Clinical Decision Making: Short
vs. Long-term Therapy
The past several decades have seen as increasing emphasis on the utility of planned short-term therapy. there are different views, however, on the types of problems and client characteristics appropriate for such treatment. the investigation described here is an exploratory study of some characteristics of clients, workers and problem areas that influence the decision-making of clinicians at JBFCS. Dr. Jonathan Rabinowitz, formerly of JBFCS, was the Principal Investigator, and Professor Irving Lukoff of CUCSSW was the consultant for this project.
The design consisted of a series of vignettes with three different symptom descriptions. For each symptom configuration clients were differentiated by age, sex and ethnicity. The three symptom pictures that were chosen reflect commonly noted ones in outpatient therapy, closely modeled to reflect DSM-III descriptions: Adjustment Disorder, Dysthymic Disorder and Border-line Personality Disorder. Additional information was also obtained on the clinician's training, years since graduation, tenure at JBFCS, job-title and demographics.
There was substantial agreement on when it was appropriate to use planned short-term therapy(PST: defined as up to 12 sessions) or to prefer long-term therapy(LT). For the Adjustment Disorder %95 of the clinicians recommended PST, while for Dysthymic Disorder %87 suggested LT, and %91 preferred LT for Borderline cases. The diagnoses accounted for %52 of the variance. There is remarkable unity among the clinicians at JBFCS on the appropriateness of PST versus LT treatment, with only a relative minority deviating from the trend. However, and examination of agency records revealed that PST was recommended far less often than would appear these findings based on vignettes.
It is also significant that client gender, race and education had negligible overall effects, although much of the literature suggests otherwise. Within the vignettes, however, there were some significant, if modest effects, where male college graduates were viewed as more desirable clients with a somewhat better prognosis. Also, younger clinicians were less likely to select PST.
Respondents were also asked to state in their own words what were the considerations that would prompt them to use PST or LT. The more salient factors in the choice of PST were: Clear Precipitant (%69); Generally High Functioning (%43); and Crisis Situation (%27), with fewer indicating other qualities. For (LT, quite different factors were noted. These include: Chronicity (%36); No Clear Precipitant (%27); and problems described as Characterological or Deep (%20). Additional research is required to both clarify and expand these findings, including studying clinicians from characteristics and diagnostic categories.