Making difficult decisions.

Social workers often help clients make decisions that they experience as "difficult" because of the stressful and challenging circumstances involved (Gibelman, 2005). However, despite extensive clinical exploration of the helping process by social work authors, the process of assisting clients with difficult decisions is not currently much explored in the literature. Because this area of practice is of significant interest to the profession, it is clearly a topic that needs further exploration. This article examines some of the current literature on the topic of difficult decision making, drawing on research in clinical medicine, psychiatry, nursing, psychology, and social work. WHAT ARE DIFFICULT DECISIONS? Difficult decisions can be defined as decisions spurred by situations characterized by high levels of uncertainty, risk, and fear. Although it has been observed that many of the decisions social work clients are required to make are routine, a large number of the decisions that clients are confronted with also involve major elements of threat and uncertainty and, thus, can be defined as difficult decisions (Murdach, 1995). The following are some examples of situations that are rife with these types of decisions: * A mother is told that her unborn child will be born with severe mental retardation. * A husband is notified that his wife was in a car accident and is now on life support at a local hospital. * A middle-aged couple returns to find that their home and possessions have been destroyed by fire. * A 45-year-old married man with an infant daughter receives a diagnosis of incurable brain cancer. * A young wife with two small children is threatened with a severe beating by her abusive husband. Although the list could be expanded indefinitely by adding less dramatic but still challenging situations, the foregoing examples serve to highlight the confusion and dread encountered by individuals and families attempting to make clear choices in difficult circumstances. It should also be noted that some clients face not just one difficult situation but multiple stressful situations requiring numerous challenging decisions. In the past few years, a number of authors in the helping professions have sought to improve our understanding of decision making in such situations and to develop ways in which clients can be helped to better cope with the challenges to dealing constructively with the stress encountered at such times. In what follows, I draw upon this research in social work and related fields to better understand this significant aspect of clinical care. DIFFICULT DECISION MAKING IN THE LITERATURE The field of social work was once in the forefront in the development of ways to assist clients with decision making in difficult situations (Perlman, 1979; Rapoport, 1965). Lately, however, this honor has been more closely associated with other fields, such as medicine (Buckman, 1992), psychiatry (Margulies, 1989), nursing (Andrews & Boyle, 1995; Purtilo, 1984), and psychology (Pollin & Koocher, 1998). This is not to imply that social work is now absent from this area of study, but only to suggest that other priorities have currently directed the field away from continuing to give sustained attention to this topic (Witkin, 2000). This shift in social work over the past several decades can be illustrated by comparing two classic social work texts, Upham's (1949) A Dynamic Approach to Illness and Germain's (1984) Social Work Practice in Health Care. Upham simply and movingly details how social workers assist clients with decision making in a number of medically oriented difficult situations. Germain says many of the same things, but in her book, the analysis of such situations occurs in the context of such a large mass of theoretical, administrative, and technical detail that the central importance of the helping relationship in assisting clients with decision-making challenges is significantly deemphasized. …