Psychotherapy Volume 35/Spring 1998/Number 1

CLINICAL DILEMMAS IN CONTEMPORARY PSYCHOTHERAPY:THE SEARCH FOR CLINICAL WISDOM

DOUGLAS J. SCATURODepartment of Veterans Affairs Medical Center at Syracuse

Department of Psychiatry and Behavioral SciencesDepartment of Family Medicine

State University of New York Health Science Center at SyracuseDepartment of Psychology

Syracuse University

WILLIAM R. McPEAKSchool of Social Work

Syracuse UniversityDepartment of Psychiatry and Behavioral Sciences

State University of New York Health Science Center at SyracuseThe concept of the clinical dilemma inthe contemporary practice ofpsychotherapy is examined in this article.The notion of "dilemma management" bythe psychotherapist is viewed as aubiquitous phenomenon in thepsychotherapeutic process. Dilemmas ina range of areas of clinical practice arediscussed and observations are madeabout the interpersonal process ofdilemma management in psychotherapythat models for patients an effective way

Portions of this article were presented at a continuing educa-tion workshop at the School of Social Work, Syracuse Univer-sity. Support for the preparation of this article was provided bythe Medical Research Service of the Department of VeteransAffairs. The opinions expressed in this article are those ofthe authors and do not necessary represent those of the Depart-ment of Veterans Affairs. The authors wish to extend theirgratitude to Robert P. Sprafkin, Ph.D., Barbara McClure,Ph.D., and Toni M. McCormick, Psy.D. for their editorialassistance on an earlier version of this article.

Correspondence regarding this article should be addressedto Douglas J. Scaturo, Ph.D., Outpatient Mental Health(116A1), Department of Veterans Affairs Medical Center,800 Irving Avenue, Syracuse, NY 13210.

of approaching the pervasive conflictsand dilemmas in their own lives.

The practice of psychotherapy can be seen as aconstant series of clinical choices and recurring setsof dilemmas. In this complex human arena, theyare a part of the everyday life of the clinician. Adilemma is denned as "a situation involving choicebetween two equally unsatisfactory alternatives"(Merriam-Webster, 1986, p. 355). Its synonymsinclude predicament, quandary, and impasseallof which are relevant to the process of psychother-apy. It is commonly said that one may find oneself"on the horns of a dilemma"; that is to say, some-where between two points and hoping not to getstuck on or by either. As a result, a dilemma, byits nature, causes anxiety. In a clinical context, itmight be said that a dilemma is any choice or con-flict that creates anxiety in the clinician about whatto do or what to say next. Indeed, the processof psychotherapy might well be regarded as themanagement of ongoing dilemmas, both for thepatient and for the therapist.

The purpose of this article is to examine theprocess of psychotherapy from the standpoint offrequently occurring dilemmas for the clinician.The concept of dilemma management is viewed asendemic to the psychotherapeutic process. Dilem-mas in the following areas of clinical practice will

D. J. Scaturo & W. R. McPeak

be discussed: (a) differing treatment modalities, in-cluding insight-oriented psychotherapy, behaviortherapy, marital and family therapy, and group ther-apy; (b) systemic issues such as spousal codepende-ncy and family homeostasis; (c) transference andcountertransference; (d) therapeutic neutrality andmanagement of the therapeutic boundary; and(e) psychological assessment and psychiatric diag-nosis. Finally, some observations will be madeabout the interpersonal process of dilemma manage-ment in psychotherapy that models for patients aneffective way of approaching the ubiquitous con-flicts and dilemmas in their own everyday lives.

Psychotherapy as Dilemma ManagementThe process of psychotherapy has been referred

to by Freud as "the talking cure" (Wachtel, 1993).As such, unique to this discipline is the fact thatwhat the therapist says, and how he or she saysit, is of crucial importance to the patient and thehealing process. When one considers the fact thatmany, if not most, patients come to psychother-apy for what Alexander and French (1946) havetermed a "corrective emotional experience," oftenfrom a history of emotional neglect by significantothers who never fully weighed their words, thenthe importance of everything that the psychothera-pist says becomes clear. Several authors, Wachtel(1993) and Wile (1984) among them, have notedthat confrontative interpretations of the patient'sbehavior and defenses, however accurate, mayeasily be viewed as accusatory or pejorative by thepatient. Thus, finding a facilitative way to confrontpatients and help them find alternative methods ofcoping becomes a decisive task for the psychothera-pist. This decision-making process becomes a min-ute-to-minute interactional dilemma for the insight-oriented individual psychotherapist.

Dilemma management in insight-oriented psy-chotherapy. The most prevalent dilemma that oc-curs in the insight-oriented psychotherapy ses-sion, frequently on a moment-to-moment basis,is how much to confront versus support a givenpatient at a given point in treatment. If confronta-tion is the metaphorical surgical incision in explor-atory psychotherapy, then providing emotionalsupport is surely the metaphorical anesthesia.1 Itis the psychotherapist's responsibility to decidehow much confrontation of defenses and behavior

1 The authors wish to acknowledge the contribution of

James T. Marron, M.D., in their use of this metaphor.

this particular patient with this particular historyand this particular diagnosis and defensive struc-ture can tolerate at this particular point in time.Alternatively, how much support is needed in thisprocess and when? This decision is an ongoingone which occurs as a result of therapy being adynamic process in which the status of the above-noted variables is changing constantly.

