THE RATIONALIZATION OF CLINICAL PSYCHOLOGY
What is rationalization?
The process of rationalization, termed McDonaldization, was developed by sociologist George Ritzer. He describes the process of rationalization as explained through four different facets. These are control, calculability, efficiency, and predictability. Efficiency is the best and most effective route to your goal. Predictability ensures that things are the same from one time or place to another. Calculability places an emphasis on quantity rather than quality. Control involves the increased control over employees and customers, as well as involves the use of non-human technology.
"Clinical Psychology is the study of individuals, by observation or experimentation, with the intention of promoting change" - Lighter Witmer
Clinical psychology surfaced and was officially coined in 1907, by Lighter Witmer. However, Sigmund Freud, developed the therapeutic approach of talk therapy, the first scientific utilization of clinical psychology. Lightner Witmer was the founder of the first psychological clinic, which he opened in 1896. Most important for the field, is how he introduced the term “clinical psychology” as well as providing a definition in a paper he published in 1907. Also in the paper, he articulated the necessity of both the existence and growth of the new sub field. By 1914 there were 26 other clinics of which their sole purpose was to practice clinical psychology on patients. Witmer publicly validating clinical psychology was the first step towards the development of the public perception of the field as well as establishing its legitimacy.
The World Wars and the Impact on Clinical Psychology
WW1: As men were heading into World War I, psychological assessments were carried out before they could be drafted. The massive expansion and the demonstration of the usefulness of these exams helped to further the credibility of clinical psychology. The necessity of standardized assessments was a step towards rationalization. The war led to the American Association of Clinical Psychology being instituted, then replaced by the American Psychological Association.
WW2: As soldiers were returning home, many were suffering from shell shock, or PTSD. The clinical psychologists that were helpful before, were called upon again. In the United States, during the 1940’s there were no schools that offered a formal degree in clinical psychology. However, the demand for clinicians to treat returning veterans only increased. In turn, the U.S. Veterans Administration set up several doctoral-level training programs, as well as funded them, and by 1950 more than half of all the Ph.D. level degrees in psychology were specifically for clinical psychology. Essentially, the rationalization of the educational process allowed for the range of services to be available to more people, an advantage of McDonaldization. The governmental support, as well as the increased number of programs in the field, altered the public perception of clinical psychology, as it became a more respected occupation.
Diagnostic and Statistical Manual of Mental Disorders (DSM)
The first version of the DSM was introduced in 1956. The DSM provides lists of specific symptoms for each mental disorder, as well as the criteria for diagnosis. This allowed for clinicians to use similar language and communicate more efficiently, between other clinicians as well as non-professionals. This increase in efficiency is how the DSM was used to allow for the rationalization of the field.
THE REPLICATION CRISIS IN PSYCHOLOGY
Clinical psychology relies on published psychological research studies to provide the evidence needed for effective treatments. Around a decade ago, a series of replication projects took place, and only 39 of 100 replications were successful. This was significant as treatments were based on this research. Many began to question the field of clinical psychology, and the “Replication Crisis” as it was termed was an identity crisis for psychology. This was a major disruption in the public perception of clinical psychology, as negative comments prevailed. Rationalization was used to transform the public’s opinion on the occupation, through control. Journals now do registered reports where they take into consideration and assess the preregistrations and the strictness of the research methods before publication. Further, more than 140 journals now use these registered reports. The journals, a necessity to distribute clinical information, are exerting control over the researchers in the field. The researchers are now having to change their methods to be published. The increased integrity of psychological research due to this control is what will allow the public perception of psychology to trend towards being more positive.
