WHAT IS RATIONALIZATION?
Rationalization can be defined as “a long-term process whereby beliefs based on morality or superstition are replaced by rules and procedures based on logic and efficiency” (Bell, 2003). This journey eventually results in efficiency, coordination, and control over social and physical aspects (Kim, 2017). This concept has led to an unprecedented rise in the production and distribution of goods and services; it is also associated with depersonalization, secularization, and oppressive routines. Rationalization results from an industrialized world, a society where calculation and reason are the main driving factors behind one’s social behaviors (Kim, 2017). Sociologist George Ritzer builds upon this ideology with his novel, The McDonaldization of Society: Into the Digital Age, where he elaborates on four key dimensions that advance rationalization: efficiency, predictability, calculability, and control.
As described by Ritzer, efficiency focuses on the optimal methods and practices to complete a task with the least amount of time, money, and effort put into it. The second principle, predictability, refers to the promise of consistency and uniformity in the goods and services provided, regardless of when or where you are, in addition to the sense of comfort that comes from that. The idea of calculability has an emphasis on the quantitative aspect of the industry, whether it be the cost, time spent, or general statistical data. Finally, control describes the implementation of human and non-human technologies that cannot be deterred from once used. Using the concepts of Ritzer’s dimensions drastically simplifies identifying the effects of rationalization when analyzing something as commercialized as a McDonald’s restaurant. However, it becomes much more complicated when looking at a more niche and complex profession such as clinical psychology.
ORIGINS OF CLINICAL PSYCHOLOGY
Before there was a true science to psychology, it had a more broadened practice. For example, this meant providing generic care/treatment to people in psychological distress. Before the job creation of a psychologist, there were various psychological practitioners in the eighteenth and nineteenth centuries with eclectic labels such as psychic, phrenologist, spiritualist, physiognomist, and more (Benjamin, 2004). There were no uniform educational or licensing requirements for those who wished to practice psychological care, and there also were no federally enforced laws to serve as protection against fraudulent and malpractice issues.
In December 1896, Lightner Witmer presented at the American Psychological Association’s fifth annual conference where he urged all of his colleagues in higher academia to use their psychology knowledge to “throw light upon the problems that confront humanity” (Witmer, 1897). He delivered this speech at a highlight time in his career; in March of that same year, he had opened the very first psychological clinic in the United States, and possibly the world where he began to assess and treat a diverse group of psychological illnesses (McReynolds, 1997).
In 1907, Witmer created an entirely new journal, titled The Psychological Clinic, which he used to publish case studies that contained detailed descriptions of his client’s presenting symptoms, explanations of their diagnoses, and the course of treatment he created for them (Witmer, 1907). Witmer’s primary article in this journal was titled “Clinical Psychology,” where he not only defined the career but also outlined his doctoral training and education for the profession.
THE CREATION OF THE DIAGNOSTIC STATISTICAL MANUAL
In 1952, the American Psychiatric Association released the Diagnostic Statistical Manual of Mental Disorders. Often referred to as the DSM, the manual provides a universal language for all mental health professionals to utilize throughout the diagnosing process (Kawa & Giordano, 2011). Before the DSM was created, psychologists lacked the necessary emphasis on nosology with their patients (Blashfield et al., 2014). Numerous patients could all have the same symptoms, but all would receive a different diagnosis because of this lack of consistency. This caused severe inefficiency as patients were not properly receiving the appropriate care for the actual illness that they suffered from. However, the DSM’s symptom explanations, outlined descriptions, and specific criteria needed to diagnose each specific mental illness helped significantly to streamline the process of diagnosing (Blashfield et al., 2014).
In this profession, clinical psychologists’ time directly equates to money, which is why the efficiency of using the DSM was such a strong selling point. Any possible form of cost reduction within this field is praised in hopes of making care more accessible for lower-income individuals in need. Its emergence also provides a sense of predictability and comfort, a feeling that psychologists and patients had never experienced before; knowing that they will receive the same treatment and diagnosis no matter what hospital or mental establishment they go to.
MANAGED CARE HEALTH INSURANCE PLANS
Community-based mental healthcare is a designed method of treatment that incorporates a series of services and programs to meet the local needs of an area (Heaton & Tadi, 2023). This form of therapy is more typically hosted by local community organizations, hospitals, or medical clinics with the primary goal of prioritizing mentally ill people in direst need (Homeless Hub, 2021). As the profession of psychology began to turn towards more community-based approaches, critics and advocates of social and ethical justice began to how citizens had to find accessible mental healthcare, as well as the quality of said care (Alem, 2002). This led to the notion that all patients deserve the right to choose their own treatment plans and what psychologists they work with, all without risking an increase in cost or a decrease in quality of care. From this point forward launched the system of managed care, where its sole purpose is to accomplish those things exactly. Most psychologists began working under this managed care system after its stark usage increase in the 1970s. Some of the most effective selling points and characteristics of managed care that were incorporated into health insurance plans are preventive care incentives, provider networks, prescription drug tiers, prior authorization, and much more (Heaton & Tadi, 2023). Additionally, this overarching system then breaks down further into varying types of managed care organizations.
