Nicholas Rosenlicht, MD
Excerpts from "My Brother's Keeper"
Released October 1, 2024 from Pegasus Books and Simon & Schuster.
"Throughout history, civilized societies have recognized the vulnerability and suffering of the ill and accordingly granted them special rights and protections, as well as a unique designation: “patient.” This is changing. In the 1990s, when I was involved in negotiating managed care contracts for a community mental health center, I was surprised when insurers insisted that contracts use the term “client”; “patient” would not be allowed. Why were they so insistent? How much does a name matter? As it turns out, a whole lot. George Lakoff, Professor of Cognitive Science and Linguistics at UC Berkeley, describes how the words we use frame how we think about and act on important matters. As we shall see, referring to someone as a client rather than a patient profoundly shifts how we think about them, the rights and protections we offer them, and how we treat them. To this end, in service of the new economic paradigm, the healthcare industry sought to reframe patients as clients, and used similar mercantile terms to free themselves from the legal and ethical responsibilities historically associated with the care of patients. More than any other area of healthcare, psychotherapists embraced this business term, eschewing their role as a healer treating patients in lieu of one as an entrepreneur catering to “clients.”
Central to the doctor’s code of ethics is to put a patient’s needs above their own, not so with a businessperson selling their wares or services to a client. For example, it is standard business practice to sell a product to a client, but it is considered unethical for a doctor to do so to a patient. What was conceived as an empowering concept served instead as a linguistic Trojan Horse, bringing business interests into the treatment room, while stripping patients of rights and protections that had been accorded them since the time of Hippocrates.
The Merriam-Webster dictionary defines “patient” (noun) as “a person who receives medical care or treatment.” It derives from the Latin “pati,” meaning to undergo, bear, or sit with pain. It is related to the adjective “patient,” as in “to endure.” Whether the patient suffers from the pain of a broken bone or depression, the caregiver helps the person withstand, endure, or conquer their suffering. Its dual meaning is referred to in the Bible when Luke, the physician apostle, counsels, “In patience possess ye your souls.” (Luke 21:19. The Bible, King John
Version.)
In contrast, “client” is defined as: “1: One that is under the protection of another: Dependent, 2: a: A person who engages the professional advice or services of another -a lawyer’s clients-, b: Customer – hotel client-, c: A person served by or utilizing the services of a social agency -a welfare client-.”
Client comes from the Latin “cliens” (plural “clientes”), meaning follower or retainer, related to “cluere”—to “listen, follow, or obey.” In today’s world, retail or service businesses have clients; the term is used interchangeably with consumer and customer. While there are analogies between clients and patients, notably that money changes hands in both, there are also crucial differences. One fundamental distinction is that a client pays for a product or service to defend them against problems in the external world. Thus, lawyers have clients, banks have clients, and social workers have clients, and they help their client manage a specific external problem such as a legal threat, their financial affairs, or a lack of income or housing, respectively. Important tasks, to be sure, but what the term “client” leaves out that the term “patient” includes is the intimate bond dedicated to the avoidance and relief of internal suffering. While a client is passive, and provided with a service or product, a patient is a partner in treatment, which emphasizes and reinforces their strength as a person, rather than their weakness.
At its core, “client” signifies the monetization of a relationship, whereas being a patient, at least as the relationship should be, is defined by empathy and collaboration, traits often absent in a financial transaction. For example, businesses themselves are frequently clients of other businesses, but they are never patients. Calling people client may allow us to pretend we are evading the stigma of mental illness and our long-standing and deep-seated fears about insanity, but it also serves to perpetuate and strengthen these fears and prejudices.
As far back as the 1970s, concerns were voiced about the erosion of the rights and protections of patients under profit-seeking companies. The American Civil Liberties Union published a cautionary handbook entitled, “The Rights of Patients,” whose author, George Annas, later summarized that: “The key to understanding patients’ rights in managed care is to understand managed care’s attempt to transform the patient into a consumer. . . .” He enumerated crucial rights that patients, but not clients, are provided under the law. Central to these rights is the concept that the law treats “the doctor-patient relationship as a fiduciary or trust-based relationship, not as an arm’s-length business relationship.” (Businesses have fiduciary responsibility to their investors, not their clients.) Other patient protections Annas describes include the right to informed consent, privacy and confidentiality, and autonomy. This latter right, autonomy, has come to stand for the “. . . proposition that the Constitution limits interference by the state in the doctor-patient relationship . . .” which formed the legal underpinning of the Roe v. Wade decision.
