The Wal-Marting of American Psychiatry: An Ethnography of Psychiatric Practice in the Late 20th Century
- Cite this article as:
- Donald, A. Cult Med Psychiatry (2001) 25: 427. doi:10.1023/A:1013063216716
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Object: U.S. psychiatry has been radicallyreorganized by changes in the way thepsychiatric hospital, the asylum, is funded.The imposition and internalization of costcontrol measures are major elements of thisreorganization. This paper traces the ways inwhich cost control methods associated withmanaged care have produced new ways oforganizing and patterning clinical work andclinical knowledge.
Methods: Participant observation, used inqualitative sociological research, wasundertaken in three settings: a publichospital, a private hospital with roots in thehistory of the asylum, and a for-profithospital chain. The research consisted ofobservation of usual clinic practices andinterviews with clinicians and ancillary staff,such as utilization reviewers, concerning theirconstruction of and understandings about theirwork experience. In addition, interviews withpersonnel at a number of managed care companieswas arranged although actual ethnographicexperience was not performed in these companiesdue to declined permission. Interviews includedclinicians whose experiences bridged the pre-and post-managed care eras.
Result: This paper argues that the widespreadadoption of Quality Assurance and UtilizationManagement procedures has created new standardsof evaluation and treatment. These standardsgrow out of a transition from a person-centeredto a population-based data base. They arejustified by a conviction on the part ofmanaged care proponents that good clinicaltreatment is equivalent to efficient costcontrol. This epistemological change results inthe development of a clinical knowledgepatterned along algorithmic pathways ratherthan subjective understanding. An increased andmore rapid rationalization of psychiatry is theresult. This rationalization process hasproduced moral dilemmas for practicingclinicians as they struggle to redefine theirprofessional purposes and identities within anew order.
Conclusion: The rise of the `Quality Movement'has led to the reconstruction of clinicalknowledge as a result of the imposition ofsocial practices influenced by the culturalconsequences of capitalism. A peculiarlyAmerican psychiatry is the result.