Abstract
Many of us, particularly those who work in the public sector, have become perturbed in recent years by the manner in which terms derived from the commercial sector and its closely allied field of management have found their way into the everyday speech of clinicians in the field of psychiatry. We can date the context of such changes to the last 15 years or so during which the effects of economic rationalist policies on the government sector have been acutely experienced. Since, our ‘service delivery’ has to conform to ‘world's best practice’ and must ‘value-add’ according to the ‘goals’ set by our ‘key performance indicators’, or at least be in that ‘ball park’. We must be ‘committed’ to ‘roll-out’ the ‘raft’ of ‘innovative strategies’ that ‘unpack’ our ‘mission statements’ while keeping our eye on the ‘bottom line’. To achieve this, of course, we must ‘performance manage’ our staff, thus ‘enhancing’ our ‘continuous quality improvement’ and hence ‘embedding’ these ‘agreed outcomes’ into our practice.
In one sense, we should not be surprised that this type of jargon and its associated modes of thinking have permeated the clinical field, given that this same tendency has spread through our culture generally. It is this very process that is denounced by Don Watson 1 in his book Weasel Words:
“… the real disease is in the system: in the new models of business organisation, in the triumph of economics. It is there in the cant of competitive advantage and human resources management, transparency, accountability: in the clichés, consumer, client, key, core, going forwards, at the end of the day, outcomes-based. It is there in the pompous lunacy of management jargon which reaches from the world's biggest corporations and government agencies … to primary schools where children now use PowerPoint in English presentations and are taught to call the conclusions of their history essays product.” (p. 3) 1
Clearly, one could easily compile a lexicon of such corporate language used in the clinical field. However, the particular terms I will address here are those of ‘consumer’ and ‘service provider’, firstly since they are archetypal in the commercialization of the clinical space, but secondly in so far as they effectively redefine the players in the therapeutic relationship and therefore provoke a mutation in the relationship that is at the very heart of our clinical practice.
I want to make it clear that in speaking of the ‘consumer’, we need to differentiate the consumer movement from the politics and economics of ‘consumerism’. What I am referring to in this paper is, on the one hand, the way in which government agencies and those who fund our services impose certain modalities of speech and language through documents and policies, and, on the other hand, the manner in which those within our services take these up, whether wittingly or not.
The debate around the term ‘consumer’ is as fierce as it is complex, including within the consumer movement itself. However, we could propose that the semantic scope of the term consumer has been altered by political and economic forces. From describing those using services and the consumer movement in the 1970s, with the advent of neo-liberalism it has come to encompass the market-place notion of the consumer as an economic unit whose choices are determined by cost (p. 40). 2 Moreover, the particular way in which this term is utilized is determined by whoever is using it at the time. Thus, it has a different ring when it comes from a patient than from a representative of the Health Ministry or other funding agency. Furthermore, if in the consumer movement it can be said that “being defined by others is exactly what this movement is NOT about”, 3 it might be equally true that as psychiatrists we cannot allow the nature of our work to be determined by a semantic slippage.
Given the degree of penetration of these terms within our clinical services, as well as what I will elaborate upon regarding the effects of this economic discourse upon our clinical practice, it is surprising that there has been little discussion of this in the psychiatric literature, notwithstanding my own modest attempts.4–6 We could hypothesize that this silence is testimony to the success and insidiousness of this process whereby our thinking has been altered in a manner in which we are not even aware of the changes, let alone dare to protest. We might be able to laugh at the ludicrousness of some of the terminology that we use. Nonetheless, to attempt a serious critique of this process is far more difficult so ingrained have many of these modes of thinking and practice become.
It is disturbing, then, that critiques of such changes need to come from outside our field, again from Don Watson:
“Economic revolution has transformed our institutions – colleges and universities, hospitals and medical practices, the public service itself – and transformed our relationships with them in doing so.” (p. 28) 1
And we even have a critique from an economist and political scientist. In discussing the changes wrought by economic rationalism upon our society, Lindy Edwards describes the manner in which economic interests cut across the traditional forms of social relationships:
“The push to user pays and an emphasis on ‘clients’ is also at risk of sterilising important social relationships. Whether people are seeking help in the welfare, health or education sectors, they have become customers and clients rather than patients, students and people in need. The market-based reforms have replaced relationships bound by trust, loyalty and reciprocity with ‘client service’. Our innate obligations to our fellow human beings have been usurped by commercial obligations.” (p. 132) 2
It is paradoxical that private psychiatry, where the user does pay, has been relatively spared from the spread of this mode of thinking. Ironically, it is our free public psychiatry services that have been most subject to the intrusion of economic discourse permeating from government bureaucracy and the political pressures upon it.
