the tragic business of mental health care explained [PODCAST]

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We sit down with Nicholas Rosenlicht, psychiatrist and author of My Brother’s Keeper: The Untold Stories Behind the Business of Mental Health―and How to Stop the Abandonment of the Mentally Ill. Nicholas unpacks the troubling shift from viewing individuals with mental health issues as “patients” to labeling them as “clients,” revealing how this change in language has eroded rights, altered care, and reframed the therapeutic relationship.

Nicholas Rosenlicht is a psychiatrist and author of My Brother’s Keeper: The Untold Stories Behind the Business of Mental Health―and How to Stop the Abandonment of the Mentally Ill.

He discusses the KevinMD article, “The dangerous shift in mental health: Are we clients or patients?”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome Nicholas Rosenlicht. He’s a psychiatrist and the author of the book My Brother’s Keeper: The Untold Stories Behind the Business of Mental Health and How to Stop the Abandonment of the Mentally Ill. We’re going to talk about that book, as well as the excerpt from that titled, “The Dangerous Shift in Mental Health: Are We Clients or Patients?” Nicholas, welcome to the show.

Nicholas Rosenlicht: Hi, thanks for having me.

Kevin Pho: So, let’s start by briefly sharing your story and journey.

Nicholas Rosenlicht: Well, I’m not sure how far to go back. I actually had a career before I was in medicine. I was sort of in engineering and environmental science. I went to medical school, and I didn’t think I’d end up in psychiatry, but I really found that when properly implemented, it was very, very effective in alleviating pain in people’s lives. Nevertheless, I did start off in internal medicine and ultimately ended up in an academic career in psychiatry with some teaching, research, and also a lot of clinical care.

What really has bothered me over the last 40 years has been a profound shift in the way we orient medicine, which is now really around a business model, and how we’ve lost sight, particularly in mental health, but I think mental health is kind of the canary in the coal mine. What are we actually doing for people, and why?

Kevin Pho: Alright, and we’re going to talk about one aspect of that business influence on mental health—the dangerous shift in mental health. Are we clients or patients? That comes from your book, and we’ll talk about that later. But let’s talk about this excerpt. Talk about that shift between calling patients “clients” versus “patients.”

Nicholas Rosenlicht: OK. Well, there was sort of a confluence of things maybe 30 years ago when I thought the smart doctors, the ones who thought they were doing the best thing, were getting MBAs and becoming administrators. And why was this? Why was our calling shifting to something else? Then, I was actually part of a team negotiating insurance contracts for a community mental health center and learned that as we did these negotiations, we couldn’t use the term “patient.” We had to use the term “client,” which seemed very odd to me. I’d heard it used and sometimes used it myself, but I thought, why would they care so much about calling people clients? What does a word matter?

As it turns out, it matters a whole lot because it really orients the way we view people and what our goals with them are. It’s basically the monetization of a relationship that shifts the focus from care and alleviating illness to money.

Kevin Pho: So, as a psychiatrist, when you’re seeing patients in your office or in the exam room, how does that shift from patient to client affect you as a physician?

Nicholas Rosenlicht: Well, I’m kind of lucky at this late point in my career that I can craft my practice the way I want, in a way many physicians can’t. I can charge people what I want, which can be very little. I can largely avoid insurance companies and let patients bill themselves. But I have a discussion about, “Why are you here? Are you here about a contract over finances, or are you here to get better?” I mean, since time immemorial, patients have had rights and privileges that others in our society don’t. We realize they need care, whereas a client has no privilege except what’s negotiated in the contract. In health care, the contracts are all drafted by health care corporations with no input from doctors or patients. So, why would you choose to have an unempowering, dependent nomenclature used when you’re most in need?

So, I really just sit down and say, “Why are you here? What are we here for? And how can I help you improve your life?”

Kevin Pho: Now, when you were having these negotiations with the insurance companies, and they insisted on calling patients “clients,” like you said, to focus more on the transaction and money. What’s the motivation of the insurance companies in doing so, the fact that they want to depersonalize that relationship?

Nicholas Rosenlicht: Well, there are a lot of things. It means another awful term, “provider,” is interchangeable. They’re providing a cookie-cutter service, and the relationship doesn’t matter. It’s very easy to swap out clinicians. It’s just much easier to run a business model when somebody’s a client. They’re bound by contractual obligations, if there are any. But things like the duty to devote your resources to the patient, rather than the client, take over. For example, businesses have a fiduciary responsibility to their shareholders and their board directors, not to their clients, whereas physicians have a fiduciary duty to their patients. That’s the focus of what we want to get done, and that shifts.

