The Advancements of Rationalization in Psychotherapy Gabriela Hinckle

What is Rationalization and McDonaldization?

George Ritzer's book "The McDonaldization of Society: Into the Digital Age" takes Max Weber's theory of Rationalization and gives it a modern spin. His thesis mainly focused on the process of the steps it takes to uphold an industrialized world and how human progression towards these goals ultimately dictates human behavior (Kim, 2019). While his work was vital in introducing this idea to sociology, many explorations of his understanding of “rationality” failed to address its multifaceted nature. Social scientists postulated that his theory of rationalization was all about getting to a goal, not considering the bigger picture. Using McDonald's as an example, Ritzer expands on Weber's ideas, saying that things like predictability, control, efficiency, and calculability are the keys to how modern systems work. Ritzer believes that many things in our lives, like how fast food places or tech companies operate, follow these principles to succeed. Take Apple, for example; they use similar ideas to dominate the tech world. Apple's infamous quantum strategy succeeds in balancing intense efficiency with serial innovation to control the masses with addictive product design, thus creating an extraordinarily profitable and calculatable income (Heracleous, 2014). It's like a never-ending chase for efficiency and control, and it's hard to find anything that doesn't fit into this rationalization trend, even in things like mental health services.

The Origins of Psychotherapy

The history of psychotherapy is a mix of Western and Eastern ideas, but in America, we usually hear more about the Western side, thanks to Sigmund Freud. He started with hypnosis but then shifted to what he called "the talking cure," where patients talked about their problems instead of being hypnotized. This idea caught on, and soon psychoanalysis was all the rage in the West, giving us terms like oedipal complex and id, ego, and superego. But as time went on, psychotherapy changed, moving away from Freud's ideas about sex and focusing more on relationships and personal experiences. As psychotherapy gained traction, arguments arose about whether psychotherapy is replicable and if it's a scientifically proven method of care. (U'ren, 1987). Pushes for psychotherapy to be more evidence-based bled into the public sphere, looking to rationalization concepts to achieve an empirically proven method of conducting psychotherapy. This shift towards efficiency and predictability clashed with the original talk-focused approach of psychotherapy, leading to some tensions in the field.

The APA and WW2

Following World War II, the United States faced a mental health crisis as returning soldiers and a rising number of individuals experienced psychological distress. The aftermath saw a surge in mental health hospitalizations, revealing a lack of resources and effective treatment methods. This led to realizing the need for significant changes in psychological care. In response, the American Psychological Association (APA) underwent restructuring, expanding its membership and advocating for psychology as a science and profession dedicated to human welfare. Starting in 1945, membership in the APA grew 630 percent, from 4,183 members to around 30,839 members in 1970 (American Psychological Association, 2008). This shift marked the beginning of a new era in psychotherapy, with the APA playing a central role in reshaping the field and better addressing society's needs for mental health services.

Pushes for Empirical Methods

Following structural changes in therapeutic methods following WW2, the 1950s yielded a growing disillusionment with traditional psychotherapy methods, such as psychoanalysis, due to a lack of empirical evidence supporting their effectiveness. Cognitive-behavioral therapy emerged as a more empirically grounded approach, emphasizing evidence-based practices and research-supported techniques. This marked a departure from earlier psychotherapeutic approaches and paved the way for a more systematic and scientifically rigorous understanding of psychological treatment. Today, cognitive-behavioral therapy is a widely respected and endorsed form of psychotherapy, representing a shift towards empirically supported methods.

"Defining Empirically Supported Therapies"

In 1998, the publication of “Defining Empirically Supported Therapies” marked a significant milestone in the evolution of psychotherapy. This work aimed to assess psychological treatments based on their effectiveness, practicality in clinical settings, and cost-efficiency. These criteria echoed principles of rationalization, focusing on efficacy, effectiveness, and efficiency (Chambless & Hollen, 1998). Through this lens, the questions posed in the evaluation process aligned with the concept of sociological control, reminiscent of Ritzer’s McDonaldization theory. The emergence of empirically supported therapies revolutionized psychology by prioritizing controllable, efficient, and economically viable treatment approaches. This shift gained traction as it intersected with factors like managed healthcare, advancements in biological psychiatry, and professional accreditation standards, ultimately reshaping the field towards rationalization and structure.

Managed Healthcare and HMOs

Managed healthcare, mainly through Health Maintenance Organizations (HMOs), became prominent as a response to the need for affordable and efficient healthcare post-WW2. By the late 1990s, managed care had gained popularity, yet it posed challenges for mental health treatments, struggling to adapt to the system's emphasis on cost reduction while maintaining quality. HMOs, with their restricted provider networks and limited treatment options, created socioeconomic disparities in access to care. Moreover, insurance companies often viewed mental health care as elective, promoting a reductionist perspective on mental illness and hindering access to necessary treatments like psychotherapy.

