McDonaldized Psychotherapy MAGGIE MCGINNIS

What is Rationalization?

Social theorist Max Weber laid the groundwork for understanding rationalization, arguing that traditions, morals, and emotions as influences on social behavior are being replaced by rational and calculated ones. Sociologist George Ritzer expands on this theory in his book, The McDonaldization of Society: Into the Digital Age which explains the four key elements of rationalization through McDonald's—everything must be fast (efficiency), the same everywhere (predictability), managed (control), and cheap (calculability). McDonald's is Ritzer's main example, but this rationalization is everywhere, from malls to schools, even therapy. Over the past century, psychotherapy has become increasingly rationalized. Although irrationalities arise throughout the process, for many patients and workers in the profession, the benefits of rationalization in the mental health field outweigh the costs.

The Evolution of Mental Healthcare: A Concise History

Mental healthcare has become increasingly rationalized over time. Early socities blamed demons for strange behavior, leading to exorcism. In the Middle Ages, misunderstood 'witches' faced torture. The 18th century brought asylums—places to warehouse, not treat, the mentally ill. Condtions were awful, with restraints and beatings. Reformers like Dorothea Dix fought for better care, leading to the first public mental hospitals. While not perfect, these institutions brought order and a more calculated approach. Each era reflects a changing approach to mental health, from fear and faith to the focus on control, efficiency, predictability, and calculability.


Aiming to standardize treatment in the field and control therapists, the first Diagnostic and Statistical Manual of Mental Disorders (DSM) was published in 1952. Before the DSM, mental health diagnoses were subjective, depending on the individual practitioner. The DSM introduced an objective approach by outlining standardized criteria for mental disorders. With clear diagnostic categories, clinicians could now diagnose illnesses through a checklist of symptoms. The DSM strengthened psychotherapy’s reputation by developing a common language for professionals to use.

The Move Toward Medicine and Deinstiutionalization

The mid-20th century brought a dramatic shift in mental health care in the U.S. The introduction of antipsychotic medications in the 1950s was a game-changer. Unlike previous treatments, these medications offered a far more effective and efficient way to manage mental illnesses, particularly psychosis. This coincided with legislative reform under President John F. Kennedy, who pushed for federal support for community-based mental health services. Large asylums began to close, replaced by a focus on supporting individuals within their communities. While deinstitutionalization may seem like a move away from control, it was also a product of rationalization. Asylums were expensive and inefficient, and community care offered a more streamlined and cost-effective approach.

The Mental Health Field Today

Rationalization continues to transform psychotherapy in the 21st century. Sessions have become more standardized with scripts, time limits, and protocols. Educational pathways, licensing, and evidence-based treatments regulate therapy sessions and control professionals. Ethical codes and government oversight protect consumers. Even the industry’s profitability reflects rationalization, with the growing demand leading to a reliance on efficiency over individualized care.

Educating and Licensing Providers

Mental health professional training used to be informal, but now it's more like McDonald's with set paths, credit hour requirements, and class guidelines to make sure therapists are all on the same page. The American Counseling Association made counselor licenses a thing nationwide, and each state sets its requirements. Licenses add rules and checks to the system, but they also make people trust counselors more. Tests and training hours are gatekeepers that only let qualified people become counselors. While this aims to be efficient, different requirements in each state can be a big headache for new mental health professionals. This confusion can lead to problems in their careers, and it also makes it harder for people to get help through telehealth because of state lines.

Evidence-Based Treatments (EBTs)

Therapy used to be based on feelings or traditions. Now, evidence-based treatments (EBT) make it more like science. EBTs are like recipes for mental health, using research to find the most effective ways to help people. These recipes give therapists a clear plan and make therapy more predictable, like how McDonald's always makes burgers the same way. The American Psychological Association (APA), the biggest group of psychologists, likes EBTs because they're reliable and cost-effective ways to treat problems.