The focus of the anxiety-provoking brief psycho-dynamic psychotherapies (e.g., Davanloo, 1978;Sifheos, 1979) has been on the confrontational ap-proach to the defensive structure. Indeed, it is thisconfrontation of the defensive structure at the outsetof therapy which largely accounts for the shorteningof the therapy in these approaches. Nevertheless,careful training in these approaches, as well as anequally careful psychological assessment of the pa-tient, is required before utilizing such strongly con-frontational techniques. Any misjudgment, particu-larly in an excessively confrontational approach,could have deleterious effects on the patient's func-tioning. The essence of the dilemma in these psy-chodynamically oriented approaches seems to bethis: too much confrontation may overwhelm anddiminish the patient's sense of self; too much sup-port without any confrontation may yield no changeor movement of the patient in therapy.

In the systemic therapies (e.g., marital andfamily therapy), this problem is compounded bythe need to not only decide when support versusconfrontation is needed within a given individual,but also to decide how and when to distributesupport and confrontation among a group of fam-ily members, some of whom may be in conflictwith one another at any given point in time. Sup-port of one family member's position against an-other's by the therapist forms a temporary alliancewith the supported member that can be toleratedby the others for only a limited period of timewithout alienating them (Minuchin, 1974). Themarital and family therapist frequently feels asthough he or she is constantly "robbing Peter topay Paul" as the therapist attempts to balanceemotional support and therapeutic alliance in anygiven family therapy session.

Dilemma management in behavior therapy.Until only very recently (e.g., Safran & Segal,1990), the notion of the therapeutic relationshipand alliance has been largely neglected in thewritings on behavior therapy, although this viewtends to be altered substantially when one dis-cusses cases with seasoned behavior therapists,as Wachtel (1982) aptly notes. Nevertheless, the

Clinical Dilemmas in Contemporary Psychotherapy

tendency toward such neglect in the behavioralliterature may be related in part to the psychoedu-cational nature of the approach, which offers abehavioral analysis of the patient's problems andstructured behavioral homework assignments thatlogically follow from this analysis. It seems gen-erally assumed by behavior therapists that the pri-mary motivation for the patient to follow throughon these assignments is symptom relief. It is alsoprudent, however, to assume that the concept ofresistance exists not only in psychodynamic thera-pies, but in the cognitive and behavioral ap-proaches to treatment as well (Wachtel, 1982).One of the other primary motivations of the pa-tient for either following through on a given be-havioral homework assignment is the quality andnature of the patient's alliance with the behaviortherapist. Failure to follow through with behav-ioral homework may be indicative of resistancederived from conflict in the therapeutic relation-ship. The behavior therapist, like any other psy-chotherapist, needs to have the ability and lan-guage to forthrightly address these issues as theyarise in the course of treatment.

Thus, the session-to-session (if not moment-to-moment) dilemma for the behavior therapistmight be characterized as the decision to assignor not to assign homework in a given behaviortherapy session. This single decision then be-comes further subdivided into intermediate deci-sions about what problems to deal with, in whatorder of importance, and with what assignedtasks. Every request to perform a given home-work assignment is potentially viewed by the pa-tient as a demand by the therapist, thereby creat-ing the possibility of resistance to the task. Asa result, every behavior therapist should likelyconsider the following question prior to assigninghomework, "How much therapeutic rapport doI now have in this patient's metaphorical 'bankaccount' to make such a 'withdrawal' (i.e., re-quest) at this point in time?"2 With the trends forbriefer and briefer treatments in which rapport isbased on a fewer number of sessions, this di-lemma for the behavior therapist becomes evenmore crucial to the success of treatment.The Textbook Practice of Psychotherapy

The guidelines and standards of practice foreach major school of psychotherapy have been

2 The authors wish to acknowledge the contribution of Janis

L. Scaturo, M.S.W., in their use of this metaphor.

an attempt to address the dilemmas and necessarychoices that predictably arise in clinical practice.In each instance, however, the standard texts, andmore recent treatment manuals (e.g., Craske &Barlow, 1989), for treatment within any singleapproach or modality, are never broad enough toprovide a full range of answers to the complexnature of problems that occur in clinical work.Psychotherapists in each of the major schools oftreatment ultimately found the constraints of for-mal methods and protocols to be too limiting toadequately address the range of patient needs ina clinical context (Scaturo, 1994).

For example, a number of the early psychoana-lysts found the constraints of the psychoanalyticmethod, as discussed in formal texts on the sub-ject (e.g., Langs, 1973), to be unresponsive to abroad range of patients' needs. Yalom (1980) hasprovided an eloquent illustration of how Freudhimself strained against the limitations of psycho-analysis in his treatment of Elizabeth Von R. Ina review of Freud's notes, Yalom finds a widerange of clinical activities by Freud intended toaddress a resolution of several problems in Eliza-beth's life. He assigned behavioral homework toaddress her grief, attempted to increase her peersocialization, worked with the family on her be-half, and even attempted to disentangle some ofher family's financial problems. None of thesetherapeutic maneuvers fall within the realm of"abreaction," which was Freud's sole explanationfor Elizabeth's improvement in her psychogenicdifficulty in walking, but clearly constituted pow-erful interventions in her treatment regimen.

