The Words Shrink and Client
-- Updated October 7, 2007 --

What About the Word "Shrink"?

    Originally, the word "shrink" referred primarily to psychiatrists, but over the last 20 years its meaning has broadened and now it can be used with respect to just about any professional who does counseling or psychotherapy.

    "Shrink" likely originated from a commingling of the two words "head shrink" and the single word "headshrinker," indicating that it likely originated as a disparaging reference comparing the process of psychotherapy to primitive tribal practices of shrinking the heads of enemies. Reportedly, "shrink" was first used in literature by Thomas Pynchon in his book The Crying of Lot 49 published in 1966. It figures that "shrink" had its literary birth out of the consciousness-expanding atmosphere of the 1960s.

    "Shrink" has paradoxical meanings and uses and, by all analytical standards, has classic potential for connoting ambivalence (a favorite shrink word!). "Shrink" allows us to compare psychotherapy to primitive rituals, shamanism, and "sorcery" while still recognizing the more modern and scientific principles of mental wellness. "Shrink" attempts to create a balance between respect and irreverence, between affection and distancing -- can't live with 'em, can't live without 'em.

    To me, that is the essence of a good word -- one that has many flavors. What sweet and sour are for taste buds, paradoxes are for the mind.

    I invite you to think of "shrink" as an appropriate, minor term of endearment -- a way of saying "psychiatrist" without creating that feeling that you are just being examined and not appreciated. After all, "psychiatrist" is not only a "big" word, but also a word that has potential for connoting a profession, which is mostly scientific and not very related to the humanities. As much as we psychiatrists would like to believe that psychiatry is mostly a science, by definition, since psychiatry deals with the mind at least as much as the brain, it has very little hope of being as scientific as, let's say, microbiology.

Wait, There's More!

    The term "shrink" really does have its fair share of different belief systems. A posted e-mail follow-up at www.psychiatry.com (no longer available) suggested that the term simply refers to the idea that psychiatrists have the ability to reduce or "shrink" one's mind into an understandable concept. Therefore, they are shrinks.

    Check the discussion at Google.com that uses this page as a reference for understanding the word "shrink." It appears that someone may have earned $5.00 from the answer that was given. Congratulations! And may the shrink-force be with you!

What About That "Ultimate" Shrink, Freud (and Others)?

    Please go to our All About Freud (and Others) Web page to get historical information and links about significant people in the world of psychology and psychiatry.

I Know What You are Thinking...   What About the Word "Patient"?

      Prior to the mid-1960s, the word "patient" was not under any major cloud of suspicion. A huge majority of those who consulted therapists or doctors in those days never gave a second thought to being thought of as a "patient." However, the times have been "a-changing," and the word patient is now kind of blowing in the wind in an uncertain dance with our psyches and our culture.

      Some of us find no problem with being identified as a patient, while others of us find it demeaning or not particularly relevant to what is actually going on with us. Some conspiracy theorists might view the word patient as a plot to keep consumers under the medical industry's thumb.

      Please note, this discussion and the ideas offered here have absolutely nothing to do with political correctness. "Political correctness" is governed by concepts associated with discrimination, prejudice and the use or non-use of derogatory terms. This discussion is more about the impact of words on how we think and behave. Words are powerful. If you don't think so, talk to your favorite mega-millions advertising agency. They know all about the power of words.

    The British Journal of Medicine 1999 Discussion of "Patient"

      The most easily found discussion of the word patient on the Internet is found at the British Journal of Medicine (BMJ) Web site -- Do we need a new word for patients? That discussion points out that the word patient comes from the Latin "patiens," which comes from "patior" which means "to suffer or bear." With that kind of history, the word patient tends to bring up thoughts and images of quiet suffering, passivity, and an inclination to listen and to obey and not to question or take part in thinking or decision making.

      The words "active patient" would be viewed as a contradiction in terms. In other words, patient is patient is patient and you cannot just try to assign some new meaning to the word. Or, if you wish to redefine the meaning, you would have to do battle with the extremely formidable history of the word. Although "patient" has taken on some more positive nuances in this age of consumer activism, it still carries significant emotional baggage and power to shape our interactions with those we consult.

