What is Rationalization?
Rationalization, as defined by Max Weber, is the process whereby conventional reasoning is “replaced by an ends/means analysis concerned with efficiency and formalized social control” (CCP.edu). In his book “The McDonaldization of Society”, George Ritzer builds off Weber’s analysis by outlining four dimensions of rationalization: efficiency, predictability, calculability, and control. The first of these dimensions, efficiency, calls for a choreographed process and the optimum method for completing tasks (Ritzer). Subsequently, predictability is demonstrated through the assurance that products and services within a profession will remain the same over time. Next, calculability places a strong emphasis on saving time and money, as well as promoting quantitative over qualitative aspects. Finally, control is indicated by attempts to strategically influence the behavior of consumers in order to maneuver a more proficient and systematic arrangement in the workplace. Ritzer models these components through the example of McDonald’s restaurants, which he argues are a nearly perfect model of how rationalization is intended to be achieved.
How does this apply to mental health?
Mental health, as defined by the World Health Organization, is a “state of well-being in which [each] individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to [their greater] community”. Mental health care has become widely stigmatized throughout modern society, and this standardization is largely due to rationalization.
Given that each individual’s psychological and emotional well-being is different, mental health care requires the establishment of a personal connection. With the implementation of Ritzer’s four dimensions, this personal connection is seemingly lost. The process of rationalization is slowly but surely changing the mental health and psychotherapy professions through strategic planning, technological changes, and research. Through Ritzer’s principles of McDonaldization, my paper outlines and analyzes the extent to which rationalization has impacted the mental health care industry, as well as whether that impact has been beneficial or detrimental.
The Origins of Mental Health Care
The implementation of tactics to promote rationalization in the psychiatric workplace began as early as the mid twentieth century. Before 1955, physical isolation and mental asylums were the preferred treatment for mental disorders. Individuals who struggled with mental health problems were considered to be “lunatics”, and insanity was thought to be an incurable disorder (Smith). This extreme stigma only exacerbated the fear surrounding mental conditions, categorizing patients as something to be locked away. However, with the start of deinstitutionalization, society's attitude towards these practices shifted. This shift was largely prompted by the introduction of psychiatric drugs, as well as individual states’ desires to reduce unwanted costs from mental institutions.
In 1955, a large sum of patients were removed from psychiatric care facilities to instead receive treatment through prescribed drugs and outpatient procedures and less “restrictive” treatment methods (Pbs.org). This shift in emphasis of care was clearly driven by a desire for efficiency and calculability within the mental health field, as there is a dominant belief that deinstitutionalization is a cost and time saving approach to psychiatric care reform. From 1955 to 1994, the number of severely mentally ill patients in the nation’s public psychiatric hospitals fell by about 87.17%, as 486,620 severely mentally ill patients had been removed from institutional care. This is a striking statistic on its own, however, when one accounts for population change over that time, the true magnitude of deinstitutionalization would amount to over 92 percent of people in institutions being removed from treatment and care (Pbs.org).
The process of deinstitutionalization as a whole left mental health patients with significantly less support in response to the effort to provide more independence and save money within the field. It caused a general increase in homelessness and incarceration. Additionally, following the Great Recession, economic struggles forced state governments to cut approximately $4.35 billion from public mental health spending from 2009-2012. This impacted patients’ access to Medicaid and vocational rehabilitation, thus, budgeting was prioritized over results.
Efficiency
When considering efficiency’s impact on psychiatric professions, one would likely assume that its implementation may inhibit success within the field. Therapy, for example, relies on personal connection, which is extremely difficult to achieve when focusing on maximizing ‘system’ efficiency. However, multiple studies have found no significant difference between computer-assisted cognitive behavioral therapy and standard practice cognitive behavioral therapy. One study, profiled in the American Journal of Psychiatry, presents the method of computer-assisted cognitive behavioral therapy as a combination of Internet delivered skill-building modules and 5 hours of contact with a therapist. The study emphasizes that the computer-assisted program was not inferior, even though the conventional cognitive course provided 8 additional hours of interaction with a therapist (Thase). This method was designed to improve efficiency by reducing the amount of consultation time, as well as reducing the effort required to effectively produce therapy courses. It was also intended to make it more widely available and accessible. When initially considering how efficiency might be implemented into mental health professions, with therapy in particular, many researchers were concerned about whether the level of connection that is typically experienced in traditional therapy would be effectively maintained. According to these studies, there is no significant loss of success with a mostly digital curriculum of therapy.
Furthermore, in an empirical study of managed mental health care, the researchers concluded that managed care providers felt their patients had considerably less access to long-term services. However, this author provides a solution for this predicament: “The way to resolve the conflict between providing a full array of services to all who need them and cost containment is to involve professionals in decisions” (Scheid 147). Scheid argues that this problem could be solved if professionals were involved in decisions regarding service planning, delivery, and establishing set standards that are to be upheld. This could maximize the resources available to patients while also maintaining the principle of efficiency.