Edwards proposes in the citation above that what is at stake is not just a question of words or terminology: these terms convey a change in the relationships involved. As Lakoff says in regard to similar changes in the political field: “the words draw you into their worldview” (p. 4). 7
Let us endeavour, then, to discern some of the ways in which the language and thinking of economics have instilled themselves into our profession. It is only in this manner that we can reclaim the relationship with our patients for the clinical practice of psychiatry. After all, as Lakoff states, “thinking differently requires speaking differently” (p. xv). 7
PATIENT AND CONSUMER
If we take the official terminology to the letter, there are no more patients. For that matter there are no more psychiatrists either, or any other caring professions. There remain only ‘service consumers’ and ‘service providers’. And if the psychiatrist is now a service provider and the patient a consumer then each of them is defined in regard to a relation of supply and demand. That is, each is reduced to being an individual economic unit.
What I am proposing here is that these re-nominations erode the symbolic value of the terms used. After all, the word ‘patient’ comes from the Latin patiens, the present participle of the verb patior which means ‘to suffer or endure’. We can say that it is the suffering of our patients that leads them to consult us in the first place. So the first effect of the re-naming of our patients is to eliminate the dimension of our patients’ suffering. This suffering is no doubt an embarrassing phenomenon in any economic exchange.
The erosion of these traditional terms that define the places of the partners in the clinical encounter is co-extensive with government policies, effected over the same time period, of realizing the financial value of public buildings. Such public goods, previously built to promote the symbolic value of the institutions they represent and often of significant heritage value, have been liquidated into their purely functional value, calculated in dollars. Hence the old post office has become a jazz club, the imposing bank building has become private consulting rooms for psychiatrists and the beautiful old asylum and its grounds on the hill has become a stylish apartment complex with ‘fantastic city views’ (p. 164). 4
Perhaps more disturbing is the fact that this new terminology of ‘consumer’, ‘provider’ and ‘service delivery’, etc., is taken up by clinical staff with an astonishing avidity. It has even become for some a stylish way of speaking, not to mention one which might hasten their ascension into the ranks of management. We need to pose the question of which master we are serving by the use of these terms.
It has also been proposed that the manner in which we perceive our patients has been altered by market forces that influence not only the diagnoses that we are inclined to make, but also the diagnostic code itself. Jureidini and McHenry, for instance, note that:
“The imperatives of marketing have overruled scientific authority. In addition it has been questioned whether the very notion of paediatric bipolar disorder is an industry creation aided by corporate psychiatry.” (p. 200) 8
Both Watson 1 and Edwards 2 propose that important social relations, including the therapeutic relationship, are being altered by an intrusion of the economic discourse upon our social ties. The French philosopher Dany-Robert Dufour in his recent work, The Divine Market, 9 goes a step further. He puts forward that this process is radically re-shaping our subjectivity with consequent effects upon our very modes of suffering, including the types of psychiatric presentations to which we are witness. According to Dufour, the liberal democracies in which we live, and their recent re-invigoration with the doctrine of neo-liberalism, convert us into postmodern herds of consumers, who faithfully consume as we are expected to do, with each of us believing him or herself to be “free, liberated and liberal” (p. 18). 9
Dufour cites the classical economist Adam Smith who tells us that we owe our dinner, not to the benevolence of the butcher, the brewer and the baker, but rather to their ‘self-love’. Such egoism, promoted by advertising on the television, the so-called ‘third parent’ of our children, is co-extensive with a ‘deinstitutionalization of the family’ (p. 39). 9 Rather than being the individualistic society that we believe ourselves to be, we find ourselves “transformed into large virtual herds of consumers” (p. 58). And, according to Dufour, 9 we consequently suffer from: “… new forms of alienation and disorders … and different forms of neurosis; these must be considered as generating new forms of uncertain (post-neurotic) subjection tied to the generalisation of life in an ego-gregarious herd” (p. 59, my translation).
Such disorders are elaborated by psychologist and psychoanalyst Paul Verhaeghe. 10 He notes that contemporary social discourse, under the banner of the ‘because you deserve it’ of television advertising, promotes the idea that everyone should receive everything without any personal effort. The guilt with which our patients previously presented has become blame of the other and a lack of personal responsibility. In part, the clinical consequence of this discourse, according to Verhaeghe, is that the manner in which our patients present has altered over time:
“Indeed, instead of phobias, we meet with panic disorders. Instead of conversion symptoms, we find somatisation disorder. Instead of hysterical nausea, there are eating disorders. With some exaggeration, it can be said that yesterday's docile psychoneurotic patient who dreamt of forbidden sexual activities resulting in massive feelings of guilt that lead to phobic and obsessional symptoms, that this patient has almost disappeared. Instead of that, we are confronted with the promiscuous, aggressive borderline patient who combines eating disorders with addictions and self-mutilation. More often than not, he or she claims our help while at the same time refusing it.” (pp. 7–8) 10
We can all recognize the types of presentations that Verhaeghe is describing. The clinical effects of the transformation of our society has been dubbed by psychiatrist and psychoanalyst Charles Melman, surely not without some irony, The New Psychical Economy. 11 If we give some credence to the social transformations described by these authors and to which we are all witness, then we might have to recognize that the conversion of our patients into ‘consumers’ might not be without a cost.