Likewise, in the early years of behavior ther-apy, rigorous behavioral manuals and protocolswere utilized that offered little in the way of ad-dressing the patient's internal life (e.g., Bandura,1969). The cognitive-behavioral movement(e.g., Mahoney, 1974; Meichenbaum, 1977) wasin part an attempt to mediate the dilemma betweenan exclusive focus on the patient's overt behaviorand the patient's cognitive and affective lifethat is, a way to address the thoughts and emo-tional needs presented by their patients.

Finally, when the field of family therapy wasin its adolescence attempting to establish its pro-fessional identity, there were insistences that thewhole family living unit be in attendance at eachsession for treatment to take place (e.g., Haley,1970). These kinds of dogmatic positions not onlyalienated many mental health professionalstrained within other, typically individual, treat-

D. J. Scaturo & W. R. McPeak

ment approaches, but (not unlike their behaviortherapy counterparts) simply failed to addressmany of the important internal needs of individualfamily members. Family therapists attempting todeal with this dilemma between the self and thesystem began to articulate a "rediscovery" of theself in the system (Nichols, 1987a, 1987b). Someindividual therapists, struggling with the samedilemma from a different perspective, began toinitiate family consultations with their patients inan effort to become acquainted with the membersof their patients' primary social system, both inreality and through transference (e.g., Wachtel& Wachtel, 1986).

Systemic Dilemma I: Couples andFamily Therapy

The unique problems associated with ex-panding the treatment system from the individualpatient to the couple or family were recognizedby the early pioneers in the field of family therapy(e.g., Haley, 1963; Napier & Whitaker, 1973).Ellen Wachtel (1979) has articulated some ofthese difficulties in the form of various dilemmasposed to the individually trained psychotherapistattempting to incorporate a family-systems per-spective into his or her clinical work.

According to Wachtel (1979), the most im-portant dilemma confronted by the psychothera-pist who treats an individual or family from asystemic view is the question of, Who is to blame!She notes that individual insight-oriented thera-pists have historically viewed poor child-rearingpractices in the patient's family of origin as theculprit for any dysfunctional behavior patternsor emotional disorders. From a family-systemsviewpoint, the responsibility for marital conflictor other types of behavioral dysfunction clearlydoes not reside exclusively within any one indi-vidual, though the patients themselves usuallyhave a more linear perspective of their difficult-ies. So, in the case of marital conflict, the di-lemma for the therapist posed by each memberof the couple entering therapy is, Is it me or myspouse! (i.e., who is to blame?). Essentially, thisis a question of externalization versus internaliza-tion of responsibility. In the case of marital con-flict, an externalized presentation of the problemis more common among both members of thecouple. People can frequently articulate in greatdetail the many complaints that they have abouttheir spouses, and in some instances, offer tre-mendous insight about their spouses' psychody-

namics. Frequently, they have little insight intotheir own contributory behavior. As a result, animportant question at the outset of marital therapyis to inquire the following of each person, "Whatdo you think you could or should do to help allevi-ate some of the difficulty and improve your mari-tal situation?" This question is usually quite unex-pected by both members of the couple, butperforms the dual purpose of assisting the couplein viewing their marital problems from a systemicperspective, which may help to reduce the mutualblaming, and once answered, can help point outsome potential avenues for change.

One method of couples therapy is to help themto understand that much of how they treat oneanother comes from what they learned about inti-mate relationships in their family of origin. Thisdilemma, a variant of the one noted above andbrought to the therapist by the patient, might beappropriately described by Is it my spouse or myparents'? (i.e., who is/are to blame?). Framo(1982) describes the family-of-origin contributionto marital distress from an object-relations theo-retical perspective.The price for robbing of self during the growing years exactsa toll and leaves a legacy, giving rise to the ambivalence thatall people feel about their close relationships. Since old scoreshave to be settled and reservoirs of hatred cannot be contained,someone has to pay. Those someones are usually the currentintimatesthe mate and children; the demons of today arepunished by the internal ghosts of yesteryear (pp. 188-189).Helping couples to see that the spouse is only asubstitute target of anger and conflict usuallyserves to soften the marital discord. Wachtel(1979) as well, has noted that this approach is awell-documented strategy in individual psycho-therapy to help lessen the blame associated witha given interpretation of the patient's maladaptivebehaviors: "Of course, your behavior is an under-standable response, given the family environmentin which you were being raised." In family-of-origin therapy, however, this dilemma is resolvedby taking the conflict out of the realm of blaming.The forgiveness of parents is a central feature inthis form of treatment. According to Framo(1992), there is therapeutic benefit from this, "be-cause when you forgive a parent you forgive your-self and do not have to suffer the manifold formsof self-hatred" (p. 59).Systemic Dilemmas II: Codependency andFamily Homeostasis

The concept of codependency provides anotherexample of a dilemma that is derived from clinical