Predictability
The dimension of predictability takes form within the spectrum of reliability in mental health diagnoses. In 1952, the American Psychiatric Association released the first edition of a guide to diagnoses within the mental health field: Diagnostic and Statistical Manual of Mental Disorders. This manual, however, did not provide adequate detail, even though the authors did not originally envision that it would be revised periodically in the future (Vahia). However, in 1980, the American Psychiatric Association developed a more detailed adaptation of their initial publication. DSM-III represents a “benchmark in the history of psychiatric nomenclature”, as it provided, for the first time, a multitude of detailed and explicit criteria for the diagnosis and identification of complex mental health disorders (Aboraya). With this volume came the assurance that patients would receive a correct diagnosis, distinctly promoting predictability and its goals. While the manual does require extensive analysis to determine a diagnosis, it was also revolutionary in terms of psychological diagnoses and analysis of those diagnoses. Since the establishment of the DSM III, the diagnostic and statistical manuals have been thoroughly revised as time moved forward and new discoveries were made about mental disorders. The most recent of these manuals is the fifth edition, DSM-5 / DSM V, produced in 2013. This was a landmark for the American Psychiatric Association that is still used to this day, as it reflects the consensus of copious psychology experts, clinicians, and researchers to promote more accurate diagnoses (Vahia).
Additionally, since patients take comfort in knowing what to expect, predictability is also present as it relates to consistency and routine treatments. The continuity of care “is considered by service users as well as professionals as an essential feature of high quality [mental] health care” (Biringer). While the continuity of care can be defined in a multitude of different ways, when services are completed routinely, there becomes a sense of consistency and security for future care with that service. Consumers take comfort in this sense of routine laid out through rules, a consistent pairing with their mental health professional, and the treatment curriculum. Mental health professions, in this way, are clearly being affected by this dimension of rationalization by guaranteeing more customer satisfaction while also contributing to a more rationalized system.
Calculability
Moreover, the dimension of calculability is present within technology-based treatment plans. The patient-client relationship is one of the most important parts of mental health care, as that intimate bond allows for an accurate diagnosis and personal connection. However, one irrationality within the online scope of mental health care is the notion of dehumanization, that this type of rationalized procedure may deplete the therapeutic environment of human connection and accuracy. While research has shown that technology-mediated therapy does not evidently show a statistical difference in results than with traditional therapy, there are questions to be raised about the use of online psychotherapy with regard to precision. With virtual counseling, a counselor may not notice important “critical nuances that could help in modifying the therapy or even reassessing the initial diagnosis” (Satalkar). Professionals have suggested that losing these essential non-verbal cues significantly impacts the validity of diagnosis and ultimately the patient’s course of treatment. For example, asynchronous options, such as emails, cannot convey if a client is under the influence or if they become uncomfortable discussing a sensitive topic during treatment. Therefore, although a calculable approach is taken through the implementation of online psychotherapy, these attempts to save time and money may be at the expense of the patient's psychological well-being. Furthermore, there have been strong attempts to minimize complexity within online psychoanalysis by attempting to operationalize competencies (Strawbridge). This is a calculable approach because it saves time and money; however, it deskills workers and routinizes a process that conventionally requires an intimate connection. Thus, individual values and personal touches that traditionally come with conventional therapy are lost.
Control
Moreover, with regard to the last element of Ritzer’s 4 dimensions of rationalization, control, mental health professionals in our modern age are trained to do tasks precisely how they are told. As with any profession, you are expected to follow specific guidelines with regard to patient care, scheduling, analysis, and formal reports of that analysis. In the case of psychotherapy, most experts must approach treatment on a case-to-case basis. Though therapy typically has an emphasis on a therapeutic relationship throughout the process, in a 2002 essay on the McDonaldization of Therapy, Strawbridge points out the continued emphasis on professional training in techniques. This training has an impact on the patient as well, because they have to fit the strong mold of progress that the therapist has been trained in (Strawbridge). This may prompt a patient to answer in a way that does not truly convey their experience, but rather fits the counselor’s mold. This type of control is also reinforced by technological advancements, as computerized treatments often prompt the user for a specific type of response and incite a pressure to correctly complete the task or routine treatment response. While it is meant to support rationalization and promote overall success, the implementation of control to mental health professions may be more detrimental than beneficial.
Conclusion
In conclusion, rationalization and its principles have made a substantial impact on the mental health professional field. From efficiency, to predictability, to calculability, to control, all four dimensions are present within the profession. Overtime, rationalization within mental health care has shifted not only in terms of scale, but also in terms of success. In the beginnings of rationalization’s impact on the mental health field, big changes were being made, but it was detrimental to patient care. In recent years, these changes are actually beneficial to patient care. I think this distinction is very important when considering rationalization’s impact on the field as a whole. Looking forward, I believe that as technology continues to advance, the presence of the four dimensions will become significantly more distinct. The transition to online treatment will continue to evolve and perhaps even more aspects of mental health professions will transition to online interactions. There has been little resistance to changes in favor of rationalization so far, but I think that in the future, as the changes become more radical, the public will react accordingly.
In my opinion, rationalization is hurting the mental health community more than it is helping it. Large corporations are more concerned with budgeting and saving money than with patient results and experience. Although current research does not find a difference between online cognitive behavioral therapy and traditional behavioral therapy, there is so much more to be learned about the mental health field and how disorders may be evolving as society advances. Overall, though not all positively, the process of rationalization is slowly but surely changing the mental health and psychotherapy professions through technological advancement, budgeting, and diagnoses.
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