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Consumerism vs. clientism: a reply to Nosek.

Before I attempt to dissect Dr. Nosek's response to my commentary, I want to set the record straight on the following matters:

1. I am strongly in favor of enlarging client choices. In fact, I believe I was the first rehabilitation professional to advocate for the application of a voucher system to the provision of rehabilitation services (Thomas, 1985).

2. I support the privatization of rehabilitation services and would like to see even more rehabilitation professionals working in private non-profit and private-for-profit rehabilitation agencies and facilities. Moreover, I believe that regardless of whether rehabilitation professionals work in public or private settings, their behavior should be guided by a professional code of ethics.

3. I believe that clients should be helped to become and feel empowered and that professionals should be educated to view and treat them as such. In addition, I believe that service delivery and attitudinal paradigms based on the perception of people with disabilities as victims are ill-advised (e.g., see Lynch & Thomas, in press).

4. I do not endorse professional behavior which is paternalistic or which perpetuates disability stereotypes (e.g., see Britton & Thomas, 1976; Lynch & Thomas, in press; and Thomas, 1993).

5. I see none of the above statements as being inconsistent with my position that the word "client" instead of "consumer" should be used to describe persons served by rehabilitation professionals.

In specific reference to Dr. Nosek's response to my commentary, I am able to offer several observations. The first relates to Dr. Nosek's statement that she "bristles" at the word "client" because client is defined by Webster as "... a person or company in its relationship to a lawyer, accountant, etc., engaged to act on its behalf" (her emphasis added). Apparently, the phrase "engaged to act on its behalf" connotes to Dr. Nosek that the individuals served are assumed by professionals to have neither the ability nor interest to act on their own. If this perspective were indeed held by most rehabilitation professionals, then Dr. Nosek would have a valid point. However, it is neither a perspective held by most rehabilitation professionals, nor even a perspective associated with any major rehabilitation approach. Rehabilitation professionals routinely encourage clients to act on their own behalfs in scheduling job interviews, confronting family members and work supervisors, securing occupational information, applying for admission to vocational training programs, and a variety of other activities. Moreover, Dr. Nosek appears to be somewhat inconsistent in her criticism of professionals acting on behalf of their clients when she suggests that the role of the rehabilitation professional should include being an advocate and a coach for individuals whose disabilities affect the ability to make sound judgments.

In addition to acting on behalf of their clients, rehabilitation professionals are variously criticized by Dr. Nosek for "asserting their superior knowledge about what we (people with disabilities) need and what is good for us"; being "paternalistic"; and perpetuating "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." While I am certain that historically and even to a significant extent today these assertions are true, I hardly see how using the term "consumer" rather than "client" would correct what any competent professional knows is inappropriate helping behavior. Moreover, I find Dr. Nosek's assertion that the shift to the use of the word "consumer" is symbolic of "a revolution toward a more humane and creative discipline that focuses on both independence and productivity" to be faulty on two accounts. In the first place, I am somewhat suspicious of symbols, especially when they have no substance. For example, as pointed out in my commentary, one of the major problems with the term "consumer" is that it inaccurately implies a marketplace of choices for clients which simply doesn't exist. Secondly, I am uncertain what if any relationship the word "consumer" has to "a more humane and creative discipline that focuses on both independence and productivity." The free-enterprise system, despite its many advantages, is not driven by humanism, what is good for the consumer, or even what the consumer needs; it is driven by profit, competition, and what the consumer will buy.

While it is fashionable and often justifiable to criticize physicians and lawyers, I would certainly be better advised to accept the recommendations of these professionals, due to their formal codes of ethics and years of professional education, than the advice of a salesperson who tells me I look great in a suit he or she wants me to purchase. I was, for example, amused by Dr. Nosek's comment that she has often heard sales staff refer to their consumers as clients. The reason for this sales staff behavior is because they want consumers to think of them as professionals (i.e., as persons who are well-informed and will not bilk them). What is amazing, at least to me, is that so many professionals, including apparently Dr. Nosek, see it as a giant step forward to be viewed as sales staff!

Throughout her response, Dr. Nosek seemed to be concern about the distribution of power and authority. In regard to professional/client relationships, she uses such terms as revolution, slavery, paternalism and feudalism, and states specifically that "... An individual cannot gain power unless someone else, i.e., the professional, loses it." Without getting into a discussion about whether power is a finite quantitative characteristic, which must be either gained or lost by the parties involved, let me just say that professional/client relationships are most appropriately structured as partnerships or "therapeutic alliances." There are no masters and no slaves; and hopefully, there are no losers. The attitude of "we against them" is clearly inappropriate. While a professional may recommend a particular course of action, the client almost always has the option of refusing the professional's advice.

As a final observation, I found it particularly remarkable that Dr. Nosek used the example of the "travesties being committed by the rehabilitation industry against people with head injuries" to support her endorsement of the "consumer" concept. She prefaced this remark by saying that rehabilitation professionals are more like retailers than I would like to believe. Perhaps I am confused, but doesn't this example prove my point that when clients are treated as sources of revenue instead of as clients, they (the clients) are likely to get hurt?


Britton, J. O., & Thomas, K. R. (1976). Rehabilitation counseling practice: Some sociological insights. Journal of Applied Rehabilitation Counseling, 7(1), 34-39. Lynch, R. T., & Thomas, K. R. (in press). People with disabilities as victims: Changing an ill-advised paradigm. Journal of Rehabilitation. Thomas, K. R.. (1985). Rehabilitation services, training and research: A political analysis. Journal of rehabilitation, 51(4), 17-21. Thomas, K. R. (1993). Attitudes toward disability: A phylogenetic and psychoanalytic perspective. Manuscript submitted for publication.

Kenneth R. Thomas, D.Ed. is a professor in the Department of Rehabilitation Psychology and Special Education at the University of Wisconsin-Madison
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Title Annotation:response to Margaret A. Nosek, Journal of Rehabilitation, vol. 59, p. 9, April 1993
Author:Thomas, Kenneth R.
Publication:The Journal of Rehabilitation
Date:Apr 1, 1993
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