Rationalization
According to George Ritzer, rationalization has four driving forces which are efficiency, calculability, predictability, and control. Efficiency is about finding and using the optimum method for a task. Calculability talks about the quantitative aspects like how many items are sold or the number of services something offers. Predictability is about how products and services will be the same no matter where you go for the business. Lastly, control is about how human behavior and decision-making are regulated.
This process of rationalization has gone far beyond the fast-food industry, and it has stepped its way into the healthcare industry. The ideas of division of labor, standardization, and technological replacements have all been adopted by the field of medicine. In psychiatry specifically, there has been an enormous amount of rationalization as people have looked to make this field more efficient, predictable, calculable, and controlled. Whether it be changing the methods of treatment or the addition of new practices for the patient, the effect of rationalization on psychiatry is undeniable.
Mental illness was originally believed to be caused by supernatural influences such as demonic possession, curses, and sorcery. This led to the treatment of trephining where people would have a hole drilled into their skull so that the evil spirits inside the patients would leave. While the process was not always fatal, many people died from having this operation done on them. After the Middle Ages, a new form of treatment started called moral treatment. Moral treatment was a result of the Enlightenment, and it advocated for kindness and patience when treating mentally ill patients. The facilities were now cleaned, and the patients were not chained. They were changing the way mental health asylums were run, so the patients could recover by being civilized and acting polite.
Eventually, moral treatment began to fade. Mental hospitals began to have more and more patients, and they could not keep up with the influx. This led to neglect and the facility's upkeep took too much time. This combined with the lack of attention given to the individual led the hospitals to abandon moral treatment. In the 19th century, Dorothea Dix played a huge role in working to improve the condition of mental health care in the United States, and many of her contributions are still visible to this day. After touring madhouses in Britain, Dix committed herself to a movement she called “lunacy reform”. One of the main goals she had was to improve living conditions at mental health facilities. Similar to moral treatment, she advocated for clean grounds and well-maintained buildings. She also worked to push the legislation past to help allocate government money to be spent on mental health reform.
There has been lots of change over the years in psychiatric treatment, and now, psychiatry is accepted and treated as a medical condition rather than a spiritual fall. The main development that happened in modern psychiatry is the rise and development of psychopharmacology. Psychopharmacology is the use of medication in treating mental health conditions and disorders. There are many different types of medicines that were developed and they include antidepressants, stimulants, antipsychotics, benzodiazepines, and mood stabilizers.
Drug therapy also helped start the shift away from many dangerous procedures like electroconvulsive therapy (ECT) and lobotomy. These are both invasive procedures that were not very reliable, and they had the potential to seriously hurt the patient. The first antipsychotic drug was approved in 1954, and it was called chlorpromazine which was supposed to help treat schizophrenia. This revolutionized the psychiatric industry and made the pathway for drugs to be introduced as a method of treatment. Now, drug therapy is used concurrently with psychotherapy to treat the mentally ill.
Efficiency
One technology that has been revolutionizing efficiency for psychiatrists is mental health apps. Mental health apps can track one’s mood and identify symptoms of mental disorders. Mental health apps are not a replacement for psychiatrists, but they are a tool that allows psychiatrists to receive vast and accurate information about their patients. Rather than relying on the patient to tell information about themselves, they have it all tracked and given to them whether it is tracking their sleep or checking if they have taken their medication. This allows psychiatrists to have access to this information faster, and they will get more accurate and up-to-date information.
One irrationality to note is that apps do not guarantee privacy. A study that looked into mental health apps says that approximately 25% pass the basic test of keeping user privacy. Some apps allow people to connect to psychiatrists via video calls. This is known as telepsychiatry, and this has been adopted due to the rising costs of medical health services and the lack of psychiatrists. Telepsychiatry helps those who live in geographically isolated regions get in contact with psychiatrists and provide mental health services at a lower cost.