Clinical Dilemmas in Contemporary Psychotherapy

work with the family system, especially aroundthe issue of blaming. Unfortunately, the concepthas been popularized by the self-help literature(e.g., Starker, 1990) in writings on children ofalcoholics and may be less clinically precise thanother concepts in the psychiatric nomenclature(Fiese & Scaturo, 1995). Theoretically, however,the concept is linked to, and is a more specificexample of, a number of broader and long-heldconcepts in family-systems theory. These con-cepts include Ackerman's (1958) notion of "inter-locking pathology," Jackson's (1957, 1965) con-cepts of "family homeostasis" and the "maritalquid pro quo," Bowen's (1960) "overfunction-ing'V'underfunctioning" relationship, and Ha-ley's (1963) "one-up/one-down" relationship. Inthe field of alcoholism, the concept of codepende-ncy refers to a relationship in which the alcoholicis married to a spouse who, despite being a non-drinker, serves as a helper/facilitator to the alco-holic and thereby, unintentionally, fosters thecontinuance of the drinking problem. The code-pendent may, for example, make the "sick" callto the alcoholic's place of employment after adrinking episode, thus delaying the problem fromcoming to the social or occupational foregroundmore quickly. Such behavior is also referred toas enabling, permitting the problem to continue.The tendency among many clinicians is to targetthe enabling behavior of the spouse as an im-portant focus of treatment. This strategy, whilewell-intended, places the clinician in a dilemmain which he or she is in the position of blamingthe victim (Ryan, 1971). In this instance, thespouse of an alcoholic may easily feel quite criti-cized by the therapist who focuses on his or herenabling behavior, especially if insufficient atten-tion is given to the origins of this behavior andthe desperation involved in this particular formof coping. It is probably important for the clini-cian to remember and respect the fact that spouseswho engage in this kind of caretaking behaviorin a marriage have most likely learned this formof adaptation in their family of origin, often beingparentified and made responsible for an alcoholicparent as a desperate way of fitting into a thor-oughly dysfunctional and chaotic family environ-ment. To confront them in a critical way aboutthe only familiar way of relating in a family,however excessive their behavior appears now,will not only be unsuccessful in affecting behaviorchange, but will likely be destructive to any thera-peutic alliance as well.

Group TreatmentOne consequence of the current trend toward

brief treatments that has affected the practice ofgroup therapy has been the increased use of time-limited therapy groups that are relatively homoge-neous with respect to some type of theme sur-rounding a diagnostic category or interpersonalproblem. It is common, for example, to see clin-ics and clinicians offering therapy groups for anx-iety or depression management, panic disorderand agoraphobia, alcoholism, adult children ofalcoholics, survivors of sexual abuse, and Viet-nam combat veterans, to name a few. Such groupcomposition is predicated upon the assumptionthat a certain commonality of experience will fos-ter an accelerated identification, trust, and cohe-sion among the group members. This question ofhomogeneity versus heterogeneity in group com-position, however, poses some very real dilem-mas for the group therapist (Fiese & Scaturo,1995; Scaturo & Hardoby, 1988). Indeed, thesense that, "we are all the same here," based onthe similarity of a diagnosis, life problem, orgiven facet of family history may not be fullyconsistent with the interpersonal goals of interac-tional group psychotherapy (Yalom, 1975), inwhich one of the major curative elements involvesa sharing of individual and variant life experi-ences and the sense of genuineness and accep-tance that comes from being fully understood andknown by another human being. Thus, if the goalof a given group is limited to that of social sup-port, then the identification that is fostered by thehomogeneity of a given group theme may havea certain clinical utility. If the goal of the group,however, is that of psychotherapy, then a fullerexploration of individual life experience whichmight be enhanced by a more heterogeneousgroup composition, providing a more accuraterepresentation of a real-world social microcosm(Yalom, 1975) might be indicated (Fiese & Sca-turo, 1995).Transference and Counter-transference

While most of the psychotherapist's dilemmassurrounding the concept of transference (i.e., thepatient's feelings about the therapist) probablyfall more within the domain of countertransfer-ence (i.e., the therapist's reactive feelings aboutthe patient), the patient's transferential reactionsare often the source or stimulus for the therapist'scountertransferential difficulties. So, for exam-ple, a patient who demonstrates a particularly

D. J. Scaturo &W. R. McPeak

strong transferential feelingeither positive ornegativetoward the therapist is likely to evokesome type of counterresponse in the therapist'semotional life, which often leads to the therapist'sstruggle about how to handle the ongoing issuesin treatment. The range of countertransferentialreactions is not limited to these emotional reac-tions alone. Sometimes the patient, by virtue ofhis or her life experiences and/or personal charac-teristics, evokes a strong emotional response onthe part of the therapist. For example, Wallerstein(1990) has discussed the range of countertransfer-ential responses associated with conducting ther-apy with family members who are undergoingdivorce. She believes that strong identification bythe therapist with one of the divorcing parties candecidedly affect the quality and effectiveness ofthe clinical work. Certainly, the dilemma thatevery psychotherapist faces in grappling withstrong countertransferential reactions is to askhimself or herself whether his or her responsesare linked to my life or my patient's life (Framo,1968), that is to say, whose agenda is being ad-dressed in a given therapy session with a givenpatient or family, and why?