THE HEALTH MAINTENANCE ORGANIZATION
Health Maintenance Organization’s treatment plans serve mostly as a means of preventative care for clients. Patients that choose this course of treatment can select an additional medical professional in supplement to their main psychologist who they can serve as a buffer and guarantee that their primary health is in good standing along with their minds (Cooper & Lentner, 1992).
Incorporating the ideas of managed care, if a patient’s primary care doctor does not agree with the course of treatment that the client personally wants to pursue, the service is then not covered through insurance – leaving them to deal with out-of-pocket costs. This process has greatly relieved the additional burden from psychologists, as before they would have to spend a great amount of time creating a treatment/service plan, and then deal with potential client backlash as well. As stated by the bureaucratic principles of Max Weber, managed care features a hierarchal division of authority, meaning that the case manager/supervisor has the highest extent of power; they can exceed the assigned psychologist on each case (Pallot, n.d.). The ideology and functioning of HMOs are built off the belief that the cost of healthcare correlates to utilization multiplied by the cost per unit, making the overall purpose of the approval process between the case manager and clinical psychologist to limit the occurrence of unnecessary tests, procedures, and of course costs (Cooper & Lentner, 1992).
INFORMATION LAW REGULATIONS
Prior to the enforcement of HIPAA, ensuring the safety and confidentiality of those in therapy was always a main concern. However, the existence of formal legislation that legally binds all healthcare providers to be compliant established a further sense of trust and comfort to mental patients, who now feel safe enough to share more vulnerable information about themselves.
While HIPAA’s main purpose is to ensure patient confidentiality, there are some limitations. Psychologists are allowed to share confidential information discussed during therapy sessions with people involved in their patient’s care under certain conditions, these are: if the client has agreed, if the client has been given the opportunity to object but did not if the client has mentioned that they do not object to having a partner or parent assist with medication and scheduling, or if the person is delirious, unconscious, experiencing psychosis, inebriated, and unable to make sound decisions (Good Therapy, 2020).
As it pertains to the mental health field, some of HIPAA’s unique conditions do not directly translate fully to the needs of smaller private psychological practices – thus leading to the creation of a different version of training specifically for mental healthcare professionals. Psychologists must uphold the same requirements in compliance with HIPAA, however, they also must use the same information taught in their education to decide the best way to comply (U.S. Department for Health and Human Services, n.d.). Psychologists who use technology in their practice must take another precautionary step to inform all clients that their communications via email are not protected. Furthermore, psychologists must share client information when they express that they are at suicide risk or risk of hurting other people.
ELECTRONIC HEALTHCARE PORTALS
Electronic medical records, EMRs, have made significant strides in making online access to information by medical professionals and patients a vital role in the healthcare process. These electronic patient portals are said to allow patients more secure access to their personal health-related information, as well as grant them the ability to communicate with their medical professionals (Pagliari et al., 2007). More advanced EMRs can even offer secured text messaging exchange functions, where patients can chat with their various health professionals for numerous reasons, including but not limited to new health/symptom development, insurance/payment concerns, appointment scheduling, prescription refills, and more.
Research is showing that both patients and clinical psychologists/providers who utilize telehealth and online patient portals tend to view it favorably and even prefer it over in-person sessions (Abrams, 2020). While the technology and infrastructure for telehealth have been available since the mid-1990s, the healthcare industry never would have embraced telehealth fully without such a world reckoning event like a pandemic. Research is pointing to promising results on the effectiveness of telepsychology. For example, the US Department of Veterans Affairs has tested multiple trials on PTSD interventions delivered in person versus by videoconference, finding that the two methods are equally effective in the majority of cases (Turgoose, D., et al., 2018).
FUTURE OF PROFESSION
As research trends are showing, the rationalization of a field is an ongoing process that snowballs over time. The clinical psychologist industry proves this sentiment to be accurate. Due to increased reliance on technological advancement and innovations, psychologists can reasonably expect their typical day’s work to shift from in-person face-to-face therapy sessions with their clients, now to purely online teletherapy services. Numerous software companies have caught on to this prediction and are beginning to develop and improve their products to ensure the overall experience and quality of treatment is satisfactory to both parties.
It is reasonable to assume that soon everyday technology on mobile devices will become very popular to deal with more popular mental disorders such as mild depression, schizophrenia, autism, anxiety, ADHD, and suicidal tendencies (National Institute of Mental Health, n.d.). They also predicted that therapy software will begin to move over to more devices other than cell phones or computers, such as TVs and smart cars.