Calculability
In psychiatry, the myth that medication is cheaper than talk therapy has been spread. While this is not a completely false statement, it ends up being a false statement for the general public because of the way their treatments end up being structured. The reason for this is how people view generic medicines. Generic medicines have played a huge role in curbing the costs of drugs, and they can be up to 85% cheaper than brand-name drugs.
A study was done where people were given the same drug, but one group was told it was expensive and the other was told it was a generic medicine. The placebo effect was observed here as the group who was told it was a more expensive medicine reported significantly higher pain reduction. The only difference between generic medicines and brand-name drugs is the inactive ingredients, but the active ingredient is always the same between these. There is no functional difference, yet people view generic medicines as inferior which leads to skyrocketing costs due to how expensive brand-name medications are. This can also be looked at as an irrationality for calculability because people go towards drug therapy for cheaper results; however, they end up choosing the more expensive option because of the mindset they have. It is essential for doctors to increase patient confidence in generic medicines and not discourage talk therapy as it is extremely effective as well.
Predictability
In psychiatry, predictability has always been lacking. One group of researchers built a machine learning model to aid with predictions of major depressive disorder (MDD) and generalized anxiety disorder (GAD). These specific disorders were chosen due to their high prevalence and potential to harm patients and patients’ families. This study is different from other studies because it is using a machine learning model to predict outcomes based on general demographic data as opposed to using data that is known to have an impact on the likelihood of psychiatric disorders. This study took 4,184 students from the University of Nice Sophia-Antipolis, and they had them take a basic medical exam.
After feeding all the information to the model, the test set is sent for the model to make its predictions. The accuracy of the model is based on the area under the operating characteristic curve (AUC) and 0.58 is considered a small effect size, 0.69 is a medium effect size, and 0.79 is a large effect size. The end results were (0.70, 0.67) and (0.70, 0.73) for MDD and GAD respectively. While this is roughly the average accuracy for machine learning models, this is a huge jump because it required much less specific data to get these results.
The results are far from perfect, but this is a huge jump in technology in the predictability of psychiatric disorders. The fact that this level of accuracy can be made on basic demographic information about a patient is a huge breakthrough. In addition, disorders like MDD and GAD take years to be discovered causing the patients to be much worse than if they were treated initially. While machine learning incorporation is still new, it has the potential to change the field of psychiatry by providing doctors with data about patients that would have been impossible to tell if a human saw their data. Prevention has always been a tough subject in psychiatry, but with the help of machine learning models, we can see who is at risk and help stop the problem before it starts.
Control
Psychiatrists are controlled by insurance companies which is why there has been a 35% decline in psychotherapy. Before there was a sense of autonomy for psychiatrists, a psychiatrist could treat a patient using various methods. However, now, insurance companies do not believe in talk therapy and prefer drug therapy. Insurance companies are not willing to pay for talk therapy. A psychiatrist can earn $150 for 3 15-minute medication visits compared to $90 for one 45-minute talk therapy session. The insurance companies that do pay have extremely low reimbursements which further discourages psychiatrists from even accepting insurance. They would rather a patient pay out of pocket, so they can get paid their regular wages.
There are many social workers who offer talk therapy at lower rates therefore, people are no longer coming to psychiatrists for talk therapy since without insurance it is extremely expensive. Psychiatrists' talk therapy is catered to the wealthy and can range up to $600 per hour. Despite the huge benefits of talk therapy, many insurance companies do not see it as necessary which is why many do not pay for it. Psychiatrists still need to make money which is why they simply prescribe medication and give a diagnosis in 15 minutes since that’s what pays.
IRRATIONALITIES
George Ritzer defines irrationalities as systems that have been rationalized and optimized for the 4 pillars, but they actually end up being less efficient which in turn is irrational. While there have been many advances in technology which in turn helped psychiatrists, not every advancement has come without a cost. Technology has caused many irrationalities and inefficiencies that arose from the rationalization of this field.
