Abstract
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.
Highlights
Clinical dilemma management is an important part of daily decision-making processes in psychotherapy, and important for the quality of mental healthcare
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 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
The rationale for the latter is that such behaviour is most often a manifestation of psychopathological behaviour, grounded in past experiences and reenacted in the present interaction. This line of work seeks to establish a window into how psychotherapists manage such dilemmas, not by logical deduction, but through interaction with their patients. This systematic demonstration might impact on how we address, evaluate and understand clinical dilemma management, which again can contribute to the reduction of moral distress amongst therapists and patients, as it opens up for a more realistic view on clinical dilemmas in real-life psychotherapy
Summary
Clinical dilemma management is an important part of daily decision-making processes in psychotherapy, and important for the quality of mental healthcare. Clinical dilemma management is an important part of daily decision-making processes in psychotherapy and important for the quality in mental healthcare Such challenges have been given little systematic attention – both in research and in practices (Molewijk and Reiter-Theil, 2016; Bruun et al, 2018). Some valuable initiatives to provide ethical support for clinical practice have been implemented (e.g. initiative such as ethics committees, ethics consultants and ethical reflection groups, cf Bruun et al, 2018) While this focus opens up for how such boards and initiatives can be used to guide practice, it provides little insight into how clinical dilemmas are managed in interaction where psychopathologies are manifested in ways that complicate decision-making significantly
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