Psychotherapy Volume 35/Spring 1998/Number 1

CLINICAL DILEMMAS IN CONTEMPORARY PSYCHOTHERAPY:

THE SEARCH FOR CLINICAL WISDOM
DOUGLAS J. SCATURO
Department of Veterans Affairs Medical Center at Syracuse
Department of Psychiatry and Behavioral Sciences
Department of Family Medicine
State University of New York Health Science Center at Syracuse
Department of Psychology
Syracuse University
WILLIAM R. McPEAK
School of Social Work
Syracuse University
Department of Psychiatry and Behavioral Sciences
State University of New York Health Science Center at Syracuse
The concept of the clinical dilemma in
the contemporary practice of
psychotherapy is examined in this article.
The notion of "dilemma management" by
the psychotherapist is viewed as a
ubiquitous phenomenon in the
psychotherapeutic process. Dilemmas in
a range of areas of clinical practice are
discussed and observations are made
about the interpersonal process of
dilemma management in psychotherapy
that 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 by
the Medical Research Service of the Department of Veterans
Affairs. The opinions expressed in this article are those of
the authors and do not necessary represent those of the Depart-
ment of Veterans Affairs. The authors wish to extend their
gratitude to Robert P. Sprafkin, Ph.D., Barbara McClure,
Ph.D., and Toni M. McCormick, Psy.D. for their editorial
assistance on an earlier version of this article.
Correspondence regarding this article should be addressed
to 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 conflicts
and dilemmas in their own lives.
The practice of psychotherapy can be seen as a
constant series of clinical choices and recurring sets
of dilemmas. In this complex human arena, they
are a part of the everyday life of the clinician. A
dilemma is denned as "a situation involving choice
between two equally unsatisfactory alternatives"
(Merriam-Webster, 1986, p. 355). Its synonyms
include predicament, quandary, and impasseall
of 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 get
stuck on or by either. As a result, a dilemma, by
its nature, causes anxiety. In a clinical context, it
might be said that a dilemma is any choice or con-
flict that creates anxiety in the clinician about what
to do or what to say next. Indeed, the process
of psychotherapy might well be regarded as the
management of ongoing dilemmas, both for the
patient and for the therapist.
The purpose of this article is to examine the
process of psychotherapy from the standpoint of
frequently occurring dilemmas for the clinician.
The concept of dilemma management is viewed as
endemic 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, behavior
therapy, marital and family therapy, and group ther-
apy; (b) systemic issues such as spousal codepende-
ncy and family homeostasis; (c) transference and
countertransference; (d) therapeutic neutrality and
management of the therapeutic boundary; and
(e) psychological assessment and psychiatric diag-
nosis. Finally, some observations will be made
about the interpersonal process of dilemma manage-
ment in psychotherapy that models for patients an
effective way of approaching the ubiquitous con-
flicts and dilemmas in their own everyday lives.
Psychotherapy as Dilemma Management
The process of psychotherapy has been referred
to by Freud as "the talking cure" (Wachtel, 1993).
As such, unique to this discipline is the fact that
what the therapist says, and how he or she says
it, is of crucial importance to the patient and the
healing process. When one considers the fact that
many, if not most, patients come to psychother-
apy for what Alexander and French (1946) have
termed a "corrective emotional experience," often
from a history of emotional neglect by significant
others who never fully weighed their words, then
the importance of everything that the psychothera-
pist says becomes clear. Several authors, Wachtel
(1993) and Wile (1984) among them, have noted
that confrontative interpretations of the patient's
behavior and defenses, however accurate, may
easily be viewed as accusatory or pejorative by the
patient. Thus, finding a facilitative way to confront
patients and help them find alternative methods of
coping 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 given
patient at a given point in treatment. If confronta-
tion is the metaphorical surgical incision in explor-
atory psychotherapy, then providing emotional
support is surely the metaphorical anesthesia.
1
It
is the psychotherapist's responsibility to decide
how 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 history
and this particular diagnosis and defensive struc-
ture can tolerate at this particular point in time.
