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Patient, Client, Consumer

Natalia J. Garland

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Lately I have noticed a new trend in how salespeople greet me in the stores. That is, if they greet me at all. They say, as they continue walking by me, "How are you today?" Before I have time to respond, "Fine, thank you," they have already passed by me. Then, before I can finish the niceties with, "And how are you," they are out of hearing range. When I check out with my purchases, the cashier says, without making eye contact, "Did you find everything you need today?"

There was a time when salespeople would ask, "May I help you?" In clothing stores there were employees who would assist customers with finding sizes, colors and styles. They would carry your items to the dressing room for you, and then stand by to offer further help. They were knowledgeable about fit, and would give you an honest opinion on whether that new dress really draped right.

Why has the language changed? It seems to me that salespeople are being trained differently because employers have hired them mainly to stock shelves rather than to assist customers. In many stores it is very difficult to find a salesperson. Whether in a department store or a bookstore, I have to go and look for someone if I need assistance. Salespeople no longer walk the floors, tending to the customers in their section (somewhat like waitresses still do in restaurants). Whenever I locate a salesperson, it means interrupting stock work or taking a cashier away from the register.

Here is another language change that I have noticed: pre-owned vehicles. I no longer see any used car lots. Is this linguistically deceptive? Or is this just an attempt to give used cars a little more dignity? Taken literally, it does not make sense. What is a pre-owned vehicle? Is it a car that was previously owned but never driven? That is absurd. A pre-owned vehicle is, of course, a used car. Everybody knows that. If a car has 120,000 miles on it, it doesn't matter what you call it--it's been driven. The reality has not changed.

The above are two different examples of current changes in our everyday jargon. The example of salesperson language reflects a change in the reality of the work which, in turn, affects the quality of the customer relationship. The example of pre-owned cars reflects a cosmetic cover which anybody can see through.

What about some of the language changes that have taken place in social work? If an individual is seeking professional help, are they a patient, a client, or a consumer? In terms of clinical social work, the words patient and client can probably be used interchangeably. Patient seems to mean that the person is sick and in need of care. Some people object to this medical model. Some professionals who emphasize a strengths-based or empowerment approach to the practice of social work prefer the terms client or consumer. A client, however, could be someone who seeks any kind of professional services from psychotherapy to interior decorating. A consumer could be someone who goes shopping and purchases a product.

We need to keep in mind, however, that there is nothing wrong with being sick. People are not morally defective if they need care. Allowing oneself to be a patient and to receive care could be liberating for some people. Perhaps social workers need to be cautious about not reinforcing the stigma of getting help for emotional problems. Dropping the word patient from our vocabulary might in itself reinforce a sense wrongness about having emotional disturbances or other challenging issues.

Although I did some research, I could not find exactly who was the first to borrow the term consumer for use in social work. Most of us would probably agree that we live in a consumer society. Perhaps the realities of managed care (note that even the insurance providers continue to use the word care) and the increased instances of malpractice suits has prompted even some clients to think of themselves as consumers of a service. The word consumer is more empowering and could be felt as more equalizing. It means that individuals can make informed choices regarding therapies and therapists, and take legal action if harmed.

Let's discuss one more language change before closing today's essay. For those of you who conduct group therapy sessions, do you have some individuals (or colleagues) who refer to group therapy as a class? Even if you conduct psycho-educational groups, there is still a difference between a group situation and a traditional classroom. If individuals who seek help refer to group as a class, then this means that they are students and that you are a teacher. The issue of patient/client/consumer has been completely eliminated. And, you have lost your job as a social worker and you are now, presto, a schoolteacher.

The reason that I have language on my mind today is that I wonder how all this affects our concept of relationship. If an individual is a consumer, are we engaged in a business transaction rather than a therapeutic relationship? Has the reality of the profession changed, such as seems to be true with salespeople? Or does it remained unchanged, as is true with pre-owned vehicles? If an individual refers to group as a class, is that individual in denial? If a social worker passively accepts the role of teacher, is there a shift in professional identity?