It should be noted that a strong identificationwith a particular patient's life situation or defen-sive structure is not, by definition, a sign of poorlyconducted psychotherapy. It is, however, a markerof some additional intensity and complexity inthe clinical context. Almost all psychotherapistswill admit in greater moments of candor that theydo not feel the same sense of rapport, identifica-tion, or closeness with each and every patient.The therapist, were he or she to have met certainpatients prior to and outside of a clinical context,could imagine being friends with some patientsand certainly not with others. And, these patients,due to the almost instinctive understanding oftheir difficulties, stand to receive one of twothings from a psychotherapist who identifiesstrongly with their concerns: either the best orworst service that such a clinician has to offer.If the clinician has sufficiently worked throughthe emotional issue in his or her life which runsparallel to the issue in the life of the patient andis able to thereby maintain adequate objectivityin the therapy, then the patient stands to gainmuch from the hard-earned intuitive understand-ing which that clinician has by virtue of his orher own life experience. On the other hand, ifthe therapist over-identifies with the patient's

conflicts and loses proper clinical perspective,then a grave disservice is being rendered to sucha patient.

An example of the intensity of these counter-transferential feelings is portrayed in the dialogueof the play, Equus (Shaffer, 1977). The dramadepicts a disturbed adolescent stable boy in En-gland who is undergoing court-mandated treat-ment after blinding six horses with a spike. Thehorses were the boy's first sexual experience. Hewould ride them naked in the evening to the pointof orgasm. The blinding occurred after his firstsexual experience with a young girl that occurredin the stable with the horses present, leaving theboy feeling that he had betrayed them. Themiddle-aged psychiatrist who is treating the boy isstruggling with the powerfully destructive passionwhich his patient feels, but which has long beenabsent in his own life. The following is an excerptof a conversation that Dr. Dysart is having oneevening with his friend Hester Salomon, the mag-istrate who referred the boy for treatment (Shaf-fer, 1977, pp. 81-82):DYSART: . . . He lives one hour every three weekshowling

in a mist. And after the service kneels to a slavewho stands over him obviously and unthrowably hismaster. With my body I thee worship! . . . Manymen are less vital with their wives.[Pause]

HESTER: All the same, they don't usually blind their wives,do they?

DYSART: Oh, come on!HESTER: Well, do they?DYSART [sarcastically]: You mean he's dangerous? A violent,

dangerous madman who's going to run around thecountry doing it again and again?

HESTER: I mean he's in pain, Martin. He's been in pain formost of his life. That much, at least you know.

DYSART: Possibly.HESTER: PossiblyV. . . . That cut-off little finger you just de-

scribed must have been in pain for years.DYSART [doggedly]: Possibly.HESTER: And you can take it away.DYSART: Stillpossibly.HESTER: Then that's enough. That simply has to be enough

for you, surely?DYSART: NO!HESTER: Why not?DYSART: Because it's his.HESTER: I don't understand.DYSART: His pain. His own. He made it.

[Pause.][Earnestly] Look . . . to go through life and call ityoursyour lifeyou first have to get your ownpain. Pain that is unique to you. You can't just dipinto the common bin and say 'That's enough!' . . .He's done that. Alright, he's sick. He's full of mis-ery and fear. He was dangerous, and could be again,

Clinical Dilemmas in Contemporary Psychotherapy

though I doubt it. But that boy has known a passionmore ferocious than I have felt in any second of mylife. And let me tell you something: I envy it.

HESTER: You can't.DYSART [vehemently]: Don't you see? That's the Accusation!

That's what his stare has been saying to me all thistime. 'At least I galloped! When did you?' . . . [Sim-ply.] I'm jealous, Hester. Jealous of Alan Strang.

HESTER: That's absurd.

(Reprinted with permission of Scribner, a Division of Simon& Schuster from Equus by Peter Shaffer. Copyright 1973Peter Shaffer.)What is not absurd is the dilemma in which Dr.Dysart finds himself: Having the unique abilityto help his patient through a remarkable under-standing of the problem, so long as he is able tocontrol his envy and maintain adequate objectiv-ity. In this instance, the latter seems unlikely,given the above dialogue. As a result, Dr. Dysartthen faces a secondary dilemma surrounding hiscountertransference: Does the therapist Keep orRefer such a patient? While it seems prudent inthe above example to strongly consider referral,one might consider obtaining for mal consultationfor such a case to decide whether or not keepingor referring the case would be most helpful tothe patient.

An even more problematic area involving thequestion of whether to keep or refer is the issueof personal attraction to a patient by the clinician.Many instances of sexual exploitation of patientsin therapy might be avoided if the therapist wereable to recognize the growing attraction and im-mediately seek consultation to assist with thecountertransference or to make an appropriate re-ferral of the case (e.g., Pope, 1994).Therapeutic Neutrality andBoundary Management

The concept of technical neutrality in psycho-therapy has been largely misunderstood, both interms of its meaning as well as in terms of itsmultiple facets. The notion of neutrality meansthat the psychotherapist maintains sufficient ob-jectivity so as to not take sides with respect tothe patient's internal conflicts (Herman, 1992).Its purpose is to respect and protect the patient'sautonomy for one's life. Neutrality should notimply that the therapist is cold, distant, or imper-sonal with respect to their patients' interactions(Wachtel, 1987). Similarly, the concept of thera-peutic disinterest means that therapists do not uti-lize the power of the therapeutic role to gratify

their own personal needs, and should not implythat the therapist is uncaring (Herman, 1992).