Alternatively, how much support is needed in this
process and when? This decision is an ongoing
one which occurs as a result of therapy being a
dynamic 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 this
confrontation of the defensive structure at the outset
of therapy which largely accounts for the shortening
of the therapy in these approaches. Nevertheless,
careful training in these approaches, as well as an
equally 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 be
this: too much confrontation may overwhelm and
diminish the patient's sense of self; too much sup-
port without any confrontation may yield no change
or movement of the patient in therapy.
In the systemic therapies (e.g., marital and
family therapy), this problem is compounded by
the need to not only decide when support versus
confrontation is needed within a given individual,
but also to decide how and when to distribute
support and confrontation among a group of fam-
ily members, some of whom may be in conflict
with 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 alliance
with the supported member that can be tolerated
by the others for only a limited period of time
without alienating them (Minuchin, 1974). The
marital and family therapist frequently feels as
though he or she is constantly "robbing Peter to
pay Paul" as the therapist attempts to balance
emotional support and therapeutic alliance in any
given family therapy session.
Dilemma management in behavior therapy.
Until only very recently (e.g., Safran & Segal,
1990), the notion of the therapeutic relationship
and alliance has been largely neglected in the
writings on behavior therapy, although this view
tends 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 behavioral
literature may be related in part to the psychoedu-
cational nature of the approach, which offers a
behavioral analysis of the patient's problems and
structured behavioral homework assignments that
logically follow from this analysis. It seems gen-
erally assumed by behavior therapists that the pri-
mary motivation for the patient to follow through
on these assignments is symptom relief. It is also
prudent, however, to assume that the concept of
resistance 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 and
nature of the patient's alliance with the behavior
therapist. Failure to follow through with behav-
ioral homework may be indicative of resistance
derived 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 they
arise in the course of treatment.
Thus, the session-to-session (if not moment-
to-moment) dilemma for the behavior therapist
might be characterized as the decision to assign
or not to assign homework in a given behavior
therapy session. This single decision then be-
comes further subdivided into intermediate deci-
sions about what problems to deal with, in what
order of importance, and with what assigned
tasks. 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. As
a result, every behavior therapist should likely
consider the following question prior to assigning
homework, "How much therapeutic rapport do
I now have in this patient's metaphorical 'bank
account' to make such a 'withdrawal' (i.e., re-
quest) at this point in time?"
2
With the trends for
briefer and briefer treatments in which rapport is
based on a fewer number of sessions, this di-
lemma for the behavior therapist becomes even
more crucial to the success of treatment.
The Textbook Practice of Psychotherapy
The guidelines and standards of practice for
each 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 necessary
choices that predictably arise in clinical practice.
In each instance, however, the standard texts, and
more recent treatment manuals (e.g., Craske &
Barlow, 1989), for treatment within any single
approach or modality, are never broad enough to
provide a full range of answers to the complex
nature of problems that occur in clinical work.
Psychotherapists in each of the major schools of
treatment ultimately found the constraints of for-
mal methods and protocols to be too limiting to
adequately address the range of patient needs in
a clinical context (Scaturo, 1994).
For example, a number of the early psychoana-
lysts found the constraints of the psychoanalytic
method, as discussed in formal texts on the sub-
ject (e.g., Langs, 1973), to be unresponsive to a
broad range of patients' needs. Yalom (1980) has
provided an eloquent illustration of how Freud
himself strained against the limitations of psycho-
analysis in his treatment of Elizabeth Von R. In
a review of Freud's notes, Yalom finds a wide
range of clinical activities by Freud intended to
address a resolution of several problems in Eliza-
beth's life. He assigned behavioral homework to
address her grief, attempted to increase her peer
socialization, worked with the family on her be-
half, and even attempted to disentangle some of
her family's financial problems. None of these
therapeutic maneuvers fall within the realm of
"abreaction," which was Freud's sole explanation
for Elizabeth's improvement in her psychogenic
difficulty 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 protocols
were 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) was
in part an attempt to mediate the dilemma between
an exclusive focus on the patient's overt behavior
and the patient's cognitive and affective life
that is, a way to address the thoughts and emo-
tional needs presented by their patients.
