Tuesday, May 12, 2009

The "McDonaldization" of Psychiatry: Psychiatric Knowledge is Not the Equivalent of "Fast Food"

I was only in callow adolescence in April of 1964, but I remember those times quite clearly. The country had just come through the assassination of JFK, and Vietnam was already looming on the national horizon. Simon and Garfunkel had just written their anthem of angst, “The Sounds of Silence”, and the nation would soon be roiled by student protests known as the Berkeley Free Speech Movement. More distantly, in the din of these events, a young psychiatrist named Melvin Gray published an article in the Archives of General Psychiatry, entitled “Principles of the Comprehensive Examination.”1 Today, as our field confronts so many challenges—epitomized on this blog as “The Couch in Crisis”—Dr Gray’s article should be read or re-read by everyone committed to psychiatry’s survival as a medical specialty.

According to Wikipedia, “McDonaldization…is a term used by sociologist George Ritzer in his book The McDonaldization of Society (1995). He describes it as the process by which a society takes on the characteristics of a fast-food restaurant.” The 4 primary features of McDonaldization, according to Ritzer, are efficiency, calculabilty, predictability, and control. Mind you, I have nothing against the occasional fast-food stop, and I will even confess to a weakness for cheeseburgers. But the McDonaldization of psychiatry is hardly the model of diagnosis and treatment we should embrace. And yet, many would argue, that is what we are now facing, as psychiatric diagnosis is reduced to endorsing and coding check-lists of manifest signs and symptoms; the 50-minute hour is reduced to the 15-minute “med check”; and psychotherapeutic acumen is reduced to a few perfunctory courses during residency. To be sure, there are many commendable exceptions to these trends, and many eloquent voices raised in discontent.2-5 Yet as we move toward the new diagnostic framework known as DSM-V, our field is arguably in the fight of its life.

It should be noted that “reductionism” in psychiatry is not confined to those who strenuously advocate DSM-style categorical diagnoses or purely biological approaches to understanding psychopathology. As one of our Psychiatric Times Board members, Dr Glen Gabbard has observed, “Both [psychoanalysts] and their patients secretly are drawn to simple formulations that eschew complexity.”3 Reductionism, in short, is an equal-opportunity state of mind.

Dr Mel Gray’s wise article—prescient in so many respects, given the problems facing present-day psychiatry—is just what the doctor ordered, even if it bears a prescription date of April, 1964. Though it appears in the Archives of General Psychiatry, it is aimed at “…the young physician…in whatever field of medicine” he or she may practice. For those of us who have become accustomed to doing a half-hour—or perhaps an hour—of initial diagnostic assessment, Dr Gray has this to say:

“The comprehensive examination requires a minimum of four to six hours. Since three to five days of examinations, observations, and tests are usual in the outstanding medical clinics in the United States, the time suggested here is relatively short.”1

Ah, as the song goes, “Those were the days, my friend!” Dr Gray’s comprehensive assessment includes not only the traditional “Chief complaint” and history of the present illness, but also a “hereditary” and “ontogenetic” biography—the former dealing with familial psychiatric illnesses, and the latter, with “…changes both normal and pathological of the individual from the time of conception to the present.” Dr Gray pays due attention to determining “the precipitating cause or causes” of the patient’s complaint, but he is skeptical regarding facile causal narratives. He writes,

“The possibility of inaccuracies increases the more one depends upon the patient’s observations and explanations. . . Although speculation is acceptable, it should not be given unwarranted value. The further one gets from the present, the more speculative becomes the explanation and the greater the danger of espousing a false causality.”1

This wisdom flies in the face of modern recourse to single, “contextual” precipitants for a patient’s depressed mood, or—for that matter—to facile explanations based on “chemical imbalances” or other biological causes. Rather, Dr Gray insists that we must assess the “total person”, by which he means

“…the cultural, sociological, biographic, biological, psychological, and behavioral levels of organization…”1

At a time when psychoanalytic concerns about “boundary violations” were discouraging psychiatrists from performing physical examinations,6 Dr Gray prominently advocated physical examination as a fundamental element of the comprehensive medical-psychiatric assessment.

Dr Gray’s synoptic description of what psychiatrists and all physicians must know reminds me of the wonderful short story by the Russian-Jewish writer, Isaac Babel (1894-1940)—“You Must Know Everything.”7 This is a tall order, of course, but it reflects the view that psychiatry will not survive, much less thrive, as a profession, if it narrows its focus and lowers its sights.8,9 Psychiatric knowledge is not the equivalent of “fast food”; rather, it is a feast that must be carefully prepared, lovingly consumed, and slowly digested.

1. Gray M. Principles of the comprehensive examination. Arch Gen Psychiatry. 1964;10:370-381.
2. Ghaemi SN. Existence and pluralism: the rediscovery of Karl Jaspers. Psychopathology. 2007;40:75-82.
3. Gabbard GO. “Bound in a nutshell”: thoughts on complexity, reductionism, and “infinite space.” Int J Psychoanal. 2007;88(Pt 3):559-574.
4. Geppert CMA. Why psychiatrists should read the humanities. Psychiatric Times. 24;2:February 1, 2008.
5. Genova P. The Thaw. Hillsdale NJ, The Analytic Press, 2002.
6. Kick SD. Medical training in psychiatry residency: a proposed curriculum. Gen Hosp Psychiatry. 1997;19:259-266.
7. Babel I. You Must Know Everything, Stories 1915-1937. Translated from Russian by Max Hayward. Edited, and with notes by Nathalie Babel, Farrar Straus and Giroux, New York, 1966.
8. Pies R. Why psychiatry and neurology cannot simply merge. J Neuropsychiatry Clin Neurosci. 2005; 17:304-309.
9. Pies R, Geppert CMA. Beyond clinical neuroscience: encephiatrics. (letter) Academic Medicine. (in press).

Acknowledgment: The author wishes to thank Dr Melvin Gray for his article, and for his book, Neuroses: A Comprehensive and Critical View, 1978.

Ronald Pies, MD
Dr Pies is professor of psychiatry and lecturer on bioethics and humanities at SUNY Upstate Medical University in Syracuse and clinical professor of psychiatry at Tufts in Boston.
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