      As Julia Neuberger points out for the British, "the strongest argument against the use of patient to describe a user of health services is that word indicates immediately the unequal nature of the relationship. The professional knows what to do, and the recipient does as instructed."

      That hierarchical structure to medical services has worked fairly well for many years, but as we have come to learn, health care and especially "wellness" is more about recipients taking an active part in their own health destiny and more responsibility for some of their own recovery. The word patient just does not properly describe the many encounters between professionals and consumers which are frequently more about making choices about lifestyles or getting advice on health matters. Such a relationship is very different from the kind of scenario we often think of when it comes to illness -- you know, a disease striking an innocent victim.

      Neuberger sums it up for the British by noting that "suffering is no longer thought of as ennobling." "That romantic and often Christian view of the ennoblement of the spirit through suffering has been overtaken by a view that suffering is unnecessary and, indeed, often bad for you."

      Neuberger, who is a patient's rights activist, does not win over any of the readers who responded to the British Journal of Medicine article. The rapid responses posted at the BMJ Web site run the whole gamut from outraged doctors to responses from non-professionals who feel that "patient" is bad, but "consumer" and "customer" are far worse.

      One of the best responses to Neuberger's article was a reader who noted that the word patient is only relevant if there is a doctor. You cannot really be a patient without a doctor. Patients do not exist, so to speak, unless they have checked into a medical treatment institution or are in the presence of and have chosen to consult with a doctor for the purpose of getting health care assistance.

    If Not "Patient," Then What?

      Neuberger laments that the words "user," "consumer," and "client" all have major drawbacks. User and consumer tend to still elicit an image of passivity, not unlike the word patient. So, what about "client"? Many doctors feel that it is too close to a word that is used most commonly in the practice of law.

    What About the Word "Client"?

      The medical community appears to want to keep a clear-cut, separate identity from other professions. However, the same identity concern does not necessarily apply to counseling professions, of which psychiatry is one. We might think that counseling professionals would lean towards using the term client more than the term patient, but so far, I have not been able to confirm it.

      I searched the words "patient" and "client" at the Web sites of the American Psychological Association and the American Psychiatric Association. Unfortunately, the search engine at the Psychiatric Association Web site is so simplified that I could not get numerical results. Most of the documents found related to the word "Oracle" which would indicate that the word client at their site was used primarily with regard to relational database or networking software. At the Psychological Association Web site, the word client was found in 544 documents and the word patient was found in 998 documents.

    My Conclusion: Client is the Preferred Word (and Mindset)

      To me, client is the most accurate term for a person participating in consultation or treatment. "Customer" implies only buying and selling, not consulting. "Consumer" implies a similar passive status. However, the term client carries practically no disadvantaged connotations or implications.

      When someone thinks of me as a client or calls me a client, I feel empowered. I feel like part of a team. My vote counts. When someone calls me a patient, I feel left out and operated on -- definitely not part of a team or even a significant player in the decision-making process.

    What Would Carl Rogers Say?

      It might be possible to blame this whole discussion on Carl Rogers, Ph.D., the psychologist who believed that the mental condition of virtually all patients, who he referred to as "clients," can be improved, given an appropriate therapeutic environment.

      Carl Rogers felt that the core requirement for an effective learning environment is a close personal relationship between client and therapist. Rogers' use of the term "client" rather than "patient" expressed his rejection of the traditionally authoritarian relationship between therapist and client, and his view of them as equals. The client determines the general direction of therapy, while the therapist seeks to increase the client's insightful self-understanding through clarifying questions and other "non-directive" techniques. The concept of an alliance between client and therapist has similarities to the methods of Carl Jung. Otto Rank (1884-1939) was also an early influence on the development of Rogers' system.

      Carl Rogers' form of therapy was a natural consequence of his belief that a fundamental element of human nature is the drive to fully actualize one's positive potential, a concept based on an essentially positive view of humanity that contrasts with the psychoanalytic view of human beings as driven by antisocial impulses that are suppressed with difficulty and often at great cost. In Rogers' view, the primary task of therapy is to remove the client's obstacles to self-actualization. A further contrast to psychoanalysis lies in the fact that Rogerian therapy emphasizes the current emotions and attitudes of the client rather than early childhood experiences.