Finally, when the field of family therapy was
in its adolescence attempting to establish its pro-
fessional identity, there were insistences that the
whole family living unit be in attendance at each
session for treatment to take place (e.g., Haley,
1970). These kinds of dogmatic positions not only
alienated many mental health professionals
trained within other, typically individual, treat-
D. J. Scaturo & W. R. McPeak
ment approaches, but (not unlike their behavior
therapy counterparts) simply failed to address
many of the important internal needs of individual
family members. Family therapists attempting to
deal with this dilemma between the self and the
system began to articulate a "rediscovery" of the
self in the system (Nichols, 1987a, 1987b). Some
individual therapists, struggling with the same
dilemma from a different perspective, began to
initiate family consultations with their patients in
an effort to become acquainted with the members
of their patients' primary social system, both in
reality and through transference (e.g., Wachtel
& Wachtel, 1986).
Systemic Dilemma I: Couples and
Family Therapy
The unique problems associated with ex-
panding the treatment system from the individual
patient to the couple or family were recognized
by the early pioneers in the field of family therapy
(e.g., Haley, 1963; Napier & Whitaker, 1973).
Ellen Wachtel (1979) has articulated some of
these difficulties in the form of various dilemmas
posed to the individually trained psychotherapist
attempting 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 a
systemic view is the question of, Who is to blame!
She notes that individual insight-oriented thera-
pists have historically viewed poor child-rearing
practices in the patient's family of origin as the
culprit for any dysfunctional behavior patterns
or emotional disorders. From a family-systems
viewpoint, the responsibility for marital conflict
or other types of behavioral dysfunction clearly
does not reside exclusively within any one indi-
vidual, though the patients themselves usually
have a more linear perspective of their difficult-
ies. So, in the case of marital conflict, the di-
lemma for the therapist posed by each member
of the couple entering therapy is, Is it me or my
spouse! (i.e., who is to blame?). Essentially, this
is a question of externalization versus internaliza-
tion of responsibility. In the case of marital con-
flict, an externalized presentation of the problem
is more common among both members of the
couple. People can frequently articulate in great
detail the many complaints that they have about
their spouses, and in some instances, offer tre-
mendous insight about their spouses' psychody-
namics. Frequently, they have little insight into
their own contributory behavior. As a result, an
important question at the outset of marital therapy
is to inquire the following of each person, "What
do 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, but
performs the dual purpose of assisting the couple
in viewing their marital problems from a systemic
perspective, which may help to reduce the mutual
blaming, and once answered, can help point out
some potential avenues for change.
One method of couples therapy is to help them
to understand that much of how they treat one
another comes from what they learned about inti-
mate relationships in their family of origin. This
dilemma, a variant of the one noted above and
brought to the therapist by the patient, might be
appropriately described by Is it my spouse or my
parents'? (i.e., who is/are to blame?). Framo
(1982) describes the family-of-origin contribution
to marital distress from an object-relations theo-
retical perspective.
The price for robbing of self during the growing years exacts
a toll and leaves a legacy, giving rise to the ambivalence that
all people feel about their close relationships. Since old scores
have to be settled and reservoirs of hatred cannot be contained,
someone has to pay. Those someones are usually the current
intimatesthe mate and children; the demons of today are
punished by the internal ghosts of yesteryear (pp. 188-189).
Helping couples to see that the spouse is only a
substitute target of anger and conflict usually
serves to soften the marital discord. Wachtel
(1979) as well, has noted that this approach is a
well-documented strategy in individual psycho-
therapy to help lessen the blame associated with
a given interpretation of the patient's maladaptive
behaviors: "Of course, your behavior is an under-
standable response, given the family environment
in which you were being raised." In family-of-
origin therapy, however, this dilemma is resolved
by taking the conflict out of the realm of blaming.
The forgiveness of parents is a central feature in
this 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 forms
of self-hatred" (p. 59).
