A very provocative study of ho clinicians make clinical decisions.

1. 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: Depression
Results: 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.
StudyBackground
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.