A response to Kenneth R. Thomas' commentary: some observations on the use of the word 'consumer.' (The Journal of Rehabilitation, vol 59, p. 6, April 1993) (Cover Story)

Why do I bristle at the word "client? " Dr. Thomas has helped me crystalize my considerable introspection over this quandary. The essence of my profound disagreement with his recommendation that we eliminate the word "consumer" and return to "client" in the field of rehabilitation, lies in the very definition he uses to support his case. Webster defines client as "... a person or company in its relationship to a lawyer, accountant, etc., engaged to act on its behalf" (emphasis added). This assumes that for some reason, individuals have neither the ability nor interest to act on their own behalf. In the field of rehabilitation, there is a long history of professionals acting on behalf of people with disabilities, asserting their superior knowledge of what we need and what is best for us. In other words, it followed the medical model and all the paternalism inherent therein. While no one will deny that rehabilitation has been a valuable resource for many people, including myself, it has suffered from too many behaviors that perpetuate disability stereotypes, such as relegating people to sheltered workshops or proscribed career paths, or labeling people as unemployable solely on the basis of the severity of their disability. I don't think anyone would argue that rehabilitation has a paternalistic past. On the other hand, anyone who does not carry a bitter grudge from receiving such treatment will acknowledge that rehabilitation is in the midst of a revolution toward a more humane and creative discipline that focuses on both independence and productivity. The shift to use of the word "consumer" is symbolic of this progress.

The dichotomy between retailers and lawyers/accountants/medical professionals does not serve this issue well. By putting rehabilitation in the company of lawyers and physicians, you have chosen to consort with those no less disreputable than retailers. Characterizing the negative side of this role as mere dispensers of services fails to acknowledge the critical role of rehabilitation professionals as educators. In my conceptualization of an ideal world., professionals of all sorts would conduct assessments and evaluations only to enable individuals to understand more completely what their goals are and what they need in order to achieve those goals. An extension of this role is to assist individuals to see through the glitz that will inevitably accompany a more competitive market of services, and make sound judgements that will enable them to reach their goals. For individuals whose disabilities affect the ability to make sound judgements, the role of the rehabilitation professional expands to that of advocate as well as coach (i.e., educator and advisor). For all but a very small traction of the population, there is some interest and ability to be self-determining, it is more a matter of degree. Respect for the right and responsibility to make judgements for oneself is the cornerstone of the new, enlightened field of rehabilitation.

Rehabilitation professionals are more like retailers than you would like to believe. I agree that rehabilitation counselor training programs focus little, if at all, on the economic aspects of making a profit. That comes when counselors become employed and are oriented by their agency or company to the operational criteria for serving individuals within the resources available. Witness the travesties being committed by the rehabilitation industry against people with head injuries, as has been the subject of a Congressional investigation. Witness the oppressive focus on going with the lowest bid, and the numerous freezes imposed by state rehabilitation agencies on their counseling staffs over the last 12 years. I cannot be convinced that these have had no effect on the counselors' economic awareness. I do not wish to continue this succession of pejorative references to retailers. The best and most successful retailers are those who constantly strive to deliver a quality product to meet their consumer's needs. By the way, I have often heard sales staff refer to their consumers as clients.

The effect of using the word "consumer" will, indeed, be devastating to the rehabilitation professional - it will destroy the status quo. To continue the comparison with physicians, they suffered considerably when they began to be viewed as providers, because they could no longer maintain the rank of Gods. As servants to the best interest of the individual, they lost the mystery and unapproachability of the omniscient. If, as the result of using this word, I call now view a rehabilitation professional as my colleague and not my master, then I say let the revolution begin!

I have gotten where I am today because, when necessary, my parents bullied the school system and, I bullied the rehabilitation system into getting what was in my best interest. System operate on the path of least resistance, not the best interest of the individual. I have spent my life forging my own path through these systems to reach my goals. I am thrilled that, as a result of the new consumer empowerment agenda that is being adopted by our society, the next generation will have more sublime battles to fight.

I unequivocally disagree with Dr. Thomas' contention that use of the word "consumer" will distort and weaken the helping relationship, demean rehabilitation professionals, give the wrong message to students, and ultimately alter the underlying humanistic philosophical basis of rehabilitation professions. If the position of rehabilitation professional is dependent on the assertion of superiority and control over the decisions that affect people's lives, then it is incompatible with new age of humanism that is dawning and it will suffer the same fate as slavery and feudalism.

It is, by definition, impossible to enlarge the power and choices that individuals have within existing systems. Enlargement means change. An individual cannot gain power unless someone else, i.e., the professional, loses it, It is my great hope that a new relationship will emerge that is based on mutual respect instead of power; one in which consumers respect the professionals' expertise. and professionals respect and facilitate the consumers' right to make informed choices. For me, use of the word "consumer" is act of optimism and affirmation that change toward a more humane society is possible.

Margaret A. Nosek, PhD. is an associate professor in the Department of Physical Medicine and Rehabilitation at Baylor College of Medicine in Houston, Texas.