Systemic Dilemmas II: Codependency and
Family Homeostasis
The concept of codependency provides another
example of a dilemma that is derived from clinical
Clinical Dilemmas in Contemporary Psychotherapy
work with the family system, especially around
the issue of blaming. Unfortunately, the concept
has been popularized by the self-help literature
(e.g., Starker, 1990) in writings on children of
alcoholics and may be less clinically precise than
other concepts in the psychiatric nomenclature
(Fiese & Scaturo, 1995). Theoretically, however,
the concept is linked to, and is a more specific
example of, a number of broader and long-held
concepts 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 "marital
quid pro quo," Bowen's (1960) "overfunction-
ing'V'underfunctioning" relationship, and Ha-
ley's (1963) "one-up/one-down" relationship. In
the field of alcoholism, the concept of codepende-
ncy refers to a relationship in which the alcoholic
is married to a spouse who, despite being a non-
drinker, serves as a helper/facilitator to the alco-
holic and thereby, unintentionally, fosters the
continuance of the drinking problem. The code-
pendent may, for example, make the "sick" call
to the alcoholic's place of employment after a
drinking episode, thus delaying the problem from
coming to the social or occupational foreground
more quickly. Such behavior is also referred to
as enabling, permitting the problem to continue.
The tendency among many clinicians is to target
the enabling behavior of the spouse as an im-
portant focus of treatment. This strategy, while
well-intended, places the clinician in a dilemma
in which he or she is in the position of blaming
the victim (Ryan, 1971). In this instance, the
spouse of an alcoholic may easily feel quite criti-
cized by the therapist who focuses on his or her
enabling behavior, especially if insufficient atten-
tion is given to the origins of this behavior and
the desperation involved in this particular form
of coping. It is probably important for the clini-
cian to remember and respect the fact that spouses
who engage in this kind of caretaking behavior
in a marriage have most likely learned this form
of adaptation in their family of origin, often being
parentified and made responsible for an alcoholic
parent as a desperate way of fitting into a thor-
oughly dysfunctional and chaotic family environ-
ment. To confront them in a critical way about
the only familiar way of relating in a family,
however excessive their behavior appears now,
will not only be unsuccessful in affecting behavior
change, but will likely be destructive to any thera-
peutic alliance as well.
Group Treatment
One consequence of the current trend toward
brief treatments that has affected the practice of
group 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 interpersonal
problem. It is common, for example, to see clin-
ics and clinicians offering therapy groups for anx-
iety or depression management, panic disorder
and agoraphobia, alcoholism, adult children of
alcoholics, survivors of sexual abuse, and Viet-
nam combat veterans, to name a few. Such group
composition is predicated upon the assumption
that a certain commonality of experience will fos-
ter an accelerated identification, trust, and cohe-
sion among the group members. This question of
homogeneity versus heterogeneity in group com-
position, however, poses some very real dilem-
mas for the group therapist (Fiese & Scaturo,
1995; Scaturo & Hardoby, 1988). Indeed, the
sense that, "we are all the same here," based on
the similarity of a diagnosis, life problem, or
given facet of family history may not be fully
consistent with the interpersonal goals of interac-
tional group psychotherapy (Yalom, 1975), in
which one of the major curative elements involves
a sharing of individual and variant life experi-
ences and the sense of genuineness and accep-
tance that comes from being fully understood and
known by another human being. Thus, if the goal
of a given group is limited to that of social sup-
port, then the identification that is fostered by the
homogeneity of a given group theme may have
a certain clinical utility. If the goal of the group,
however, is that of psychotherapy, then a fuller
exploration of individual life experience which
might be enhanced by a more heterogeneous
group composition, providing a more accurate
representation 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 dilemmas
surrounding the concept of transference (i.e., the
patient's feelings about the therapist) probably
fall more within the domain of countertransfer-
ence (i.e., the therapist's reactive feelings about
the patient), the patient's transferential reactions
are often the source or stimulus for the therapist's
countertransferential difficulties. So, for exam-
ple, a patient who demonstrates a particularly
D. J. Scaturo &W. R. McPeak
strong transferential feelingeither positive or
negativetoward the therapist is likely to evoke
some type of counterresponse in the therapist's
emotional life, which often leads to the therapist's
struggle about how to handle the ongoing issues
in treatment. The range of countertransferential
reactions is not limited to these emotional reac-
tions alone. Sometimes the patient, by virtue of
his or her life experiences and/or personal charac-
teristics, evokes a strong emotional response on
the 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 undergoing
divorce. She believes that strong identification by
the therapist with one of the divorcing parties can
decidedly affect the quality and effectiveness of
the clinical work. Certainly, the dilemma that
every psychotherapist faces in grappling with
strong countertransferential reactions is to ask
himself or herself whether his or her responses
are 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 given
patient or family, and why?
