The Wal-Marting of american psychiatry: An ethnography of psychiatric practice in the late 20th century

Object: U.S. psychiatry has been radically reorganized by changes in the wa y the psychiatric hospital, the asylum, is funded. The imposition and inter nalization of cost control measures are major elements of this reorganizati on. This paper traces the ways in which cost control methods associated wit h managed care have produced new ways of organizing and patterning clinical work and clinical knowledge. Methods: Participant observation, used in qualitative sociological research , was undertaken in three settings: a public hospital, a private hospital w ith roots in the history of the asylum, and a for-profit hospital chain. Th e research consisted of observation of usual clinic practices and interview s with clinicians and ancillary staff, such as utilization reviewers, conce rning their construction of and understandings about their work experience. In addition, interviews with personnel at a number of managed care compani es was arranged although actual ethnographic experience was not performed i n these companies due to declined permission. Interviews included clinician s whose experiences bridged the pre- and post-managed care eras. Result: This paper argues that the widespread adoption of Quality Assurance and Utilization Management procedures has created new standards of evaluat ion and treatment. These standards grow out of a transition from a person-c entered to a population-based data base. They are justified by a conviction on the part of managed care proponents that good clinical treatment is equ ivalent to efficient cost control. This epistemological change results in t he development of a clinical knowledge patterned along algorithmic pathways rather than subjective understanding. An increased and more rapid rational ization of psychiatry is the result. This rationalization process has produ ced moral dilemmas for practicing clinicians as they struggle to redefine t heir professional purposes and identities within a new order. Conclusion: The rise of the `Quality Movement' has led to the reconstructio n of clinical knowledge as a result of the imposition of social practices i nfluenced by the cultural consequences of capitalism. A peculiarly American psychiatry is the result.