Technology has allowed for the development of mental health apps, which has helped with the efficiency of treatments and the control of patients’ lives when they are being treated for mental disorders. A major issue is that there are so many apps that people cannot tell which ones are actually helpful and which ones are not. Many apps are not backed by clinical evidence, and only 15% of the apps were based on studies that had feasibility. Privacy concerns are a major thing to worry about because 44% of apps shared users’ health information with third-party sources.
Another problem that has risen for psychiatrists because of rationalization is overdiagnosis. Rationalization in this field has allowed for efficiency with doctors only seeing their patients for ten to fifteen minutes each. The downside is that now psychiatrists are focused purely on patients’ symptoms. Doctors no longer consider the possible social, cultural, and environmental factors that could be contributing to the patient's condition. This leads to both unnecessary diagnoses and over-treatment for something that is not there.
On top of that rationalization is focused on standardization, and standardization is not good in a field like psychopharmacology because people respond to medications extremely differently. There is a huge dependence on these drugs in the psychiatry industry due to their rationalization, but they are not necessarily the best option for patients as they can do more harm than good. Rationalization has benefitted the industry as a whole, but the newfound efficiency and calculability in this field have not come without a price.
Covid-19 and Psychiatry
When the COVID-19 pandemic hit the world, the profession of psychiatry reached unprecedented demand due to the huge increase in mental health issues in people. As mentioned earlier, there is already a growing shortage of psychiatrists. The pandemic showed that the world’s mental health services were not on par with the need. One technology that grew in prevalence when the pandemic arose was telepsychiatry. This allowed for efficiency because during the pandemic going places took lots of time. Also, this helped prevent the need for extra space because of distancing rules during COVID. One thing that was a tradeoff was that some patients preferred the environment at psychiatrist's offices because it allowed for a better mindset and transition. However, there are also some people who like having the appointments at home since it eliminated the stigma for them. It has drawbacks and benefits, but it is mainly based on the individual. However, its efficiency cannot be denied for both the provider and the consumer.
One new technology developing for psychotherapy is virtual reality (VR). VR is used as a way for users to explore a simulated environment while working with psychiatrists, and it allows for the digital treatment of various mental disorders. One disorder that scientists are trying to help alleviate symptoms of is anxiety. People have fears of presenting in front of huge crowds, and VR helps them by creating simplistic environments and situations to help people face their fears.
Technological advances all relate to Ritzer’s model because the goal is to make treatments more efficient, cheaper (calculability), standardized (predictability), and controlled. The impacts of COVID-19 may seem brief, but its impact is one that has a ripple effect. One’s mental health problems do not go away quickly and can be life-long recurring issues.
Conclusion
Over the years, the profession of psychiatry has changed tremendously, and the treatments and ideologies for this field have made huge advances. The constant in this change is the presence of rationalization. The four pillars of rationalization have changed how people receive healthcare, and it has allowed people to get much better mental health treatments compared to a few decades ago.
The efficiency of mental health care has greatly improved with the new advances in technology allowing doctors to get real-time data as well as providing more autonomy for the patients to do their own research. Calculability has been encouraged through the promotion of generic drugs so that patients can recover quickly and cost-effectively. Predictability has been completely revolutionized with the introduction of machine learning which now allows for predictions of patient remissions unlike before when one could make only educated guesses about the patient’s future. However, irrationalities do exist, and there are drawbacks to this system too. The aspect of control negatively impacts the patients as insurance companies refuse to pay for specific treatments. There are new problems that arise due to innovative solutions such as privacy for those who use mental health apps and dependency for those who are under drug therapy.
Overall, mental health care has improved, and it is not perfect but better. The irrationalities and problems within the system exist, but mental health care access has increased via technology and there is much less of a stigma surrounding mental health. Rationalization has helped fight inequality in mental health care as poorer people can now afford medications, and they can get quick treatment to get better faster. We don’t know the future of the rationalization of this field, but it looks hopeful with all of our technological advancements and innovative solutions. Rationalization, as Ritzer has defined it, is the pillar for change and is paving the way for a better future for mental health care.
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