diagnosis for two different reasons: because he is annoyed with you and also because once he gives you that pejorative label, he is relatively off the hook as far as treating you goes. Since it is “well known” that folks with personality disorders are by-and-large unreachable and untreatable, his job has just become that much easier. A person’s unwillingness to participate in reducing his own emotional distress coupled with a therapist’s wish to take it easy on himself when dealing with uncooperative clients leads us to this exact moment in the history of mental health, where chemicals are running rampant and everyone acts as if human beings have caught various versions of mental flu.
It also follows that the more difficult you are, the more society will react coercively. Produce headaches for your parents and psychiatrists are waiting. The more antisocial you act, the more society will want you handled. Your screaming on the street will not be tolerated. Your suicide gesture will be criminalized. Society wants peace and quiet. Why should society’s desire to protect itself surprise anyone? If you throw your pumpkin soup in the face of your waitress because you believe that she is trying to poison you, society cares about only one thing: you must stop that.
Where we have arrived is the completely predictable result of two agendas marrying: the marriage of the sufferer’s wish to remain the same and the helper’s wish to make it through the day. We must somehow factor this reality into any new system we devise and into our decision about how to name you. How good can any new system be if it doesn’t take into account that human beings are only sometimes actually interested in reducing their emotional distress? In medicine, the issue is compliance: will a patient take his meds? Our issue is an even more intractable version of the same problem: will sufferers actually “transcend their human nature” and help themselves?
In light of these various realities, there is probably really only one thing to call you: a person. An individual who crosses a service provider’s threshold is neither a patient nor a client but a person. There. We have named him. Every single other appellation confuses and obscures matters. Since only “person” captures the flavor of human obstinacy, of human resiliency—of everything human—“person” is what we must call the customer of a mental health service provider. Our human experience specialists will say, for example, “I am currently working with several people.” How simple, straightforward, and truthful!
And where will that leave them? They will face the reality of difficult human beings with their tricks, adamancy, evasions, and finger pointing—that is, facing real members of our species. They aren’t naïve: They expect adamancy. We respect that people who have spent a lifetime dealing with the undeniable difficulties of living will have built up protective armor. If life were easier, maybe people would defend themselves less fiercely. But it is human nature to resist change, exposure, discomfort, and so on. We are all resistant. So, while we would love it if we could propose a collaboration model as the model of the future, we must think twice about that. In such a collaboration model, the fundamental stance of helpers would change from “I am an expert with superior understanding who can diagnose you and treat you” to “I am a person with some understanding of human nature and some helping strategies who will work with you to help you frame your ‘mental health’ goals and achieve those goals.” That is a destination we would love to arrive at; we will have to see (in future chapters) if there is a way to get there.
It matters what we call the people who visit our new human experience specialist. The name they bear is important because it helps define the nature and dynamics of the relationship. The very act of naming produces consequences. “Patient” will not do and “client” carries its own baggage. Only “person” will do. We had to get to this obvious conclusion in this laborious way because calling you a person is not customary or popular inside the mental health establishment. You yourself may have forgotten that that is who you are. When we take you to be the person you are, we can help you better. We can say, “You’ve been through a lot.” We can ask, “Do you intend to help yourself?” We can empathize with you in all of your humanness because that is what you are, a human being. We must do this even though we find ourselves in a climate where it feels like heresy to announce that each of us is human.