It should be noted that a strong identification
with a particular patient's life situation or defen-
sive structure is not, by definition, a sign of poorly
conducted psychotherapy. It is, however, a marker
of some additional intensity and complexity in
the clinical context. Almost all psychotherapists
will admit in greater moments of candor that they
do 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 certain
patients prior to and outside of a clinical context,
could imagine being friends with some patients
and certainly not with others. And, these patients,
due to the almost instinctive understanding of
their difficulties, stand to receive one of two
things from a psychotherapist who identifies
strongly with their concerns: either the best or
worst service that such a clinician has to offer.
If the clinician has sufficiently worked through
the emotional issue in his or her life which runs
parallel to the issue in the life of the patient and
is able to thereby maintain adequate objectivity
in the therapy, then the patient stands to gain
much from the hard-earned intuitive understand-
ing which that clinician has by virtue of his or
her own life experience. On the other hand, if
the therapist over-identifies with the patient's
conflicts and loses proper clinical perspective,
then a grave disservice is being rendered to such
a patient.
An example of the intensity of these counter-
transferential feelings is portrayed in the dialogue
of the play, Equus (Shaffer, 1977). The drama
depicts a disturbed adolescent stable boy in En-
gland who is undergoing court-mandated treat-
ment after blinding six horses with a spike. The
horses were the boy's first sexual experience. He
would ride them naked in the evening to the point
of orgasm. The blinding occurred after his first
sexual experience with a young girl that occurred
in the stable with the horses present, leaving the
boy feeling that he had betrayed them. The
middle-aged psychiatrist who is treating the boy is
struggling with the powerfully destructive passion
which his patient feels, but which has long been
absent in his own life. The following is an excerpt
of a conversation that Dr. Dysart is having one
evening 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 slave
who stands over him obviously and unthrowably his
master. With my body I thee worship! . . . Many
men 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 the
country doing it again and again?
HESTER: I mean he's in pain, Martin. He's been in pain for
most 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 it
yoursyour lifeyou first have to get your own
pain. Pain that is unique to you. You can't just dip
into 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 passion
more ferocious than I have felt in any second of my
life. 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 this
time. '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 1973
Peter Shaffer.)
What is not absurd is the dilemma in which Dr.
Dysart finds himself: Having the unique ability
to help his patient through a remarkable under-
standing of the problem, so long as he is able to
control his envy and maintain adequate objectiv-
ity. In this instance, the latter seems unlikely,
given the above dialogue. As a result, Dr. Dysart
then faces a secondary dilemma surrounding his
countertransference: Does the therapist Keep or
Refer such a patient? While it seems prudent in
the above example to strongly consider referral,
one might consider obtaining for mal consultation
for such a case to decide whether or not keeping
or referring the case would be most helpful to
the patient.
An even more problematic area involving the
question of whether to keep or refer is the issue
of personal attraction to a patient by the clinician.
Many instances of sexual exploitation of patients
in therapy might be avoided if the therapist were
able to recognize the growing attraction and im-
mediately seek consultation to assist with the
countertransference or to make an appropriate re-
ferral of the case (e.g., Pope, 1994).
Therapeutic Neutrality and
Boundary Management
The concept of technical neutrality in psycho-
therapy has been largely misunderstood, both in
terms of its meaning as well as in terms of its
multiple facets. The notion of neutrality means
that the psychotherapist maintains sufficient ob-
jectivity so as to not take sides with respect to
the patient's internal conflicts (Herman, 1992).
Its purpose is to respect and protect the patient's
autonomy for one's life. Neutrality should not
imply 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 imply
that the therapist is uncaring (Herman, 1992).
