Social Worker, Psychologist, or Psychiatrist: Does Profession Matter for Treatment Decisions for Antisocially Behaving Youth?

Background and Purpose:  Selecting an appropriate treatment for clients with mental health problems is central to clinical practice.  The treatment decision-making process generally involves formulating judgments about the nature of the individual's problem, and the most effective form of treatment. The literature describes best treatment practices based on diagnostic syndromes described in the DSM-5 (APA, 2013). Training and socialization experiences differ among professional groups, but it is unknown whether these differences result in different treatment decisions. This study asks: Given identical DSM criteria, do social workers, psychologists, and psychiatrists make the same treatment judgments for youth with antisocial behavior? What clinician and youth characteristics are associated with treatment judgments?

Methods: We used a between-subject design of mailed, experimentally manipulated realistic case vignettes of Black, White, and Hispanic youths on a national sample of 1,401 experienced social workers (N= 418, 29.8%), psychologists (N=544, 38.8%), and psychiatrists (N=439, 31.3%). Vignettes describe behaviors meeting DSM-5 criteria for conduct disorder, but contain contextual information suggesting either internal dysfunction (i.e., disorder) or a normal response to a difficult environment (i.e., environmental reaction). Surveys included clinicians’ age, gender, race and ethnicity, years of mental health experience, and theoretical orientation. Respondents rated the effectiveness of 14 practices used for treating antisocially behaving youth. Frequency, median and mean scores of effectiveness level were compared in bivariate analyses, stratifying professional group. Multivariate regression analyses investigated influence of clinician and youth characteristics on effectiveness judgments. Our response rate was 48.6%; comparisons with known national characteristics of the occupational groups yielded few differences.  

Results:  The clinicians’ profession statistically differentiated judgments of treatment effectiveness for antisocially behaving youth in 10 out of 14 treatments.* Social workers reported more confidence in the effectiveness of problem-solving skills training, pro-social peer groups, and anger management training than psychologists and psychiatrists.* However, all groups judged these three treatments as the most effective ones (median > 7 of 9).

Psychiatrists had more confidence in the effectiveness of psychiatric medication, residential treatment, special education, and juvenile correctional facility, compared to psychologists and social workers.* Compared to others, psychologists had more confidence in the effectiveness of cognitive approaches, and had less confidence in psychodynamic psychotherapy.* Rating differences in behavior modification, parent management training, systems oriented family therapy, and community mobilization and planning were non-significant (NS).

Multivariate analyses confirmed these professional differences.* In addition, clinicians’ race, gender, and theoretical orientation were associated with different judgments; years of mental health experience and age were not. Treatment effectiveness differed by youth’s social context (disorder vs. environmental reaction), though race or ethnicity had no effect. Professional group and social context interactions will be analyzed. 

Conclusions and Implications: Our study provides new insight about clinicians' treatment decision-making, demonstrating that the professional socialization processes may generate disparities in judgments regarding treatment effectiveness. These results suggest that clinician characteristics and normative professional experiences may bias decision-making, and have important implications for inter-professional clinical training to improve service delivery and for future research to improve consistent quality of care.  

*All significant results at P<.05.