CONSUMER SURVEYS
A study published in this journal attempted to resolve the question of what to call our patients by conducting a survey of mental health recipients. 12 The results indicated that 34% of respondents preferred the term ‘client’, 28% ‘consumer’ and 23% preferring ‘patient’. Similar results were found in a study in the United States. 13 Other studies, of course, show different results, with Wing 14 finding that 74 out of 101 medical patients surveyed preferred the term ‘patient’ over ‘client’. An Australian survey of various healthcare recipients indicated that 85% of women surveyed and 83% of men preferred the term ‘patient’. 15 A number of respondents rejected terms that sounded “too commercialised”. “It's not a business”, commented one respondent.
In Canada, Deber and colleagues 16 conducted a study of people receiving health care in order to determine by which terms these service users preferred to be called. The term that was discovered to be most acceptable was that of ‘patient’, over others including ‘client’, ‘customer’ and ‘consumer’. The authors noted that their results suggested that “the individuals we surveyed still place high value on a relationship with their providers that is based on a model other than that between buyer and seller. It seems to be captured by the term ‘patient’” (p. 350). 16
But when did the survey become a methodology of choice in psychiatry? Here we must distinguish the survey as a marketing tool which elicits opinions regarding services or products, from the important task of the collection of epidemiological data.
In an editorial in Hospital and Community Psychiatry, 17 Richard Elliot, criticizing the “dictates of political correctness in public psychiatry”, argues that:
“… a shift from a doctor–patient relationship to a provider–consumer or vendor–consumer relationship involves a shift from a high level of trust and responsibility to more limited concerns. The use of “consumer” implies that professionals are mere vendors and trivializes the fiduciary responsibility of physicians.” (p. 5) 17
Similarly, the question I am posing here is: in what manner is the place of the patient construed by those who fund our services? Additionally we may ask: what place do we as clinicians construe for our patients in calling them consumers? These questions cannot be resolved by surveying our patients as to what they would like to be called. In attempting to do this, we perhaps shift our responsibility onto our patients to determine the nature and quality of our work. In any case, our patients are at least as vulnerable as we are ourselves to the influence of the prevailing economic discourse.
We discussed above the proposition that one effect of the liberal economy was to convert us into consumers in a manner that changes our very subjectivity. 9 Melman examines some of the consequences that follow from this in his work The Weightless Man. 18 One of these is the contemporary propensity in our society, and in our clinical services, for surveys:
“There results from this a subject who is eminently manipulable and manipulated. He is even placed theoretically at the centre of the system, as if he were the decider. It is said that it would be his options, his behaviours, in particular as a consumer, which would decide the organisation of his world. This is what justifies him being incessantly surveyed. But his responses to the surveys are nothing other than what he was inculcated with the day before.” (p. 157, my translation)
Now when I go to the bank, after my transaction I am prompted by the teller: “I hope I gave you 10 out of 10 service today”. I am then told that I might receive a call from a contracted market survey representative. Clearly, the consumer survey is anticipated by the score that I am encouraged to give the teller.
While consumer satisfaction may be one factor to be taken into account in directing a clinical service, its predominance and imposition by funding bodies surely promotes a different relationship of the patient to the service, and indeed to the psychiatrist, one which risks by-passing the critical dimension of the suffering of the patiens.
THE LANGUAGE OF CONSUMERISM
Words are thus the means by which a change in mentality and a change in the modalities of social relations are effected. In utilizing the terms ‘consumer’, ‘service provider’ and so on, whether we like it or not, whether we are aware of it or not, we take up a different social contract or rather a commercial contract based upon the principles of economics. By taking up the words and expressions promoted by multinationals and in politics, we hand over to them the power to redefine what we do. As Don Watson says: “The more we listen to the public language of our times, the more we are driven to believe that it has been gutted for the specific purpose of denying us that agency, denying consequences, denying control over a living thing. We are left with the system, the shell…” (p. 5) 1
So then to speak such language is to submit to the implicit tenets of the imposed terms: “To speak the words the powerful speak is to obey them, or at least give up all outward signs of freedom” (p. 2). 1
Such effects are not lost on participants of the consumer movement. Take, for instance, the following comments from Merinda Epstein, a prominent local consumer activist:
“Whenever we speak or write we are in fact translating or interpreting the world we live in and our relationships to that world … The ways that words are used do have significant material effects on the lives of human beings: for example in perpetuating powerful myths, stereotypes, and dominant social perceptions … in our very human need to create meaning and impose order amidst the chaos we all insist on believing that some language at least is value neutral: for example the languages of justice, science, economics or perhaps just ‘our own languages’. In fact, all languages, including the language of ‘best intentions’, are not only value laden but value dependent.” 19
In this paper, we have begun to discern some of the ways in which the language and thinking of economics and management have instilled themselves into our profession. In a second article, 20 we will take up this theme once again by examining the origin and prevalence of the term ‘excellence’ in both commercial and clinical services and the corresponding preoccupation with ‘strategies’ and ‘outcomes’. In a third paper, we will conclude by examining the context of these phenomena in the ascendency of economic rationalist policies and associated changes to our society and attempt to discern some effects of these upon our clinical practice of psychiatry.
DISCLOSURE
The author reports no conflict of interest. The author alone is responsible for the content and writing of the paper.