Professional Organizations

The American Psychological Association (APA) is a great example of how mental health care became more organized. Founded in 1892, the APA set the standards for who could be a psychologist, creating a system with clear experts. They also developed advanced degrees and training, making sure psychologists learned the same things. This led to a big jump in psychologists after World War II, as veterans needed help and the government funded new training programs. This period, called the "Golden Age" of psychology, saw professional groups take control and make mental health care more consistent.

Into the Digital Age

Psychotherapy, once characterized by face-to-face interactions, is experiencing a digital revolution. Electronic Health Records, telehealth, and Generative AI are reshaping the profession. These digital evolutions offer benefits like increased efficiency and accessibility but also introduce challenges like potential dehumanization and the erosion of authenticity. Technology has transformed treatment delivery, the therapist-patient relationship, and the nature of the profession itself.

Electronic Health Care Records

Electronic health records (EHRs) started in hospitals in the 1970s, but they were basic compared to today's systems. Mental health was slow to adopt EHRs because of privacy concerns and worries that therapy notes wouldn't be helpful if analyzed for patterns. However, as mental and physical healthcare became more connected, EHRs became more common in therapy too. Now, EHRs are seen as a good thing for keeping track of patient info, research, treatment, and even suggesting the best treatments.


Before COVID-19, almost no therapy happened over video chat. But the pandemic changed that. Studies show therapy appointments offered remotely jumped from 1% to 30%. Therapists had to adjust to this new way of working, which could be stressful. However, telehealth also made therapy more accessible and efficient, allowing people to get help from home. Some worry this might make therapy less personal, or even lead to more automated programs. However, research shows online therapy can be effective, and many people find it even better than expected. So, while there are concerns, telehealth also offers new possibilities for mental health care.

Generative AI

Studies show computer programs and Generative AI chatbots might be cheaper ways to treat anxiety and depression than regular therapy. You can find these online therapy programs easily with a search engine and they are also available 24/7, making it easier to get help whenever you need it. This could be a good option for people who might not otherwise have access to therapy. However, some worry that relying on machines for therapy could make it feel impersonal, which is the opposite of what therapy is supposed to be.


The theories of Ritzer work to curb irrationality, also referred to as inefficiency, unpredictability, incalculability, and a lack of control. In psychotherapy, the development of the DSM brought order and recognition to the field, but sometimes its focus on diagnoses overshadows individualized treatment plans. The emphasis on efficiency and control may lead to rising levels of therapist burnout, as they feel pressured to meet quotas and follow rigid protocols that hinder their creativity and autonomy. The benefits of rationalization should not be ignored, but neither should the costs of rationalization.


The DSM made therapy a respected field, but it's not perfect. The DSM sorts people into groups based on symptoms, which can miss the unique struggles of each person. This focus on diagnosis can make therapy more about checking boxes than understanding the patient's situation. Some experts worry this leads to overdiagnosis and unnecessary treatment. The best approach is to use the DSM as a guide, but also consider the individual's story.

Job Satisfaction & Burnout

The pandemic made psychologists way more stressed than usual (Lin et al., 2023). Many had to work a lot more, with 38% reporting longer hours than before COVID-19. This heavier workload made it harder to keep up with patients - struggles rose from 30% in 2020 to 46% in 2022. There could be a few reasons for this burnout. Therapists might feel pressure to see too many patients too quickly, just like fast food workers. Strict rules and scripts might also make them feel like robots, taking away their creativity and making them feel stressed. This shows that focusing too much on efficiency can actually hurt things. Burned-out therapists can't help as many people and might even make mistakes. So, the best approach is to give therapists some personal time to relax, and also allow them more freedom in their work.


Mental healthcare has come a long way, from harsh treatments to using evidence-based methods. This shift, influenced by a focus on efficiency and control, has brought both benefits (standardization, accessibility) and drawbacks (overdiagnosis, burnout). As technology advances, the field will likely continue to change. The key will be finding a balance between efficiency and human connection.


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