Additionally, it is probable that psychologists will soon only offer a hybrid option for their appointments to establish a balance between the necessary human touch and interaction with ease and convenience (National Institute of Mental Health, n.d.). Technology’s domination over the profession is predicted to ultimately meet the efficiency and accessibility desires of clients while still maintaining the high standard of care that is necessary for psychologists, showing that rationalization can provide methods of compatible progress.
CONCLUDING THOUGHTS
Throughout the new methods, systems, and technologies that have been created and become available for practicing clinical psychologists to use, the existence of rationalization has remained consistent. Despite how Ritzer’s dimensions of rationalization can be attributed to a magnitude of evolutionary changes within the world of psychology, it is still difficult to make overall access to psychologists and mental healthcare obtainable for all citizens of all backgrounds.
As rationalization will continue to evolve in the work of clinical psychologists, still a lot of work needs to be done. By analyzing how the field has progressed, and by reflecting on where it began, it can be hypothesized that its main issue of inaccessibility will continue to resolve itself as time progresses. It is imperative to address this problem area because for a system of healthcare, regardless of specialty, to remain viable, it must be accessible to the most people possible. The viability of systems and practices then directly translates into job security and outlook. In this case for psychologists, implementing Ritzer’s dimensions of efficiency, predictability, calculability, and control appears to be a reasonable method to ensure this positive growth.
REFERENCES
Alem, A. (2002). Community-based vs. hospital-based mental health care: The case of Africa. World Psychiatry, 1(2), 98-99. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1489871/
Abrams, Z. (2020, July 1). How well is telepsychology working? Monitor on Psychology, 51(5). https://www.apa.org/monitor/2020/07/cover-telepsychology
Bell, K. (2003). rationalization definition. Open Education Sociology Dictionary. Retrieved April 18, 2023, from https://sociologydictionary.org/rationalization/
Benjamin, L. (2004). A History of Clinical Psychology as a Profession in America (and a Glimpse at Its Future). https://doi.org/10.1146/annurev.clinpsy.1.102803.143758
Cooper, S., & Lentner, T. H. (1992). Innovations in Community Mental Health (1st ed.). Professional Resource Exchange Inc.
Good Therapy. (2020, January 8). HIPAA for Mental Health Professionals: The Basics. GoodTherapy. Retrieved April 18, 2023, from https://www.goodtherapy.org/for-professionals/software-technology/hipaa-security/article/hipaa-for-mental-health-professionals-the-basics
Heaton, J., & Tadi, P. (2023, March 6). Managed Care Organization - StatPearls. NCBI. Retrieved April 19, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK557797/
Homeless Hub. (2021). Community-Based Mental Health Care. The Homeless Hub. Retrieved April 16, 2023, from https://www.homelesshub.ca/about-homelessness/service-provision/community-based-mental-health-care
Kawa, S., & Giordano, J. (2011). A brief historicity of the Diagnostic and Statistical Manual of Mental Disorders: Issues and implications for the future of psychiatric canon and practice. Philosophy, Ethics, and Humanities in Medicine: PEHM, 7, 2. https://doi.org/10.1186/1747-5341-7-2
Kim, Sung Ho, "Max Weber", The Stanford Encyclopedia of Philosophy (Winter 2022 Edition), Edward N. Zalta & Uri Nodelman (eds.), URL= <https://plato.stanford.edu/archives/win2022/entries/weber/>.
McReynolds, P. (1997). Lightner Witmer: His life and times. American Psychological Association.
National Institute of Mental Health. (n.d.). Technology and the Future of Mental Health Treatment. NIMH. Retrieved April 18, 2023, from https://www.nimh.nih.gov/health/topics/technology-and-the-future-of-mental-health-treatment
Pallott, H. (n.d.). 1996 Resolution No. 2: Negotiating Managed Health Care Plans | American Federation of State, County and Municipal Employees (AFSCME). AFSCME. Retrieved April 19, 2023, from https://www.afscme.org/about/governance/conventions/resolutions-amendments/1996/resolutions/2-negotiating-managed-health-care-plans
Turgoose, D., Ashwick, R., & Murphy, D. (2017). Systematic review of lessons learned from delivering tele-therapy to veterans with post-traumatic stress disorder. Journal of Telemedicine and Telecare. https://doi.org/10.1177/1357633X17730443
U.S. Department for Health and Human Services. (n.d.). HIPAA Privacy Rule and Sharing Information Related to Mental Health (hhs.gov). HHS.gov. Retrieved April 18, 2023, from https://www.hhs.gov/sites/default/files/hipaa-privacy-rule-and-sharing-info-related-to-mental-health.pdf
Witmer, L. (1897). The organization of practical work in psychology. Psychological Review, 4, 116-117.
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