Framing people as clients can cause healthcare professionals to forget these ethical duties to those they treat. The subjugation of ethical responsibilities to patients in the service of marketing to clients recently caused the American Psychological Association (APA) considerable embarrassment. Vying for military contracts, some psychologists were eager to market themselves as experts on torture, or, using another euphemism, “enhanced interrogation,” and obtained the support and approval of the APA. With no relevant experience or training, these
psychologists advised and assisted at CIA “black sites,” Abu Ghraib prison, and the Guantanamo Bay “detention camp” (other cynical euphemisms). When this shameful dereliction of professional ethics came to light, the APA characterized it as the work of a couple of rogue psychologists. Later, an independent investigation found that, in fact, the association’s leadership, led by the APA’s director of ethics, was at the heart of the effort.
The use of business euphemisms facilitates the corruption of healthcare priorities in the interest of profit. Barry Farkas, a geriatrician and family physician, perhaps said it best: “The term ‘provider’ for clinical caregivers, like the term ‘client’ for patients, depersonalizes and commodifies that which is neither and so very much more. The more we use these commercial terms to refer to intimate and personal care, the more that care becomes commercial and impersonal. Such is the power of language.” "
"One Sunday in February of 2022, I sat reading the New York Times while eating breakfast. On the front page was the story of how Martial Simon, a homeless man known for his incoherent rants, shoved Michelle Alyssa Go to her death in front of a subway car. For years Mr. Simon had been in “revolving door” treatment. The story told how he had been hospitalized twenty times, but never received consistent care. Minutes later, I picked up my local paper the San Francisco
Chronicle. On its front page, an article entitled “The disastrous results of S.F.’s program to house homeless in hotels” described the failure of a 2019 law designed to assist the then 4,000 (now estimated to be 8,000) unhoused people in San Francisco who struggle with addiction and mental illness. The law changed rules so that the most ill, disruptive, and dangerous individuals could be forced into court-ordered treatment. Three years on, two (!) individuals had been treated under the program, and none stayed in the program. San Francisco implemented a bold plan in 2017 to cut in half its chronically homeless population over the subsequent five years. Rather thandecrease, the population has grown.
Nowhere in health is this obscuring of the consequences of our policies greater than in mental health. Stigma in mental illness is real, and leads to discomfort and discrimination. People are particularly troubled by the mentally ill because their symptoms and behavior are disturbing. As D. J. Jaffe quotes from a 1961 federal task force, “Mental illness is different from physical illness in the one fundamental aspect that it tends to disturb and repel others rather than evoke their sympathy and desire to help . . . The reason the public does not react desirably is that the mentally ill lack appeal. They eventually become a nuisance to other people and are generally treated as such. This is what causes the public aversion. People will never tolerate bizarre, violent, psychotic behavior. Never have. Never will.”
Laws are meaningless if we have neither the facilities nor the will to implement them. We can’t expect the homeless mentally ill to utilize housing without treatment, or to access regular treatment without stable housing. As a 2020 study found, 86 percent of people experiencing chronic homelessness were able to achieve housing when enrolled in a permanent supportive housing program, as opposed to only 36 percent who were not. The two must go hand-in-hand, combined with strong social and vocational support. Some with severe mental illness simply may not have the insight, judgment, or rationality to accept treatment without monitoring and guidance, at least initially. In the first seven months of 2022, fourteen out of 1,071 patients at the Psychiatric Emergency services department of San Francisco General Hospital, the city’s only such unit, were admitted between eleven and twenty times. One came more than twenty times. Five individuals alone over the past five years had at least 1,781 ambulance transports. The price tag paid by taxpayers? $4 million. And these patients are getting worthless, ineffective care.
A 2024 study of the “Housing First” program in Denver, that prioritizes permanent housing of the mentally ill, found that participants attended more office-based psychiatric visits, were more accepting of medication, and had fewer emergency department visits than the control group. Another 2024 study estimates that mental illness costs the US economy $282 billion annually, the equivalent of an average economic recession. But in the case of mental illness, it’s a recession that occurs every year without fail.
Most of us would feel a lot more comfortable living with those with mental illness in our midst if we felt that our government and healthcare system provided adequate and appropriate support and treatment for them. As the policy analyst Steven Eide points out: “Most people don’twant to live next to a homeless shelter that cares for mentally ill people because they don’t trust the government and shelter providers to run such facilities in a way that would keep neighborhood conditions stable. Who can blame them?”
"Justin, a forty-four-year-old Black man, was a patient of mine. A devoted father with a loving family, soft-spoken, a veteran, and with a passion for karaoke, he also suffered from bipolar disorder. Stable for long periods of time when in treatment, he still occasionally lapsed into manic or depressive episodes. One afternoon while in a manic episode he went to visit an elderly friend at her apartment complex. There, he got into a verbal altercation with a known drug dealer he wished to keep away from his friend. The police were called and in assessing the situation questioned Justin. Lacking his usual judgment and restraint he was incensed that he was being questioned along with the dealer. He made an insulting sexual comment to a female officer who replied, “Would you like to go to jail?” His answer: “Yes.”
