I hear some therapists referring to their clients and some refer to their patients. What am I?
Alright, I confess. I only dream of being asked this question, and I planted it. See, the two terms highlight an interesting evolution in my field.
Long ago, sparse treatment choices included couch-and-cigar style psychoanalysis, stark hospitals and crude medical procedures. The practitioners in the field were physicians, and this made you the patient. Now, seeing me, you are a patient again. Here is how this happened.
Starting in about the fifties, you would have become a client. At that time there was a reaction against the “medicalization” of mental illness. We wanted to remove the stigmas surrounding the field. We wanted to normalize everyday neurotic concerns rather than to view them as a disease. Behaviorists persuaded us that we could view our concerns in terms of what we had learned, and that therapy essentially was to be instructed in better ways. Many wanted to point out that social and economic inequities were at fault for much of our misery, and that to blame the individual was to compound the broader problem.
There was the need back then to take the field from the sole ownership of MD’s and spread it around to psychologists, social workers and counselors, in part to make therapy less mysterious and more accessible. Therapy became a more egalitarian, collaborative process, and in those days “doctor and patient” implied a more directive, hierarchical set-up than it does today. Also, the therapy office needed to be perfectly private and removed from your usual surroundings, so that you could feel safe enough to open up about matters kept confidential from your physician. Finally, many thought that to prescribe medication, or to focus much on behavior, was to ignore the workings of the unconscious and the deep complexities of our inner lives. Putting aside this last item, I do still hold to the ideas above, generally speaking. But they don’t hold the gravity they used to.
In the nineties, the pendulum began swinging back. Why? First there is recognition of the fact that a small percentage of those who experience mental illness ever see a therapist. Most do, however, see a primary care doctor. A great percentage of complaints brought to doctors, including back, chest and abdominal pain, headaches, fatigue, insomnia, dizziness and so on often have no apparent physiological cause. Psychology, environment and behavior however relate closely to all of them. Stress and life satisfaction levels have a huge influence on the impact of physical disorders and on the outcome of treatment, and are beginning to get the attention they deserve in the exam room. For most, the few minutes spent discussing these matters in the doctor’s office are all there is. Physicians are de-facto therapists.
Another change is in the fact that we are chipping away at the perceived wall between the body and the mind, between physical and mental health. The distinction between the two is so small and so fluid that it is not particularly meaningful. The details here deserve another discussion but consider this: The quality of our health and the duration of our lives may not have much to do with medical care. Setting aside economic forces, and environmental factors such as pollution and social ills, the biggest factor is our own behavior. Obesity, heart disease, diabetes, addictions, injuries and in many ways even cancer and communicable diseases, are prevented, and perhaps treated, more by our own behavior than by any medical interventions.
In therapy, your level of physical activity and social connection is one of the better predictors of a good outcome. Often, a solid exercise program can get a better result for depression than counseling does. Therapists now routinely inquire about chemical use, exercise, sleep, nutrition and other aspects of physical self-care.
You might ask, “Apart from all of this, if I’m a patient, the implication is that I’m sick, isn’t it? But I don’t want to be considered sick just because I’m getting therapy.” My response is, “sick” or “not sick” is hardly relevant. I see some unfortunate people who have no problem viewing their mental health condition or chemical addiction as a sickness. Also, I am a patient any time I see a doctor for a physical exam or to treat an injury, and am not concerned with “sick”.
Few of us would want our personal physician to overlook our emotional well being, or to ignore a component as important as our behavior and emotions. Neither would we want him or her to be cut off from the medical specialists we might need. Why then, would we want our mental health work to be separated out?
Our recognition of all of this is leading to more integration between the fields. Patients tend to be more satisfied when care is integrated, and overall costs can be lowered. But to do this, barriers need to be overcome. One such barrier is the need for strict confidentiality. Mental health records have tighter privacy safeguards than do medical records. The records cannot be fully combined, but the advent of electronic records allows for strong safeguards while eliminating the need for a complete schism. Another barrier is in the fact that the different fields use slightly different languages. The term behavioral health has emerged as something more useful to the physician, and it can combine the mental health and chemical dependency fields (there is another rift to discuss another day). Finally, there is of course the word for those receiving care.
This can all be summarized like so: I deliver care in support of your overall wellness. This makes me a health practitioner, and it makes you a patient.