Patient Psychopathology and the Management of Clinical Dilemmas in Psychotherapy: A Qualitative Analysis of Clinical Decision-Making

Introduction: Clinical dilemma management is an important part of daily decision-making processes in psychotherapy, and hence important for the quality of mental healthcare. However, the situated particularities of such dilemmas have been given little systematic attention – both in research and in practice, even though an improved understanding of the nature of clinical dilemmas is a central key to managing dilemmas successfully. Method: Eight cases of authentic clinical dilemma management in psychotherapy have been analysed from the perspective of interaction analysis and psychopathology. The article uses video data and narrative interviews from a larger cognitive ethnography study conducted at a psychiatric Hospital in Denmark. Results: The analysis demonstrates how clinical dilemma management in psychotherapy is particularly difficult due to the nature of a patient’s psychopathology. Thus, it is often difficult to discern whether a given dilemma is intrinsically ethical, or if it is a manifestation of the patient’s pathology. Two overall interaction patterns were identified: In the first pattern, the therapist fails to manage the clinical decision-making in accordance with the therapeutic goal, which strengthens the patient’s psychopathological behaviour, for instance by giving in and do what the patient demands. In the second pattern, the therapist uses the situation as an opportunity to work with the patient’s psychopathological behaviour in situated interaction. Conclusion: This article presents a model for integrating an understanding of patient pathology into clinical and ethical decision-making. It establishes a window into how psychotherapists manage clinical dilemmas (successfully or not) through interaction. This illustration might impact on how we address, evaluate and understand clinical and ethical dilemma management, which again can contribute to the reduction of moral distress amongst healthcare practitioners, as well as amongst patients.

Reputation and Legitimacy

The aim of this study is to map the principal reputation risks and threats to legitimacy in the processes of organisational change among the three cases in question. The key focus is on the core aims and dilemmas associated with transformation into a municipal enterprise form. According to the results, isomorphic forces affect the institutional process in enhancing and diminishing the isomorphism, and in simultaneously creating dilemmas that pose a risk to the organisation’s reputation and threaten its legitimacy. The findings further highlight the need to investigate strategic dilemma management as a tool for controlling reputation risks and legitimacy in the management of change in the public-healthcare sector.