In jail he was put in isolation, allowed no visitors, and deprived of his medications. His condition rapidly deteriorated. He became frightened and paranoid. To attract attention he shouted threats against President Obama, someone he respected and supported. He was hauled out of his cell by guards and when he tried to defend himself with a two-inch long mini-golf pencil he was severely beaten. Later he was charged with making “terroristic threats” (while locked in an isolation cell!) and assault with a deadly weapon (the pencil). Ultimately, despite his family and treatment team spending many hours in court explaining his diagnosis and history, he ended up spending months in jail without treatment. The judge, citing his “history of violence,” determined he should remain in jail, isolated and untreated, rather than be transferred to a psychiatric hospital. His only “violence” had occurred in jail, off of his medications, at the hands of guards. After release, his nightmare of legal fights, court-ordered monitoring, and restrictions continued. His life in shambles, he ultimately jumped to his death. Rather than a tragic anomaly, Justin’s experience is more the norm for people with mental illness in our society, especially for people of color."
"A 2023 Gallup poll found that rates of depression in this country are skyrocketing, with more than one in six Americans saying they are currently depressed or receiving treatment for depression and 29 percent reporting that they have been diagnosed with depression at some point in their life. A 2022 survey by the U.S. Department of Health and Human Services found that nearly forty-nine million adults in this country, more than one in six, had a substance abuse disorder. That same year a CNN/Kaiser Family Foundation survey found that nine out of ten adults said they believe there’s a mental health crisis in the US today, and a 2022 survey byIPSOS, a global market research and public opinion firm, found that mental health is now the single greatest health concern for Americans, surpassing even COVID. Who among us has not been touched by mental illness or addiction? Who does not personally know someone, maybe a family member or friend, whose life was upended by mental illness?
Data from SAMHSA shows the critical shortfall of mental healthcare: in 2018 less than half of adults with mental health diagnoses received any treatment for their illness (and I’m sure the number is far less for kids), and in the midst of the opioid epidemic, while tens of thousands die annually of overdose, only one in five people with an opioid use disorder obtained any treatment at all. As our healthcare system restricted the prescription of opiates in an attempt to slow the epidemic, it did not provide treatment for those it had addicted, so patients had to turn to illegal suppliers for the drugs. This, combined with the spread of the powerful synthetic opioid fentanyl, led to a tripling of overdose deaths from 2010 to 2020. A 2023 Kaiser FamilyFoundation poll found that a staggering two-thirds of American adults “. . . said either they themselves or a family member have experienced addiction to alcohol or drugs, homelessness due to addiction, or an overdose resulting in an emergency room visit, hospitalization or death.” More than one-half of all people in this country injured or killed in traffic crashes have one or more drugs or alcohol in their bloodstream. Yet our healthcare system acts like substance misusedoesn’t warrant treatment."
"Once the envy of the world, our healthcare system is consistently rated dead last among developed nations in measures of quality, outcomes, and accessibility. In terms of cost, it’s in a league of its own, double that of other developed countries. But the most shameful aspect of our last-place healthcare system is its treatment of mental illness. In 2022 we lost roughly 300,000 people to suicide, excessive alcohol use, and overdose, more than to AIDS, guns, and motor vehicle accidents combined. This is more than we lost to COVID (244,000), which dominated the news and public discussion and overturned our lifestyle. Suicide is now the second most common cause of death in ten- to twenty-four-year-olds in this country, behind only accidents. For all our worry about violent crime, we are more than twice as likely to die at our own hands as at the hands of another, and five times as likely to die by overdose. Yet it’s estimated that health insurers allocate little more than 4 percent of healthcare dollars to the treatment of mental illness and addiction."
A leading psychiatrist seeks to transform our understanding of mental health care and how it fits into larger social and economic forces—and proposes an effective and compassionate new framework for healing.
Mental health care in America has become nothing short of atrocious. Supposed developments in treatment methods and medication remain inaccessible to those who need them most. Countless people seeking treatment are routinely funneled into homelessness and prison while a mental health epidemic ravages younger generations. It seems obvious that the system is broken, but the tragic truth is that it is actually functioning exactly as intended, providing reliably enormous profits for the corporate entities who now manage mental healthcare.
In the tradition of Andrew Solomon or Bessel van der Kolk's The Body Keeps the Score, My Brother's Keeper is a paradigm-shifting book that can help us find our way to real and lasting solutions.
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