A Transtheoretical Concept*
The transtheoretical nature of fundamental dilemmas in contemporary psychotherapy is explored. The basic distinction between technical and ethical dilemmas in clinical practice is discussed, as well as the ramifications for the psychotherapist. Clinical dilemmas identified by survey research studies and interviews with master psychotherapists are reviewed. In addition to dilemmas relevant to circumscribed areas of psychotherapy, such as brief therapy, managed mental health care, sexual questions, feminist therapy, dilemmas fundamental to the psychotherapeutic process as a whole are examined. Finally, clinical examples are provided that include such issues as hospitalization of the suicidal patient, dealing with known contraindications, treating the intractable patient, and self-care of the psychotherapist.
Dilemmas and emotional conflicts are endemic to the human condition. The notion of intrapsychic conflict has been basic to psychological theorizing since its early beginnings (1). Freud (2) saw conflict as the foundation of neurotic disturbances and anxiety-based behavior. In parallel fashion, Pavlov (3) demonstrated that dogs in a laboratory setting displayed behaviors that could be described as "neurotic," if they were continuously subjected to discrimination learning tasks that were increasingly difficult to perform. While the dogs were initially trained to expect food and salivate in response to the stimulus of a circle and not to that of an ellipse, the previously calm animal demonstrated increasingly agitated behavior as the ellipse was gradually changed to be nearly identical to the circle. Finally, social psychological field theory (4) viewed conflict as the effect of the bipolar opposites of "attracting" and "repelling" aspects of an organism's environment, yielding a classic three-fold categorization of conflict in "approach-approach," "avoidance-avoidance," and "approach-- avoidance" terminology.
A dilemma is "a situation involving choice between two equally unsatisfactory alternatives" (5, p. 355). Synonyms include predicament, quandary, and impasse, as well as the colloquial expressions of "catch-22" and a "tight spot." In social psychological terms, such a scenario would be described as an avoidance-avoidance conflict (4). Avoidance conflicts have been described as having a "damned if you do, damned if you don't" quality (6). Since such conflicts are highly stressful and rarely resolved fully, they are a significant source of anxiety. Why then are dilemmas critical to the practice of psychotherapy? This answer is in part related to the unique nature of avoidance-avoidance conflicts in contrast to other forms of psychological conflict.
By contrast, approach-approach conflicts represent a choice between two positive alternatives, and are typically resolved more easily. Such conflicts are often resolved so rapidly that people are frequently not cognizant of the momentary conflict that they had produced (1). Basic learning research (7) has demonstrated that aversive consequences entail a much greater valence than a choice between positive alternatives. It, therefore, might be concluded that the avoidance of severely negative alternatives carries with it a certain survival value in an evolutionary sense (8). Likewise, the approach-- avoidance conflict tends to be prevalent in life, and therefore difficult to circumvent. However, in this situation, the person is both attracted and repelled by a given selection (1). A central characteristic of an approach-- avoidance conflict is the experience of ambivalence, i.e., the mixture of positive and negative feelings about the same event. Many of life's more important decisions are characterized by approach-avoidance conflict, such as wanting to eat when overweight, or wanting to marry someone of whom one's parents strongly disapprove (6). Such concerns may entail sufficient emotional distress to bring one to engage the services of a psychotherapist. …