Paul Wachtel (1987) in his chapter entitled,
You Can't Go Far in Neutral, points out a number
of 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 an
atmosphere of safety in the therapeutic context,
Wachtel notes that a neutral stance on the part of
the therapist may not be the best vehicle to foster
safety. He points out that when the psychothera-
pist is consistently ambiguous in his or her re-
sponses, the patient's inclinations to experience
rejection are given full reign. Alternatively, neu-
trality may be experienced by such patients as an
invalidating response and contribute to doubting
their sense of reality about their life experiences.
Instead, many patients require a positively af-
firming stance to their life circumstances and
emotional dilemmas.
Wachtel's observation is similar to Herman's
(1992) criticisms about the notion of moral neu-
trality in the psychotherapeutic situation. Herman
points out that, particularly in clinical work with
victimized populations, a committed moral stance
from the therapist and solidarity with the patient
regarding this issue is a prerequisitethat neu-
trality with regard to this issue is simply too weak
of a stance for the therapist to assume. In these
instances, the victim may reasonably expect the
therapist to share in his or her moral outrage and
to demonstrate an implicit understanding of the
injustice inherent in the traumatic situation.
The clinical dilemma, however, is how to be
sufficiently engaged with the patient, on the one
hand, without losing one's sense of clinical objec-
tivity and ability to be effective with the patient,
on the other (i.e., therapeutic neutrality versus
therapeutic engagement). In short, therapeutic
neutrality is not a simplistic, unidimensional an-
swer to the complex question of boundary man-
agement in clinical practice. The absence of self
in the clinical interview through the concealment
of one's reactions to what the patient brings to
the session is hardly reassuring to most patients.
Indeed, it is questionable as to whether the mask-
ing of the therapist's personal reactions is even
possible, given the attitudinal metamessages in-
trinsic in almost all clinical interpretations (Wach-
tel, 1993). Alternatively, however, this does not
mean 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 right
to self-determination in their own lives. Such clin-
ical work requires a consistent and vigilant atten-
tion to, and management of, the therapeutic
boundary in all sessions with patients and/or
their families.
An example from literature of inattention to
such necessary boundary management can be
found in the novel The Prince of Tides by author
Pat Conroy (1988). The story involves a high
school football coach from South Carolina named
Tom Wingo who, in the midst of a marital crisis,
spends his summer in New York City consulting
with his sister's psychiatrist, a Dr. Susan Lo-
wenstein, following his sister's psychotic epi-
sode and hospitalization while in a catatonic
state. During this time, Mr. Wingo and Dr.
Lowenstein become involved in a personal and
eventually a sexual relationship. Consider the
following 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 even
know your first name."
"That's not important. My patients don't call me by my
first name."
"I'm not your patient. My sister is. I'm her Cro-Magnon
brother and I'd like to call you by your first name. . . . You're
calling 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 have
come here because you are trying to help me with one of my
patients. I would like you to call me Doctor because I'm most
comfortable with that form of address in these surroundings.
And it scares me to let a man like you get too close, Tom. I
want 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. I
want 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. Wingo
asks Dr. Lowenstein out to dinner, and she ac-
cepts the invitation. The violation of professional
boundaries provided in this example from litera-
ture is not that Dr. Lowenstein allows Mr. Wingo
to call her by her first name, but it lies in the
context in which this permission is given. In the
course of this conversation, Dr. Lowenstein re-
treats from the wavering professional argument
which she has already given to Mr. Wingo, a
family 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 of
reality. The patient, for a variety of motives, is
not necessarily expected to perceive the bounda-
ries of the professional relationship without some
possible distortions; it is, however, the psycho-
therapist's responsibility to correctly perceive the
parameters of the dyadic doctor-patient relation-
ship and the triadic doctor-patient-family rela-
tionship (e.g., Doherty & Baird, 1983) and to
act accordingly. The professional's punctuation
of the relationship, thereby, assists the patient in
reducing any distortions which might occur.