Paul Wachtel (1987) in his chapter entitled,You Can't Go Far in Neutral, points out a numberof limitations in the concept of neutrality in psy-chotherapy, particularly with respect to misunder-standing of the concept of neutrality. While origi-nally intended to provide the patient with anatmosphere of safety in the therapeutic context,Wachtel notes that a neutral stance on the part ofthe therapist may not be the best vehicle to fostersafety. He points out that when the psychothera-pist is consistently ambiguous in his or her re-sponses, the patient's inclinations to experiencerejection are given full reign. Alternatively, neu-trality may be experienced by such patients as aninvalidating response and contribute to doubtingtheir sense of reality about their life experiences.Instead, many patients require a positively af-firming stance to their life circumstances andemotional dilemmas.

Wachtel's observation is similar to Herman's(1992) criticisms about the notion of moral neu-trality in the psychotherapeutic situation. Hermanpoints out that, particularly in clinical work withvictimized populations, a committed moral stancefrom the therapist and solidarity with the patientregarding this issue is a prerequisitethat neu-trality with regard to this issue is simply too weakof a stance for the therapist to assume. In theseinstances, the victim may reasonably expect thetherapist to share in his or her moral outrage andto demonstrate an implicit understanding of theinjustice inherent in the traumatic situation.

The clinical dilemma, however, is how to besufficiently engaged with the patient, on the onehand, without losing one's sense of clinical objec-tivity and ability to be effective with the patient,on the other (i.e., therapeutic neutrality versustherapeutic engagement). In short, therapeuticneutrality is not a simplistic, unidimensional an-swer to the complex question of boundary man-agement in clinical practice. The absence of selfin the clinical interview through the concealmentof one's reactions to what the patient brings tothe session is hardly reassuring to most patients.Indeed, it is questionable as to whether the mask-ing of the therapist's personal reactions is evenpossible, given the attitudinal metamessages in-trinsic in almost all clinical interpretations (Wach-tel, 1993). Alternatively, however, this does notmean that excessive self-disclosure is a viable

D. J. Scaturo & W. R. McPeak

therapeutic stance. Ultimately, effective thera-pists must be able to relate to their patients genu-inely, while respecting the patients' inherent rightto self-determination in their own lives. Such clin-ical work requires a consistent and vigilant atten-tion to, and management of, the therapeuticboundary in all sessions with patients and/ortheir families.

An example from literature of inattention tosuch necessary boundary management can befound in the novel The Prince of Tides by authorPat Conroy (1988). The story involves a highschool football coach from South Carolina namedTom Wingo who, in the midst of a marital crisis,spends his summer in New York City consultingwith his sister's psychiatrist, a Dr. Susan Lo-wenstein, following his sister's psychotic epi-sode and hospitalization while in a catatonicstate. During this time, Mr. Wingo and Dr.Lowenstein become involved in a personal andeventually a sexual relationship. Consider thefollowing dialogue early in the book as Mr.Wingo and Dr. Lowenstein define their profes-sional versus personal relationship (Conroy,1988, pp. 165-166):

"What's your first name, Doctor?" I asked, studying her."I've been up here for almost three weeks and I don't evenknow your first name."

"That's not important. My patients don't call me by myfirst name."

"I'm not your patient. My sister is. I'm her Cro-Magnonbrother and I'd like to call you by your first name. . . . You'recalling me Tom and I'd like to call you by your given name."

"I'd prefer to keep our relationship professional," she an-swered . . . "Even though you're not my patient, you havecome here because you are trying to help me with one of mypatients. I would like you to call me Doctor because I'm mostcomfortable with that form of address in these surroundings.And it scares me to let a man like you get too close, Tom. Iwant to keep it all professional."

"Fine, Doctor," I said, exasperated and bone-tired of it all."I'll agree to that. But I want you to quit calling me Tom. Iwant you to call me by my professional title."

"What is that?" she asked."I want you to call me Coach.""My name is Susan," she said quietly."Thank you, Doctor," I almost gasped in my gratitude

toward her. "I won't use your name. I just needed to know it."I saw the softening around her eyes as we both began the

voluntary withdrawal from the field of conflict.