I saw my colleagues and me, when we were working for companies, thinking that as health care businesses got bigger and bigger, there’d be more of a sense of community. But that just wasn’t it. Instead of meeting in the hallway, having time to chat and do curbside consults, and talking about the focus of what you were doing with that patient, it became business meetings and rushed—no time for that supportive chatter that keeps us focused on what we’re here for.

Kevin Pho: Have you ever had a conversation with an administrator or someone with that business focus, debating the term “client” versus “patient?” If so, what was that like?

Nicholas Rosenlicht: Well, that’s sort of why I wrote this book. I did have those conversations, and with colleagues who were offended that you’d call a patient a patient. People just didn’t get it, which is why I wrote the book—to tie up all the loose ends about why it does matter. It changes the way we view people, and it really is an insidious shift.

For them, especially someone steeped in the business model—if you’re talking to a health care administrator or a drug rep—they just don’t see the difference. But there’s a long history in just about every society, realizing that people who are ill have special needs and require special protections. Clients don’t get that, but patients do. You’re supposed to take care of them.

Kevin Pho: So, the fact that we’re talking about this insidious shift to a more business-oriented vernacular, how does that affect patients in general? Why should patients care about what they’re being called?

Nicholas Rosenlicht: Well, I think they want to know that the person they’re spilling their guts to, their stories, letting people give them poisons and cut their body, has their best interest at stake. Why would I trust somebody to open my belly, prescribe a pill to me, or tell my deepest secrets to if they’re not on my side? Who, at the end of the day, are they most interested in helping? And that matters. There’s this whole thing about “the client is always right” in business, but that’s just not true. It sounds good, but who are you oriented with? Businesses themselves can be clients, but they’re never patients. We’re talking about an individual who is suffering, who wants alleviation from that suffering. Is this person I’m meeting with behind that, or do they have other agendas?

Kevin Pho: So, let’s talk about that depersonalization of medicine—from patient to client, from physician to provider. You even said that some of your colleagues don’t really see the dangers that we’re articulating today. I’d like to hear about that commentary on a broader scope. What does that say about the current state of medicine, and for the state of medicine going forward?

Nicholas Rosenlicht: Well, I think it’s not good. I, again, view mental health as sort of the canary in the coal mine. It’s the only area of medicine I know where the term “client” has been embraced. It’s making inroads elsewhere, usually through administrators and businesspeople, but clinicians are actually calling people clients in mental health.

A lot of it has to do with the stigma around being psychiatrically ill. To refer to somebody as a psychiatric patient is really scary. I think it threatens all of us, even the clinicians. You think you’re being nice by using a watered-down euphemism, but it pollutes the relationship. Are you here for a serious matter, or are you here to get your hair cut? It degrades the importance of what we do.

There’s a lot more to this, and words really do matter. For example, during the Nazi regime, Jewish doctors had the term “Arzt,” meaning doctor, taken away and were called “Krankenbehandlers,” which means illness managers. The same thing was done under the Nazi regime. It’s a way of disempowering the clinician and taking away the autonomy that is meant to protect patients. It’s a way of turning people into commodities, not suffering human beings.

Kevin Pho: I know there are some physicians who push back against being called a “provider.” Have you ever pushed back about calling patients “clients,” even with your fellow behavioral health colleagues?

Nicholas Rosenlicht: Oh, I’ve had people really bristle. People don’t think about it—they do what their colleagues do. I don’t think there’s a lot of thought about what’s in a name. A lot of mental health clinicians would just think it’s odd to call someone a patient, and that solidifies the stigma around being psychiatrically ill. It sanitizes it, but it solidifies it. People just don’t think. Mental illness is scary, and it’s frustrating, especially with the inadequate resources we have for treatment. Anything that makes it smoother and easier is the way people go. They’re tired of fighting with the insurance company or reluctant patients. They call people what they want, but it’s worth having a discussion about why they want to be called something else, and what our purpose is here. “Client” distracts from that. A client is something—a lawyer helps you with your divorce, your CPA helps with your taxes. It’s external help. A patient is someone dealing with an internal problem, and they’re the ones who have to do most of the work. So, it takes the burden off the patient and allows people to slide along without doing the work themselves. It really takes the focus off what our work is, and this is true in psychiatry, but it’s true in all of medicine.