3
Dilemmas in Psychological Assessment
and Diagnosis
The focus of this discussion thus far has been
on the patienttherapist dilemmas that take place
in the ongoing interaction of psychotherapy per
se. There are, however, other dilemmas that con-
cerned clinicians experience in the practice of
their profession, and these may affect their pa-
tients less immediately, but will affect them none-
theless. Such dilemmas abound in the area of
psychodiagnostic assessment.
Diagnostic dilemmas. The first assessment-
oriented dilemma might be described as a choice
between The less severe versus the more severe
valid differential diagnosis. Frequently, patients
present with a clinical picture that places them
3
Another dimension contributing to the poorly defined na-
ture of the professional relationship in this fictional example
is the probable emotional agenda of the therapist who allows
the 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 that
the boundary violations exhibited here also enter into the
domain of ethical conflict, as well. It is beyond the scope of
this article to address the separate area of ethical dilemmas
in clinical practice, and there is ample literature on this single
topic alone (e.g., Bersoff, 1995). For the purposes of this
discussion, suffice it to say that there is an abundance of
dilemmas that exist in the practice of psychotherapy without
ever entering into the arena of clinical ethics.
Clinical Dilemmas in Contemporary Psychotherapy
diagnostically in a grey area between two or more
equally valid diagnoses. Despite the decision
trees, descriptions of essential features, and sec-
tions in "differential diagnosis," offered by the
DSM-IV, psychodiagnosis is still not an exact
science. In these instances, which diagnosis does
the clinician choose, and what are the "horns" of
this particular dilemma? Consider the phenome-
non of clinical depression that varies on a contin-
uum of severity from Adjustment Disorder with
Depressed Mood to Dysthymia to Recurrent Ma-
jor Depression with or without Suicidal Ideation.
Historically, clinicians in the area of mental
health have been concerned about the possibility
of stigma associated with psychiatric diagnoses
and treatments (e.g., Goffman, 1961, 1963;
Szasz, 1970). It might well be argued that the
existence of stigma in this area has decreased
substantially over the past three decades, espe-
cially with acknowledgement and discussion of
psychological disorders in the popular media. Al-
ternatively, one might argue that with the in-
creased access of employers to the healthcare
information of their workers via employee assist-
ance programs and insurance benefits, the issue
of stigma for emotional disorders, however les-
sened in this era, is of no less importance in
the workplace.
So, clinicians who are concerned about such
issues for their patients might, for example, lean
toward diagnosing Adjustment Disorder as op-
posed to Dysthymia, or Dysthymia in place of
Major Depression, in order to lessen the degree
of 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 patients
to obtain authorization for adequate levels of
treatment, thereby placing the issue of stigma as
a secondary concern? There is no easy or clear-
cut answer to this question. While most clinicians
would likely agree that obtaining sufficient levels
of care is the first priority, the concern over the
possible stigmatization of the patient does not
vanish with this prioritization. At some point, it
may be important to discuss the diagnostic consid-
erations and concerns with patients and/or their
families 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 for
the clinician can be the result. The main thrust
of these dilemmas seems to center around one
key issue that might be described as follows: For
whose good: The patient or the institution? When
an evaluation is done for treatment purposes, there
is the presumption of an intent to help or assist
the patient in some way. When an evaluation is
done for some purpose other than treatment, the
patient or examinee may not feel that the results
are necessarily intended for his or her benefit.
Furthermore, in many instances, the customer
may not be the person being examined by the
clinician. Such may be the case, for example, in
child custody evaluations, insanity determina-
tions for legal purposes, alcohol assessments for
DWIs, and psychosocial assessments for medi-
cal procedures.
An example of the complexity of this dilemma
is the institutional requirement of psychosocial
evaluations for liver transplant surgical opera-
tions. These assessments take into account a wide
range of variables pertaining to psychological
functioning, family history, and alcohol usage,
to name a few (e.g., Beresford, 1997). Because
alcohol usage compromises both the likelihood
of success and medical compliance, it is a factor
that is generally weighted negatively when con-
sidering a given patient for such a procedure.