(From the book The Prince of Tides by Pat Conroy. Copyright(c) 1986 by Pat Conroy. Published by Houghton Mifflin Com-pany, Boston. Reprinted by permission.)Before this conversation is through, Mr. Wingoasks Dr. Lowenstein out to dinner, and she ac-cepts the invitation. The violation of professionalboundaries provided in this example from litera-

ture is not that Dr. Lowenstein allows Mr. Wingoto call her by her first name, but it lies in thecontext in which this permission is given. In thecourse of this conversation, Dr. Lowenstein re-treats from the wavering professional argumentwhich she has already given to Mr. Wingo, afamily member of one of her patients. Ultimately,and unfortunately, she accepts the patient's defi-nition of the context (i.e., that he himself is tech-nically not her patient) and his punctuation ofreality. The patient, for a variety of motives, isnot necessarily expected to perceive the bounda-ries of the professional relationship without somepossible distortions; it is, however, the psycho-therapist's responsibility to correctly perceive theparameters of the dyadic doctor-patient relation-ship and the triadic doctor-patient-family rela-tionship (e.g., Doherty & Baird, 1983) and toact accordingly. The professional's punctuationof the relationship, thereby, assists the patient inreducing any distortions which might occur.3

Dilemmas in Psychological Assessmentand Diagnosis

The focus of this discussion thus far has beenon the patienttherapist dilemmas that take placein the ongoing interaction of psychotherapy perse. There are, however, other dilemmas that con-cerned clinicians experience in the practice oftheir profession, and these may affect their pa-tients less immediately, but will affect them none-theless. Such dilemmas abound in the area ofpsychodiagnostic assessment.

Diagnostic dilemmas. The first assessment-oriented dilemma might be described as a choicebetween The less severe versus the more severevalid differential diagnosis. Frequently, patientspresent with a clinical picture that places them

3 Another dimension contributing to the poorly defined na-

ture of the professional relationship in this fictional exampleis the probable emotional agenda of the therapist who allowsthe boundary to be violated when faced with her own needi-ness, rather than handling these conflicts through internal con-trols, consultation, or even referral. It should be noted thatthe boundary violations exhibited here also enter into thedomain of ethical conflict, as well. It is beyond the scope ofthis article to address the separate area of ethical dilemmasin clinical practice, and there is ample literature on this singletopic alone (e.g., Bersoff, 1995). For the purposes of thisdiscussion, suffice it to say that there is an abundance ofdilemmas that exist in the practice of psychotherapy withoutever entering into the arena of clinical ethics.

Clinical Dilemmas in Contemporary Psychotherapy

diagnostically in a grey area between two or moreequally valid diagnoses. Despite the decisiontrees, descriptions of essential features, and sec-tions in "differential diagnosis," offered by theDSM-IV, psychodiagnosis is still not an exactscience. In these instances, which diagnosis doesthe clinician choose, and what are the "horns" ofthis particular dilemma? Consider the phenome-non of clinical depression that varies on a contin-uum of severity from Adjustment Disorder withDepressed Mood to Dysthymia to Recurrent Ma-jor Depression with or without Suicidal Ideation.Historically, clinicians in the area of mentalhealth have been concerned about the possibilityof stigma associated with psychiatric diagnosesand treatments (e.g., Goffman, 1961, 1963;Szasz, 1970). It might well be argued that theexistence of stigma in this area has decreasedsubstantially over the past three decades, espe-cially with acknowledgement and discussion ofpsychological disorders in the popular media. Al-ternatively, one might argue that with the in-creased access of employers to the healthcareinformation of their workers via employee assist-ance programs and insurance benefits, the issueof stigma for emotional disorders, however les-sened in this era, is of no less importance inthe workplace.

So, clinicians who are concerned about suchissues for their patients might, for example, leantoward diagnosing Adjustment Disorder as op-posed to Dysthymia, or Dysthymia in place ofMajor Depression, in order to lessen the degreeof stigmatization, if all other variables are equal.However, with the advent of the concept of"medically necessary psychotherapy" and man-aged care, should clinicians opt for the more nec-essary (i.e., often more severe) diagnosis, in or-der to meet their responsibilities to their patientsto obtain authorization for adequate levels oftreatment, thereby placing the issue of stigma asa secondary concern? There is no easy or clear-cut answer to this question. While most clinicianswould likely agree that obtaining sufficient levelsof care is the first priority, the concern over thepossible stigmatization of the patient does notvanish with this prioritization. At some point, itmay be important to discuss the diagnostic consid-erations and concerns with patients and/or theirfamilies to more fully enlist them in the treat-ment process.

Dilemmas in nontreatment oriented assess-ments. When the customer (i.e., the person or

institution) paying for the psychological evalua-tion, to use the contemporary healthcare lexicon,is not the "patient," a number of dilemmas forthe clinician can be the result. The main thrustof these dilemmas seems to center around onekey issue that might be described as follows: Forwhose good: The patient or the institution? Whenan evaluation is done for treatment purposes, thereis the presumption of an intent to help or assistthe patient in some way. When an evaluation isdone for some purpose other than treatment, thepatient or examinee may not feel that the resultsare necessarily intended for his or her benefit.Furthermore, in many instances, the customermay not be the person being examined by theclinician. Such may be the case, for example, inchild custody evaluations, insanity determina-tions for legal purposes, alcohol assessments forDWIs, and psychosocial assessments for medi-cal procedures.