The Future of Managed Healthcare and Mental Health Services

Legislative efforts like the Mental Health Parity Act (MHPA) of 1996 and the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 aimed to address disparities within access to insured mental healthcare. While these acts attempted to bridge the gap between general and mental health care by prohibiting discriminatory coverage practices, loopholes persisted, allowing insurance companies to maintain restrictive policies. Challenges remain in ensuring equitable access to mental health services within managed healthcare systems, highlighting the ongoing need for policy reform and advocacy.

Electronic Healthcare Records

Electronic Healthcare Records (EHR) debuted in 1972, initially adopted by the Veterans Administration (VA) for medication orders, procedures, nursing orders, dietary records, and diagnostic tests (Boyles, 2019). While their integration into mental health care was initially slow due to privacy concerns and professional reluctance, the 1970s saw a shift towards their acceptance, particularly with the growing integration of cognitive and general medicine. Today, EHR systems are lauded for enhancing diagnosis accuracy and recommending empirically supported treatments (ESTs), streamlining treatment processes, and research efforts in mental health. Many people support EHRs and believe they are helping the landscape of healthcare, supported by the figure below. (Muñana et al., 2019). However, criticisms against EHRs highlight concerns about the corporatization of medicine, arguing that these systems may overshadow physician judgment and diminish the human connection in healthcare. Despite these debates, EHRs have reshaped healthcare documentation, research, and delivery, with patient satisfaction generally high, albeit accompanied by concerns about decreased physician-patient interaction. The implications of EHRs extend beyond general medicine, influencing the landscape of mental health care.

The Public's Response to EHRs

Muñana et al., 2019

Rationalization of Licensure

Mental health services rely on qualified professionals who undergo a rigorous licensure process shaped by the rationalized structure of mental health care in America, particularly within the American Psychology Association (APA). Efforts to define specialization and qualifications began in 1917 with the Association of Clinical Psychologists, leading to the establishment of accreditation standards by the National Council of Schools and Programs of Professional Psychology (NCSPP) in 1981 (American Psychological Association, 2024). This accreditation process streamlines education, ensuring standardized training nationwide. However, while following APA guidelines, state-based licensure requirements vary, causing confusion and hindering accessibility, especially with the emergence of telehealth services, adding new complexities to the process.

Telehealth and Mental Health Services

Telehealth, which has evolved from radio doctor visits at the beginning of the 20th century to a significant surge during the COVID-19 pandemic, is a vital tool for accessible healthcare. However, despite its potential, challenges arise due to state requirements, particularly in mental health care. Licensed psychologists can offer therapy online, but state regulations often limit care to within state borders, creating barriers for patients seeking help outside their area. This limitation disproportionately affects lower socioeconomic groups, as many individuals in lower socioeconomic groups benefit from the availability of telehealth substantially more than those in the upper class due to the inaccessibility of travel opportunities to get to viable care and the lack of mental health professionals in low-income areas. Obtaining licenses to practice across state lines adds further complexity, hindering access to care. Additionally, some find technology access challenging, with internet and computer ownership disparities affecting telehealth utilization, as shown in the figure below (SAMHSA, 2021). Despite its benefits, telehealth can feel disconnected, raising concerns about its effectiveness compared to in-person therapy. Efforts to address these challenges, including providing technology access in underserved communities and fostering creativity in online therapy sessions, aim to maximize telehealth's potential while acknowledging its limitations.

Technological Access in the U.S.

SAMSHA, 2021

The Good and Bad or Telehealth-Based Mental Health Services

Works Cited

American Psychological Association. (2008). APA History and Archives. Https://

American Psychological Association. (2024). CRSSPP History.

Boyles, O. (2019, April 16). History of Electronic Health Records | EHR | ICANotes. ICA Notes.

Chambless, D. L., & Hollon, S. D. (1998). Defining empirically supported therapies. Journal of Consulting and Clinical Psychology, 66(1), 7–18.

Heracleous, L. (2014). Quantum strategy at Apple Inc.

‌Kim, S. H. (2019). Max Weber (E. N. Zalta, Ed.). Stanford Encyclopedia of Philosophy; Metaphysics Research Lab, Stanford University.

Muñana, C., Kirzinger, A., & Brodie, M. (2019, March 18). Data Note: Public’s Experiences With Electronic Health Records. The Henry J. Kaiser Family Foundation.


U’ren, R. C. (1987). The Rationalization of Psychotherapy. Perspectives in Biology and Medicine, 30(4), 586–589.