If a surgeon cuts on you, you may have a lot of tissue disruption, but it’s going to take an hour or two. The person has six months to heal. The burden of healing is really on the patient, not the provider.

Kevin Pho: This excerpt is from your book My Brother’s Keeper: The Untold Stories Behind the Business of Mental Health and How to Stop the Abandonment of the Mentally Ill. Tell us what led you to write this book in the first place.

Nicholas Rosenlicht: Well, it’s funny. It started as an op-ed I wanted to write with another MFT therapist about examining why people are calling patients clients. We had a conference where a clinician, a master clinician, described a lot of clinical cases and always used the term “patient.” He wasn’t actually a physician, but when they published an excerpt of this in their news magazine, they changed the word to “client.” They misquoted him. So, we wrote an op-ed questioning why this happened, asking why it was OK to change people’s names and the terms we use to describe them.

We went through a long editorial process, and at the last minute, the board of this institute refused to publish it, saying it would be offensive to clinicians. I’m not sure why clinicians would be so sensitive and not want to examine this. This was a publication specifically for controversial subjects, but it showed me just how deeply people are clinging to the term “client,” and I started to examine why. I think it really comes down to stigma, and the courtesy stigma that psychiatrists and other mental health clinicians have. I think we are somewhat reviled for dealing with things and talking about issues that others would rather not look at. Mental health and mental illness are just ugly sometimes. When somebody is having an asthma attack or a heart attack in front of you, you don’t hesitate to drop to your knees and help them. When somebody is ranting and spitting, it’s often revolting. I think the people who have to deal with this would really rather hide behind a euphemism, but it’s not serving us because it has allowed a business model to take over, which is not serving the clinicians or the patients.

Kevin Pho: Mental illness is a difficult and often unpleasant reality, and you mentioned that this business model has taken over. So, given that context, what are some of the paths forward for people who do want better access to behavioral health services?

Nicholas Rosenlicht: I wrote the book with the hope that it would reach an informed lay audience. Physicians, I think, largely know the problem, although mental health is, again, somewhat marginalized. We have laws to protect against the commodification of medicine and patients, but they’re not being enforced. We have corporate practice of medicine laws in all states, which are supposed to keep key business decisions out of health care decisions, but they’re not being enforced. Corporations aren’t allowed to practice medicine, yet by setting up elaborate shell structures and holding the purse strings, they effectively are practicing medicine.

I think we need to let our legislators know what’s going on. The health care industry is the largest lobbying industry in the United States, and we need to make people aware, including legislators, that this is killing us. We don’t want profit to be made from suffering and death. The 401k funds that many people rely on are making money by closing rural hospitals, and that is killing people. Is that how we want to be making money? Maybe your child’s educational fund is making a lot of money, but it closed the hospital that could have saved her life if she inadvertently overdosed at a dorm party. We need to look at the consequences of our actions and not be so myopic.

Kevin Pho: We’re talking to Nicholas Rosenlicht. He’s a psychiatrist and the author of the book My Brother’s Keeper: The Untold Stories Behind the Business of Mental Health and How to Stop the Abandonment of the Mentally Ill. Nicholas, tell us some of the key points that you want the KevinMD audience to take away from your book.

Nicholas Rosenlicht: I would say that when we’re making health decisions, we need to follow the money. We need to take the time to sit down with our peers and talk to them about what’s actually working and what’s not. We used to have the time to hang out and do this. Grand rounds were presented by master clinicians talking about what they’ve learned, not drug company-sponsored talking heads about the latest medication. We need to look at the data when the latest drug comes out, especially in psychiatry. What is the real effect size? Will it move the needle in terms of health outcomes?

When you sign up for a job, and nowadays it’s so hard in most areas of medicine to be an independent practitioner, you need to ask yourself what you’re giving up in terms of autonomy and choice. Things like non-compete clauses, which may become illegal soon, are one example, but there are always ways around these restrictions. Be very careful—it’s a slippery slope when you sign away your rights to practice medicine as you think it should be, and the rights of your patients are affected by the contracts you agree to. I don’t think we fully realize the long-term impact when we get into it.

Ultimately, doctors are becoming such a scarce resource. I think we have a whole lot more power than we realize. We may not be organizing strikes, and I’m not advocating for that, but we’ve basically been sitting ducks because we won’t stand together as a group to say, “No, this is not what our field should look like. This is not how I’m willing to practice. I’m not going to enrich you by restricting care to the people who are entrusting me with their life.”

Kevin Pho: Nicholas, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

Nicholas Rosenlicht: Thank you for having me.