How precise do we need to be regarding our use and the public's use of professional terminology? The individuals who come to us for help are possibly all three: patient, client, and consumer. They are patients or clients in their need for care from a qualified professional and in their willingness to participate in their own growth. They must also be smart consumers who have the wherewithall to walk away from a therapist with whom they are dissatisfied and to take legal action if appropriate.

Those who refer to group as a class should probably be evaluated on an individual basis. Their language could indicate the presence of defense mechanisms which need to be addressed in therapy. Or, it could simply indicate ignorance or confusion. (If you work in a facility where various levels of services are offered such as community education classes, psycho-educational groups, and psychotherapy groups, then it is necessary to clearly distinguish one from the other.)

It reminds me of a time when I was doing a home improvement project. I went to the hardware store and asked for a bag of cement mix. The salesman corrected me and told me that it is called concrete mix. Cement, he explained, is an ingredient in concrete. On the one hand, I appreciated the information and I have never made that mistake again. On the other hand, I thought he seemed a little arrogant. He knew what I meant, and he could have sold me the concrete mix without correcting me. Either way, it would have had no impact on my ability to complete my home improvement project.

Although accurate language is essential to communication, I suppose it is possible to get too picky. As professional caretakers we need to be secure in our identity and make sure we understand the scope of our work. If someone makes an innocent error in their use of professional language, we cannot take it personally. If there are deeper emotional issues involved, or if there are political ramifications, then we must respond in a way that promotes the wellbeing of those in our care and the purpose of the profession. (Written 03/07/05 - Revised 08/01/06: bibliography available.)


I'm still not certain who was the first to refer to patients/clients as consumers in the practice of social work, but the theoretical concept of consumerism possibly developed after the passage of the Rehabilitation Act of 1973 and was related to the treatment of people with disabilities. For more information, see "Evolution of Consumerism in Rehabilitation Counseling: A Theoretical Perspective," by Donna R. Rhoades, published in the Journal of Rehabilitation, April-June 1995.

The following might be among the earliest instances of the use of consumerism in social work. Robert Perlman wrote Consumers and Social Services in 1975. Burton Gummer wrote "Consumerism and Clients' Rights" which was published in Handbook of Clinical Social Work in 1983. There are undoubtedly other instances: it is just a matter of having access to old social work textbooks and scouring the bibliographies to find them.

The following two paragraphs are quoted from "Down and Out in America," an article by Liza Featherstone which was published in The Nation, in the December 18, 2004 issue.

The invention of the "consumer" identity has been an important part of a long process of eroding workers' power, and it's one reason working people now have so little power against business. According to the social historian Stuart Ewen, in the early years of mass production, the late nineteenth and early twentieth centuries, modernizing capitalism sought to turn people who thought of themselves primarily as "workers" into "consumers." Business elites wanted people to dream not of satisfactory work and egalitarian societies--as many did at that time--but of the beautiful things they could buy with their paychecks.

Business was quite successful in this project, which influenced much early advertising and continued throughout the twentieth century. In addition to replacing the "worker," the "consumer" has also effectively replaced the citizen. That's why, when most Americans hear about the Wal-Mart's worker-rights abuses, their first reaction is to feel guilty about shopping at the store. A tiny minority will respond by shopping elsewhere--and only a handful will take any further action. A worker might call her union and organize a picket. A citizen might write to her congressman or local newspaper, or galvanize her church and knitting circle to visit local management. A consumer makes an isolated, politically slight decision: to shop or not to shop. Most of the time, Wal-Mart has her exactly where it wants her, because the intelligent choice for anyone thinking like as a consumer is not to make a political statement but to seek the best bargain and the greatest convenience.
[End of quote.]

If the business-tactic outcomes of consumerism are given credibility, then social workers might be wise to reconsider their purposes for having adopted this term. Is the profession empowering people, or possibly eroding the concepts of and the power of people for self-awareness or problem-solving? Are clients being stripped of their capacity for introspection, insight, reasoning, and relationship? Should a person have a right to be a therapy patient and to choose, as a consumer, to seek help from a professional expert? In the attempt to find a positive alternative to the medical model, perhaps some practitioners have turned to a business model which also may prove to be inadequate and corruptible. (Written 08/29/08)

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Copyright 2005, 2006, 2008 Natalia J. Garland