Decision making in social work is high-stakes work. Regardless of practice setting, client population, and role, practitioners confront the challenge of both making and facilitating good decisions. Decisions are defined as intentional choices made from a number of alternative possibilities that will result in some effect (Van Bemmel & Helder, 1997).
In the course of a day, social workers make countless decisions. Clinicians assess problems and determine treatments of choice. Policymakers and administrators determine program priorities. Purchasers must choose between alternative providers and benefit packages. Agencies decide service eligibility rules. Child protection workers determine whether children are at risk, whether courts should be petitioned, and whether out-of-home placements are necessary.
In yet other cases, the very problem presented by a client is one of choice, and the social worker's task is to strengthen the client's decision-making skills. Women facing choices among adoption, abortion, and keeping their babies; women in abusive domestic situations planning how to be safe; troubled couples contemplating divorce; and families considering when and if to seek institutional care for an elderly loved one--these are but a few of the many practice situations that can be conceptualized as counseling in decision making. In decision counseling, the shared tasks of social worker and client are assessing and improving the client's decision-making efforts.
Social workers' decisions determine efficiencies, effectiveness, and even fates. Services are delivered or denied. Children stay in foster care or return to once-abusive parents. Couples choose counseling or divorce. Elderly people live alone or enter nursing homes. Families are housed or not. Troubled teenagers are sent to counselors or to court. Professional decision making is recognized as a matter of public policy, given its impact on client access to care, type and quality of care received, third-party payment, and outcomes (Chapman & Sonnenberg, 2000; Matchar & Samsa, 2000; Rosen, Proctor, & Livne, 1985).
Whereas our practice necessitates that we make decisions, our professionalism demands that we do so in an informed and rational manner. Society expects that professionals, by virtue of their knowledge and skill, to make decisions carefully and well. Yet evidence from the burgeoning field of decision-making research warns us that decision quality may be compromised by factors such as time pressure, emotions, cultural differences, lack of information, and a wide range of alternatives for choice. These factors are the rule, rather than the exception, for many contexts in which social workers make decisions.
Social workers' decisions are increasingly subject to scrutiny for purposes of payment authorization or quality assurance. External reviewers want to know why treatment decisions are made, and increasingly practitioners are asked to articulate their clinical rationale for the recommended treatment and to provide the evidence that is the basis for treatment decisions (Goodman, Brown, & Deitz, 1992). Implicit in the requirement that providers prepare treatment plans and in the use of such plans for quality monitoring is the assumption that the plans are a product of careful, deliberate decision making.
How, then, can we strengthen social workers' capacity for making critical decisions? How do we ensure that decisions are made on the basis of the best information available? How can social workers, ever pressed for time and resources, make decisions efficiently? How do we structure the decision-making process to ensure the inclusion of critical stakeholders--families, clients, purchasers, advocacy groups--in decisions about choice of intervention? How can we use information and choice to help empower clients (Jimison & Sher, 1999)? …