An example of the complexity of this dilemmais the institutional requirement of psychosocialevaluations for liver transplant surgical opera-tions. These assessments take into account a widerange of variables pertaining to psychologicalfunctioning, family history, and alcohol usage,to name a few (e.g., Beresford, 1997). Becausealcohol usage compromises both the likelihoodof success and medical compliance, it is a factorthat is generally weighted negatively when con-sidering a given patient for such a procedure.With limited organ availability, few would arguewith society's right to choose an organ recipientwith the highest probability of success. On theother hand, each patient in desperate life circum-stances has the understandable wish to maximizethe likelihood of acceptance for a life-preservingmedical procedure. If a given patient freely dis-closes information about an extensive alcohol his-tory, for example, to an apparently warm andunderstanding mental health professional in thecourse of a psychosocial evaluation, how couldsuch a patient not feel betrayed in finding outafter the fact that the information which he or sheoffered so openly was used to personal detriment?Indeed, should patients not know in advance notonly the purpose of the evaluation, but also howcertain information is likely to be assessed? If so,does this not afford the opportunity to skew ordistort such information in the course of the inter-view? While this may indeed be so, should suchpatients not have the right to at least not work toone's own detriment, leaving it up to the clinician

D. J. Scaturo &W.R. McPeak

to invoke sound clinical judgment about the valid-ity of guardedly offered information? These areonly a sampling of the professional dilemmas con-fronted by the clinician conducting nontreatment-oriented assessments.

ConclusionFor beginning psychotherapists, even those

with a high tolerance for ambiguity, it is easy tobecome exasperated by the many dilemmas, andabsence of clear-cut answers, replete in clinicalwork. Wachtel (1982) appears to concur with thisview when he writes,Practicing psychotherapy is a difficultif also rewardingway to earn a living. It is no profession for the individualwho likes certainty, predictability, or a fairly constant sensethat one knows what one is doing. There are few professionsin which feeling stupid or stymied is as likely to be a part ofone's ordinary professional day, even for those at the pinnacleof the field (p. xiii).

For the seasoned clinician, navigating throughthe quagmire of the psychotherapeutic processfrequently becomes a metaphor for the complexi-ties and conflicts that the patient brings into psy-chotherapy for examination and guidance. Forthe novice, the dilemmas are disturbing and thepsychotherapy "cookbooks" are the clinical lifepreservers to which one clings for an answer ordirection, even if left wanting. For the experi-enced clinician, the dilemmas are reaffirming ofwhat many therapists (e.g., Yalom, 1980) con-sider to be a basic truth: that not all of psychother-apy, nor all of life, can be traversed with a cook-book. Quite possibly, this is why the concept ofwisdom continues to have relevance in the prac-tice of psychotherapy (Karasu, 1992). How thepsychotherapist handles the dilemmas of therapybecomes a metaphor, and possibly a guide, forthe patient in handling the conflicts of his or herlife. Overtly recognizing the inherent complexityof these dilemmas, and attempting to respond toall of the significant facets with rationality andhumanity, and an understanding of the impact onone's emotional life, models for the patient a wayto approach the predicaments of his or her lifewith thoughtfulness and deliberation. Providingthe patient with a more complex view of causalityand decision-making can be an asset in clinicalwork and an asset in life.

An example of the complexity in clinical work,and the dilemmas in treatment that arise from thiscomplexity, might be seen in the treatment of

panic disorder and agoraphobia (Scaturo, 1994).When a patient with panic disorder and/or agora-phobia comes to a psychotherapist for treatment,there are many necessary clinical decisions thatare dependent on various facets of the clinicalpicture and the particular patient and his or herhistory. A sampling of these questions are as fol-lows: Does the psychotherapist refer the patientfor a medication evaluation immediately or doeshe or she defer for a while, attempting behavioralinterventions first (Mavissakalian, 1991; Shear,1991)? Given the proven effectiveness of behav-ior therapy in gaining symptom control of thisdisorder (e.g., Barlow & Cerny, 1988), does theclinician move immediately into this type of psy-choeducational modality if the patient feels thatan extensive discussion of his or her interpersonalhistory and object relations would be helpful andrelevant (Friedman, 1985)? Given the significantrole of separation anxiety and themes of abandon-ment with these disorders (e.g., Sable, 1994), isit prudent to conduct a behavior-therapy programexclusively without some exploration of thesepossible concerns in the patient's history? Giventhe proven enhanced effectiveness of couplestreatment with these disorders (Barlow,O'Brien, & Last, 1984; Cerny, Barlow, Craske,& Himadi, 1987), does one invite the spouseor significant other to be a part of the treatment,and, if so, when? Finally, if all of the above-noted factors likely play some role in the etiol-ogy and treatment of panic disorder and agora-phobia, is it not possible to address each ofthese variables integratively in treatment so asto provide a more comprehensive view of theproblem and treatment (Scaturo, 1994)? If so,sound clinical judgment would undoubtedlyplay a major role in addressing these concernsin a given patient in an understandable and ac-ceptable way. As such, psychotherapy consti-tutes the integration of art and science.

An examination of the myriad of complex di-lemmas in clinical work underscores the impor-tance of training and mentoring in the practice ofpsychotherapy. It may be especially true as thefield moves toward the practice of brief psycho-therapy, where the therapist narrows the focus ofintervention, that it is important for the under-standing and conceptualization of the problem toremain broadly based to allow for the shifts intherapeutic focus that a constantly changing clini-cal picture demands.

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