A topic of certain difference, and at times discussion in the field of psychotherapy, is whether we refer to those we treat as ‘clients’ or ‘patients’.
Why might this matter?
On the face of it, it should arguably matter little to someone attending psychotherapy, as to what the therapist calls them on paper; in the room they will be referred to by name and thus, to some extent, the nomenclature used is academic.
However, psychotherapy is about how the psychotherapist thinks about the person who engages their services and this thinking will inevitably influence how the psychotherapist refers to those who come to see them and vice versa.
Why such different terms?
Psychotherapy was born out of psycho-analysis. And in both classical and modern psychoanalysis, as well as in the language of many psychoanalytical psychotherapists, the term patient is commonly used.
Historically, this is derived from Freud’s use of the term, whereby he situated psycho-analysis firmly in the medical field.
There is an additional term that is used in analysis which is ‘analysand’ – the person who goes for analysis. Whilst it bridges the gap between client and patient, I find it somewhat clunky and it is not a valid term to use in psychotherapy.
Who is the expert?
Much progress has been made in the field of psychotherapy to shift from a ‘blank-screen’ model on the part of the psychotherapist, to a relational approach – meaning broadly that the psychotherapist plays an active role in co-constructing the relationship and works within the context of the relationship to bring about change.
Many in the more humanistic field argue that one of the goals should be to bring about as much equality between the therapists and ‘client’, so as to eliminate the power imbalance.
Whilst a noble endeavour, I think this is naïve, as firstly, we are are there in an expert capacity and those of us who are trained and work at depth, understand that we carry an enormous burden of responsibility to those who engage our services. We are therefore, not equals.
Secondly, depth psychotherapy, using a psychoanalytic model, works with what the client or patient ‘projects’ onto us – something we refer to as transference. In the transference, we inevitably represent one of the parents for the client and it is arguable that the treatment process in psychotherapy is one of re-parenting.
Parents and children are never equal
I believe that roles come with firm boundaries – many of which are frustrating. For example, it is a parent’s role to always be a parent to their child. This role will evolve and change over time and eventually there will be two adults in the relationship, however, this does not imply that there are two equals. Part of the frustration of being a parent (and the child of a parent) is in acknowledging the firm boundary, meaning that a parent should not become a friend to their child, no mater the age of that child. This does not mean that this does not happen in some families, however, I view this as unhelpful.
The therapeutic relationship between a psychotherapist and their client or patient is sacrosanct – as should be the relationship between parent and child. We are there in an important, and at times, critical capacity and co-create with those who come to see us a deep intimate relationship that must be alive, messy, creative, conflictual, loving and hateful – but always and forever boundaried.
Boundaries frustrate but facilitate grieving
Over the past decade of being a UKCP registered psychotherapist, I have seen a fair few people come and go from my practice. Most have stayed for years and, I believe, done some very good and important work.
As in life, the relationships we form with those whom we see week after week matter to us and I have grieved with the end of the work and having to say ‘good-bye’ when treatment ended.
The grieving is necessary as, irrespective of how much we have come to matter to each other, I shall always be in the role of psychotherapist for all of my former patients. Most will never cross my threshold again, however, it is vital that they can hold me in mind in the role they assigned me and that I don’t deviate from that position and ‘befriend’ them. Whilst this may feel seductive to both sides (as it does for a parent and child), the boundary enables the relationship to work and continue working in the capacity it must for the patient.
On why I use the term ‘patient’
I have shown my hand in the previous paragraphs in using the nomenclature of ‘patient’ and shall now explain why I have, over time, shifted in my way of thinking.
Patients come to me because they are in distress. I am there as an expert, not to tell them how to live their lives, but to help them understand how and why they live their lives they way they do and offer them a stable and secure relationship through which to bring about change.
Psychotherapy is about change – it is not about enabling existing behaviour and this needs to be agreed between therapist and patient.
I view the term ‘client’ as representing a grey area when it comes to boundaries – with clients we can ‘have a chat’ and maybe take the relationship outside of the context in which it began. It also seems to me to be very transactional. This is a personal view and not an accusation of anyone who has a preference for this term.
My work as a psychotherapist is to ‘treat’ my patients. I am accountable for understanding their minds and helping them find a way through their distress. If they knew how to do this, they would not need me.
Lastly, rather than being a distancing term, I view ‘patient’ in this context of one towards which I can show the upmost respect. It does not imply, to me, that I am better than them, but it does show that I am willing to take on the responsibility for my part in their treatment and that the boundary will always hold. For me it is ultimately a term of ‘love’, in the way Freud meant it.
Mark Vahrmeyer, UKCP Registered, BHP Co-founder is an integrative psychotherapist with a wide range of clinical experience from both the public and private sectors. He currently sees both individuals and couples, primarily for ongoing psychotherapy. Mark is available at the Lewes and Brighton & Hove Practices.
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Jay Beichman says
Whilst some contemporary psychotherapy has been born out of psychoanalysis there are many other kinds of psychotherapies: humanistic, existential and transpersonal for starters.
Carl Rogers did not deny the existence of transference and countertransference and the implications around power of transference and countertransference. He did not believe that an I-Thou relationship was a given but more of an ideal towards which a necessarily transferential relationship might travel. Thinking that remaining stuck in the transferential relationship as an ideal might similarly be seen as naive from a therapeutic (i.e. healing) point of view.
I understand the preference for the term ‘patient’ from the psychoanalytical history. Unfortunately it also reinforces therapy as a medical procedure which, in my view, it definitively is not. I don’t know if I like the term ‘client’ either. I like working with people but I suppose that is not a good enough professional term.
Brighton and Hove Psychotherapy says
Thanks for your thoughtful comments. I largely agree with you. I have not specifically referenced Carl Rogers and in the same way psychoanalytic psychotherapy and analysis has developed since the days of Freud, so has the world of humanistic psychotherapy, including person-centred. I would suggest that the analytical position is to not try and remain stuck in a transferential relationship – that would be a very outdated perspective. A good psychoanalytical psychotherapist moves between transference and the here-and-now work.
If you come up with a better term than client or patient please let me know as I would be happy to adopt it but for the foreseeable I see patient as more respectful and boundaried.