      "Rogerian" therapy was widely practiced in the 1950s and 1960s, when its tenets of anti-authoritarianism gave it a wide appeal. Rogers published Client-Centered Therapy: Its Current Practice, Implications, and Theory in 1951 and produced numerous of papers in the decade that followed. In 1956, the American Psychological Association awarded him its Distinguished Scientific Contribution Award. In the 1960s, Rogers was attracted to the human potential movement that had begun in California, and he adopted some of its principles, including its emphasis on frank and open expression of feelings and its use of group therapy.

      On Becoming a Person , published in 1961, became Rogers' most widely read book. In the last ten years of his life, Rogers was deeply interested in educational reform. Borrowing a central principle from his therapeutic method, he proposed that truly effective teachers (like therapists) should serve as facilitators rather than judges or mere conveyors of facts.

      Rogers believed that the most important factor in effective therapy was not the therapist's skill or training, but rather his or her attitude. Three interrelated attitudes on the part of the therapist are central to the success of client-centered therapy: congruence, unconditional positive regard, and empathy.

      Congruence refers to the therapist's openness and genuineness -- the willingness to relate to clients without hiding behind a professional facade. Therapists who function in this way have all their feelings available to them in therapy sessions and may share significant ones with their clients. However, congruence does not mean that therapists disclose their own personal problems to clients in therapy sessions or shift the focus of therapy to themselves in any other way.

      Unconditional positive regard means that the therapist accepts the client totally for who he or she is without evaluating or censoring, and without disapproving of particular feelings, actions, or characteristics. The therapist communicates this attitude to the client by a willingness to listen without interrupting, judging, or giving advice. This creates a non-threatening context in which the client feels free to explore and share painful, hostile, defensive, or abnormal feelings without worrying about personal rejection by the therapist.

      The third necessary component of a therapist's attitude is empathy ("accurate empathetic understanding"). The therapist tries to appreciate the client's situation from the client's point of view, showing an emotional understanding of and sensitivity to the client's feelings throughout the therapy session.

      In other systems of therapy, empathy with a client would be considered a preliminary step enabling the therapeutic work to proceed, but in client-centered therapy, it constitutes a major portion of the therapeutic work itself. A primary way of conveying this empathy is by active listening that shows careful and perceptive attention to what the client is saying. In addition to standard techniques, such as eye contact, that are common to any good listener, client-centered therapists employ a special method called reflection, which consists of paraphrasing and/or summarizing what a client has just said. This technique shows that the therapist is listening carefully and accurately and gives clients an added opportunity to examine their own thoughts and feelings as they hear them repeated by another person. Generally, clients respond by elaborating further on the thoughts they have just expressed.

      Two primary goals of client-centered therapy are increased self-esteem and greater openness to experience. Some of the related changes that it seeks to foster in clients include increased correspondence between the client's idealized and actual selves; better self-understanding; decreases in defensiveness, guilt, and insecurity; more positive and comfortable relationships with others; and an increased capacity to experience and express feelings at the moment they occur.

      Beginning in the 1960s, client-centered therapy became allied with the human potential movement. Rogers adopted terms such as "person-centered approach" and "way of being" and began to focus on personal growth and self-actualization. He also pioneered the use of encounter groups, adapting the sensitivity training (T-group) methods developed by Kurt Lewin (1890-1947) and other researchers at the National Training Laboratories in 1950s.

      While client-centered therapy is considered one of the major therapeutic approaches, along with psychoanalytic and cognitive-behavioral therapy, Rogers' influence is felt in schools of therapy other than his own, and it has greatly influenced how doctors, therapists and teachers conduct their business and how they think about the process of consulting, teaching, assisting in healing, and facilitating growth and learning.

      For more information about Carl Rogers, please check the following links:

Thank You for Stopping By!

            -- Best wishes, Dr. Sterling


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