“I’ve seen a culture change. “If a team of research psychologists were to emerge today from a 7-year hibernation, they would not recognize their field." - Leif Nelson, Social Scientist
Mental Healthcare and Insurance Coverage
On October 1st, 2014, the United States approved the standard coding system of ICD-10-CM, which is used to code diagnoses from the DSM. Health care systems require these codes for mental disorders to be used when billed for mental healthcare to allow for coverage. This is advantageous for clinicians and insurance companies due to the uniformity of billing. However, this strict categorical approach to diagnosis as well as how it translates to insurance coverage, is dehumanizing. We are dimensional beings, and having only 4 symptoms, but not 5, could disqualify an individual from diagnosis. In turn, this disqualification results in there being no code to send to insurance companies, and thus, no coverage. This diagnostic cutoff encourages upcoding where clinicians will diagnose patients who are close to the cutoff so they can receive healthcare coverage. Also, calculability has taken a toll and created an occupation where at times quantity is valued over quality. In most subsidized plans that cover mental health services, the services are standardized and are based on getting clients in and out in as little time as possible. It is desirable for as many people to receive care for mental disorders as possible; however, it seems there may be a disadvantage, lessened individualized care.
Goodman described a clinician as, “a psychotechnician who is a dispenser of a predetermined set of technical maneuvers'' - ( Goodman, 2015).
Clinician Judgement to Standardization
There has been a shift from clinician judgment to a focus on increased standardization. Resistance has occurred and doctors have spoken out about the importance of clinician judgment. Dr. Daniel Marston stated that, “As a psychologist with years of clinical experience, I am really concerned about where clinical psychology is headed.” He discusses how many cases receive similar diagnoses, and clinicians often are not expected to use their personal understandings. Another opponent of standardized therapy is Dr. Wade H. Silverman. He explained that how rationalized therapy has been shown to hinder the humanistic aspects of therapy.
There are also individuals who view the standardization of clinical psychology in a positive light. One group of clinicians believe that the decreased personalization is a sacrifice that will increase efficiency as well as decrease inconsistencies throughout the field. Although others believe there should be a presence of both clinician judgment and standardization. According to the APA Presidential Task Force, the “best available research” should be integrated with “clinical expertise in the context of patient characteristics, culture, and preference." They argue for rationalization of research to continue, but not to replace clinician judgment. It should be used as a complement, not a replacement.
Risk-Averse Approach
The rationalization of clinical psychology has been enabling in some senses, but highly constraining in others. If there becomes a possible risk of harm to themselves or others, there is a process of rules and procedures a clinician is asked to conduct. When there is a concern about risk regarding a patient, they are asked to complete a risk assessment. This could be exemplified by a client explaining they are self-harming, and instead of discussing this and exploring the topic, the clinician would have them complete a risk-assessment. This is in case the client does harm themselves or others, the procedures will have been done correctly, and the clinician is not at fault. This risk-averse approach is irrational as it lacks authenticity and is void of human emotion. This system is advantageous to the employers, but not the clients who are there to receive care, not only to be viewed as a possible risk.
Technotherapy?
Technology in Clinical Psychology
Following the trend towards standardization, new technology has emerged in the field of clinical psychology. The facet of control is seen through the use of non-human technology. The COVID-19 pandemic increased the rate of this process significantly. Many therapy sessions moved online, due to necessity. However, now that virtual therapy has been completed effectively many may begin to choose it solely out of convenience. Clinicians cite the “lack of travel time as advantageous” (Bierbooms et al, 2020). By technology, the field is becoming more efficient for the clinician and patient.
Besides virtual therapy, there are other forms of online mental health services. There are countless websites dedicated to self-help and will put the patient in touch with a mental health provider. For example, on the website “eTherapyPro”, all you do is click the link and then begin to speak with a free online therapist (the website is linked below). The online format is a highly efficient model for therapy and ensures that a wider range of services is becoming readily available to an increased number of people. Through technology and further rationalization, the public perception regarding mental healthcare is evolving. It is much more accessible than it used to be. The increase in control and increase in the technological format has changed the profession by demonstrating clinical psychology is for everyone, not just the few.
References
American Psychiatric Association. 2013. Implications of DSM 5 https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM_Insurance-Implications-of-DSM-5.pdf.
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