With limited organ availability, few would argue
with society's right to choose an organ recipient
with the highest probability of success. On the
other hand, each patient in desperate life circum-
stances has the understandable wish to maximize
the likelihood of acceptance for a life-preserving
medical procedure. If a given patient freely dis-
closes information about an extensive alcohol his-
tory, for example, to an apparently warm and
understanding mental health professional in the
course of a psychosocial evaluation, how could
such a patient not feel betrayed in finding out
after the fact that the information which he or she
offered so openly was used to personal detriment?
Indeed, should patients not know in advance not
only the purpose of the evaluation, but also how
certain information is likely to be assessed? If so,
does this not afford the opportunity to skew or
distort such information in the course of the inter-
view? While this may indeed be so, should such
patients not have the right to at least not work to
one'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 are
only a sampling of the professional dilemmas con-
fronted by the clinician conducting nontreatment-
oriented assessments.
Conclusion
For beginning psychotherapists, even those
with a high tolerance for ambiguity, it is easy to
become exasperated by the many dilemmas, and
absence of clear-cut answers, replete in clinical
work. Wachtel (1982) appears to concur with this
view when he writes,
Practicing psychotherapy is a difficultif also rewarding
way to earn a living. It is no profession for the individual
who likes certainty, predictability, or a fairly constant sense
that one knows what one is doing. There are few professions
in which feeling stupid or stymied is as likely to be a part of
one's ordinary professional day, even for those at the pinnacle
of the field (p. xiii).
For the seasoned clinician, navigating through
the quagmire of the psychotherapeutic process
frequently becomes a metaphor for the complexi-
ties and conflicts that the patient brings into psy-
chotherapy for examination and guidance. For
the novice, the dilemmas are disturbing and the
psychotherapy "cookbooks" are the clinical life
preservers to which one clings for an answer or
direction, even if left wanting. For the experi-
enced clinician, the dilemmas are reaffirming of
what 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 of
wisdom continues to have relevance in the prac-
tice of psychotherapy (Karasu, 1992). How the
psychotherapist handles the dilemmas of therapy
becomes a metaphor, and possibly a guide, for
the patient in handling the conflicts of his or her
life. Overtly recognizing the inherent complexity
of these dilemmas, and attempting to respond to
all of the significant facets with rationality and
humanity, and an understanding of the impact on
one's emotional life, models for the patient a way
to approach the predicaments of his or her life
with thoughtfulness and deliberation. Providing
the patient with a more complex view of causality
and decision-making can be an asset in clinical
work and an asset in life.
An example of the complexity in clinical work,
and the dilemmas in treatment that arise from this
complexity, 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 that
are dependent on various facets of the clinical
picture and the particular patient and his or her
history. A sampling of these questions are as fol-
lows: Does the psychotherapist refer the patient
for a medication evaluation immediately or does
he or she defer for a while, attempting behavioral
interventions first (Mavissakalian, 1991; Shear,
1991)? Given the proven effectiveness of behav-
ior therapy in gaining symptom control of this
disorder (e.g., Barlow & Cerny, 1988), does the
clinician move immediately into this type of psy-
choeducational modality if the patient feels that
an extensive discussion of his or her interpersonal
history and object relations would be helpful and
relevant (Friedman, 1985)? Given the significant
role of separation anxiety and themes of abandon-
ment with these disorders (e.g., Sable, 1994), is
it prudent to conduct a behavior-therapy program
exclusively without some exploration of these
possible concerns in the patient's history? Given
the proven enhanced effectiveness of couples
treatment with these disorders (Barlow,
O'Brien, & Last, 1984; Cerny, Barlow, Craske,
& Himadi, 1987), does one invite the spouse
or 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 of
these variables integratively in treatment so as
to provide a more comprehensive view of the
problem and treatment (Scaturo, 1994)? If so,
sound clinical judgment would undoubtedly
play a major role in addressing these concerns
in 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 of
psychotherapy. It may be especially true as the
field moves toward the practice of brief psycho-
therapy, where the therapist narrows the focus of
intervention, that it is important for the under-
standing and conceptualization of the problem to
remain broadly based to allow for the shifts in
therapeutic focus that a constantly changing clini-
cal picture demands.
10
Clinical Dilemmas in Contemporary Psychotherapy
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