Rectifications (9) – Client, patient, customer, consumer…a psychologist’s work dilemma

Rectifications (9) – Client, patient, customer, consumer…a psychologist’s work dilemma.

Torrey Orton – May 26, 2009

My rectification fire is deeply stoked by our current confusion of life roles. This appears in the tendency to turn all life roles into variations on consumption – as if we’re eating our way through life. No wonder we’ve got an “obesity epidemic”. This seems a particularly appropriate expression for a time when overconsumption abounds in a spiritually anorexic culture.

One deep source of confusion is the ever thinner boundaries for our life roles and activities. For example, not-for-profit organisations increasingly mimic in structure and self-description the modes and moods of commercial ones. They ‘manage’ things, including themselves, while claiming to engage in helping the dispossessed, dissociated, etc. This has been forced on them over the last 20+ years, with the effect of turning their activities often into agencies of the existing powers and systems which produce the dysfunctions they are addressing. I do not say this with blame or disdain for their efforts. It is endemic in our social and workplace cultures.

What follows explores some aspects of this situation, with emphasis on health and backup from education. Starting at home, for me as therapist the question of what to call those who I treat (itself a wonder word) is increasingly fraught. ‘Client’ is the preferred term among psychs, but from the viewpoint of the agency which pays half their bills – Medicare – they are patients. And my professional association, the APS, is busily propelling itself into the medical arena on the foundation of “evidence-based” care. Now a mantra, evidence-based care is a professional aspiration turned into a quality compliance mechanism linked directly to funding. It has been growing among medicos for 20-30 years, depending on your reading of its history .

A Medical Deviation

From patient perspectives, there is questionable reduction in cost or increase in effectiveness of health care delivery from that history. This is partly because, in some domains of practice, the patients don’t care what evidence says, they just want a pill (e.g. - antibiotics for viral events; anti-depressants for life-constraining social or physical events, and so on). This is a public consciousness residual, sustained to this day by the big pharmas, of the early revolutionary successes of the antibiotics (penicillin and co’y.) and antipsychotics (lithium to Prozac). If you catch it, you can pill it.

And, in other respects, health is a political matter, not merely a scientific one. So evidence-based practice can’t control consumption rates and types – e.g. there are over-priced and over-consumed treatments which have marginal rates of return in wellness. It’s increasingly argued that shifting medical focus to prevention is the only serious hope for increased wellness. Seriously doing this would uproot the health economy as we know it – which, like other parts of the economy, are geared to growth through innovation and profitability, and tend to resist change. In particular they tend to resist investments in public goods which cannot be individualised (and then amortized).

The medical model of services provides the accounting underpinnings of hospital and medical practice funding – the item numbers we psychologists use on our Medicare referred invoice. Item based funding and service payment to professionals tends to encourage focus only on the diagnosed and diagnosable problems which fit the remuneration system. This also encourages speedy throughputs.

Part of this movement towards consumerist language and constructs has occurred in tandem with the greater economic culture’s focus on service effectiveness for customers (mainly understood as consumers) and service efficiency for corporate stakeholders (narrowly construed as shareholders). This is a combination which can provide a rationale for almost any ‘management’ undertaking you can imagine. If everyone is a customer (or, more basically, a consumer) then there is no question except what “value-for-money” can be achieved in the eyes of the customers. the behavioural / emotional markers of which are determined by focus groups (establishing the mind of the consumer) and comparative dollars establishing the measure of service ‘outcomes’. Some struggle against this current occurs at global (corporate social responsibility, sustainability protocols) and local levels (neighbourhood climate groups, social enterprises, etc.).

Back to therapy

If psychology clients are really patients, it cannot be long before the design and delivery of therapeutic action is wholly medicalised, more like treatment for a cut or break than a long-term sadness, anger or anxiety. Such feelings are the underlying evidences and sources of most normal psychological problems which appear almost always in long-term human relationships. That is, they are developed in, and sustained by, relationship systems like families, work groups and affinity groups.

The increasing specialisation in psychology spreads hand in hand with service dis-integration. That is, each piece of a treatment process is analysed into measureable segments that also fit within normal therapeutic requirements. Service specialisation (which also derives from knowledge specialisation in the endless pursuit of ‘solutions’ to main morbidity effects, medical or psychological) in turn drives licensing specialisation and the concomitant professional training silos.

So what?

So, what am I arguing here? Just what I said at the start – the boundaries between life roles are too thin and the weight of incentives is in the direction of collapsing their differences into unified sameness – in this case, consumption. This way of arguing is unlikely to be very persuasive to anyone. I can only hope that I get better at grounding the argument as I inevitably will be singing this plaint elsewhere in my mad man travels. If you know interesting examples, please share.

Some channels to reconnect these key role terms with the world of experience and need might be:
1- Establish the appropriateness of a role term by applying the backward fit test; so, if your clients can also be patients, try out whether the patients can also be clients; similarly, if your patients can be customers, can all customers be patients in all their life activities; and, thirdly, can anyone consume everything in their life that they need? Can all those needs be handled with instruments (forks, knives, spoons, etc.)?
2- Notice the emergence of new role names into public space. ‘Carer’ comes to mind. This is a role with a history of millennia, extending into the non-human genera and acknowledged as such by our use of the term for cat, dog, roo, spider, fish behaviour, but not plants or rocks. Caring has been transformed from a normal role in the household economy to an accountable role in the consumer economy, driven by the latter’s penetration of every cranny of life.
3- Engage others with you in the small scale drawing of important boundaries around our professional domains and relationships. For example, honour the role meanings of client or patient, or student or citizen…and what is expected of them and what they should expect of us in the caring, teaching, helping roles.