What’s in a Word(s)? Difficult Decisions



By Al Murdach, LCSW (Retired)

This column explores some of the meanings behind words that today have a significant impact on social workers. Our words for today are “difficult decisions.”

Social workers are often called upon to help clients make difficult decisions. While in the past this topic was uppermost in many early social work publications (see, for example, Upham, A Dynamic Approach to Illness, 1949), it appears to be little studied today. This is somewhat remarkable given the fact that social workers have always worked with clients involved in multiple stress situations, all of which require difficult decisions. Just a cursory glance would include such knotty problems as addiction, divorce, spousal abuse, immigration, family violence, mental illness, mental incapacity such as dementia, eviction, homelessness, etc. The list is endless.

Difficult decisions can be characterized as decisions involving a high level of uncertainty, risk, and fear. In the past few years various authors have tried to improve our understanding of decision-making in such situations and devised ways to navigate and assist clients in such fraught situations. Reviewing this literature, we see that the process of helping someone make difficult decisions can be encapsulated in the following five steps: building the client’s trust; offering consolation and hope; reviewing past experiences; negotiating a plan; and following through on the plan(s) of action.

Looking at this list, we can see that this process of decision-making resembles much of what has been characterized as “good” social work practice for decades, especially in such areas as clinical social work and private practice. However, since this this type of practice takes time, much effort, and requires an intense focus on the client’s needs, it appears to differ in significant ways from more typical types of decision-making situations that are more often studied by social work researchers since these situations are increasingly encountered by the majority of social work practitioners today. These can be characterized as decisions in crisis, decisions under pressure, and decisions that are heavily routinized. Various authors describe these decision situations as follows:

Decisions in Crisis — These situations are characterized by emergency conditions, rapid changes of pace, and expectations, and feature set formulas for response hopefully well-rehearsed in advance. Little time exists for reflection, gentle prodding or investigation.

Decisions Under Pressure — Tight deadlines, set time periods for intervention, and well-established goals characterize decision-making in these situations. These characteristics tend to predominate in team settings in which the worker must closely coordinate interventions with those of other team members to best benefit the client.

Decisions in Heavily Routinized Practice — Work with financial benefits, job placements, courts, medical settings and heavily bureaucratic organizations often require practitioners to be skillful in “working the system” to benefit clients. Such work requires skill in decision-making heavily influenced by rules, manuals and formal contractual agreements.

None of the above situations are especially conducive to skillful help with difficult decisions, since this type of practice requires a response characterized by carefully graduated phases, patience, willingness to fail occasionally, and frequent and meaningful presence by the worker. As mentioned above, this type of practice has long existed in the profession but only recently has it been the focus of scholarly attention. See, for example, the article by Jill Levenson, “Trauma-Informed Social Work Practice,” in the April 2017 issue of Social Work. Obviously, because of its importance, more social work research and study needs to be devoted to this aspect of practice to better understand its parameters and contributions to the field.