Many medical and perhaps most psychiatric conditions cannot be eradicated totally. The affected individual must often learn to manage a protracted or chronic condition. The scope of medical, surgical, and psychiatric intervention is therefore appropriately not limited to acute pathologic states in which a definitive therapy is applied and the person is restored to perfect function. Humans are subject to a multitude of adverse influences, both external and internal. Whether these adverse influences are from bad luck, bad genes, bad environment, or simply the effects of aging, suffering is inherent in the human condition, and the individual must learn to manage personal suffering. It is appropriate that physicians provide others with assistance in the management of suffering. Analogously, psychotherapy often is focused on modifying the patient's overall pattern of adaptation to life (personality). As Cloninger and others (1993) note, personality is best considered as an interactive combination of factors that are gene-based and relatively immutable with factors stemming from the nonshared environment. While the expressive psychotherapies may make some modifications in character as defined, there is very little that a psychological intervention can do to alter the gene-based expressions, which are conceptualized as “temperament” (novelty seeking, harm avoidance, reward dependence, and persistence). Thus, the psychotherapist must help the person accommodate to the more gene-based temperaments so that they are expressed in ways that create less havoc or irritation for the person's relational world.
Psychotherapeutic treatment is an important weapon in the armamentarium of the physician and a necessary component of the management strategy of many and diverse forms of human suffering. It is both common knowledge and the finding of considerable research that human suffering is eased by the ministrations of another caring human being. In psychotherapy, this easing of suffering is conceptualized to be a product of “the therapeutic relationship.” For example, children learn to comfort themselves via the comforting presence of their mothers, participation in therapy groups may enhance the immune response of patients who have malignant melanoma, and patients who have schizophrenia and who receive psychotherapy in addition to psychopharmacologic agents spend less time hospitalized.
Physicians need to learn the principles of psychotherapeutic management of human suffering in the interest of easing their patients’ pain and transferring to them an improved ability to self-manage. It is not clear that a particular type of psychiatric disorder (e.g., depression) should necessarily be treated with a particular type of psychotherapy (e.g., interpersonal psychotherapy). Individual human suffering is so unique, and the life circumstances of any individual so varied, that psychotherapy must perforce be custom designed, at least in part. It is therefore more important to learn to conduct a coherent and useful psychotherapeutic experience for a patient than to learn one narrowly defined therapeutic style and expect all patients to fit its Procrustean bed.
This chapter is also concerned with another form of management: that of the physician's career and life. A real and multifaceted peril coexists with ...