How Experienced Social Work Practitioners Make Clinical Decisions in Real World Settings

J. Christopher Hall, LCSW, Ph.D. & J. Anthony Hall, LCSW, CEAP

Licensed clinicians in current fulltime practice were recruited nationally and asked to complete a quantitative and qualitative online questionnaire regarding their practice decision-making.

Participants (N=175) had a minimum of eight years practice experience with a Master’s degree and clinical license. Survey question responses were summed and qualitative responses were analyzed using grounded theory (Corbin & Strauss, 2007).

Minami, T., Serlin, R. C., Wampold, B. E., Kircher, J. C., & Brown, G. S. (2008). Using clinical trials to benchmark effects produced in clinical practice, Quality and Quantity, 42, 513-525.

Minami, T., Wampold, B. E., Serlin, R. C., Hamilton, E., Brown, G. S., & Kircher, J. (2008). Benchmarking the effectiveness of psychotherapy treatment for adult depression in a managed care environment: A preliminary study. Journal of Consulting and Clinical Psychology, 76, 116-124.

Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ: Erlbaum.

Most experienced practitioners view their practices as ongoing collaborations with clients and match clinical approaches to client understandings. These findings indicate that the academy is making some impact on how clinicians make treatment decisions with regard to person-centered work, while the low use of the evidence-based decision making model by experienced clinicians requires further exploration. One possible interpretation is that practicing clinicians do not see value in its use because they believe that the vehicle of change is not located in a treatment approach.

This research provides support for the incorporation of real world practice decision making into the training of student clinicians. Next steps include exploration with practitioners regarding the skills they feel are most helpful for their clients, the incorporation of these skills into student training, and evaluation of these skills to determine whether this training leads to improved client outcomes.

The purpose of this study was to explore the following questions:

(a)How do practitioners in real world settings make decisions regarding which clinical approach(es) to use with clients?(b)Which clinical approaches are most utilized by practitioners in real world settings? (c)How do practitioners in real world settings conceptualize their practices with others? And, finally, (d) When practitioners in real world settings need to refer clients, what is their decision making process? .

Efficacy is the term used for results that come from clinical research performed in controlled environments, where clients are screened for one diagnosis/issue, and variables are controlled.

Effectiveness is the term used for results which come from research in the real world in which real world complexities are present.

It cannot be assumed that efficacy will equate to effectiveness

Which Clinical approaches are Most Utilized?Cognitive behavioral and solution focused therapy tied as the most utilized approach with 14 approaches being represented.

“Concerns that psychotherapy delivered in a naturalistic setting is inferior to treatments delivered in clinical trials appear unjustified.”

Primary Referenced Study: Minami, T., Wampold, B. E., Serlin, R. C., Hamilton, E., Brown, G. S., & Kircher, J. (2008)

Setting: National provider network national Participants N=5,704 Clients & 1,859 providers. Measure=OQ-30 Problem Type: DepressionResults: The effect size of treatment was equal to or greater than .8 (the average of clinical trials)

A systematic review of the literature over the last 10 years surprisingly reveals that little research exists on the clinical decision making process of experienced clinicians in natural settings (Murdach, 2009; Zeldow, 2009).

Understanding how experienced clinicians practice in real world settings is of vital importance to the field because front line clinicians are the change agents of the social work profession.

Efficacy VS Effectiveness Is Real World Practice as Effective as Clinical Trials? Study Rational: If Real World Practice Effectiveness is = or > than Clinical Efficacy How Do Practitioners Practice?

How Do Practitioners Decide on Clinical Approaches?95% of practitioners match the clinical approach to the client’s understanding of the problem while 5% used the evidence based decision making process to decide on the clinical approach to utilize.

What is the Referral Decision Making Process?When referring, only 3% relied on matching client problems to a EBP practitioner, 4% relied on insurance type, 20% relied on therapist reputation, and 73% attempt to match a referred client to a therapist based on factors such a gender and personality fit.

Do Practitioners Keep Strict Fidelity to a Clinical Approach? 77% of practitioners routinely mixed clinical approaches, 33% choose one model, and 0% used manualized practice.