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INTRODUCTION

Human beings are subject to a multitude of adverse influences arriving from both external and internal sources. These adverse influences include internal conflicts (between one's aims and goals or urges and prohibitions), interpersonal disputes, certain cognitive and/or behavioral "errors" (e.g., catastrophizing and avoidance of exaggerated anticipated danger), personal and relational loss (both loss of significant attachment figures and loss of physical or cognitive abilities through illness, injury, or aging), and sociocultural or spiritual struggles. Through psychotherapy, physicians provide assistance in the managing of suffering resulting from these adverse influences. Structured professional relationships have been developed to address each of these adversities as the different forms of psychotherapy. Psychotherapy may also be focused on modifying the patient's overall pattern of adaptation to life (or personality). As Cloninger and others (1993) have demonstrated, personality is best considered as an interactive combination of factors that are gene-based, and, therefore, relatively immutable, with factors stemming from the nonshared environment. Some of the expressive psychotherapies make modifications in "character" as defined by Cloninger, but there is relatively little that a psychological intervention can do to alter the gene-based determinants of personality. These are often conceptualized as "temperament" (novelty seeking, harm avoidance, reward dependence, and persistence). To address problems related to temperament, the psychotherapist helps the patient to accommodate to the gene-based determinants of behavior so that they become expressed in ways that create less chaos or conflict in the person's relational world.

Psychotherapeutic treatment is an important tool in the professional skill set of the physician and a necessary component for the successful management of many forms of human illness and suffering. Illness and suffering are eased by a therapeutic relationship with another caring human being that helps the suffering individual feel less isolated and more connected with a social community. In psychotherapy, this easing of suffering is conceptualized to be a product of the therapeutic relationship. The terms of that relationship are defined implicitly or explicitly in the therapeutic alliance and contract developed between patient and therapist.

The psychodynamic therapist needs to learn the evidence-based and technical principles of the psychotherapeutic management of the various adverse influences on human development and functioning. However, it is not proven that a particular type of psychiatric disorder (e.g., major depression) should always be treated with a particular type of psychotherapy (e.g., cognitive, interpersonal, or psychodynamic). In fact, Wampold (2001) has documented that the theoretical orientation of the therapist is only modestly predictive of patient outcome. Because individual suffering is unique, and life circumstances in any individual are so varied, psychotherapy must be custom designed even though learning a manualized therapy is often helpful for the therapist in early phases of professional development. It is as important, however, to learn to conduct a coherent and useful psychotherapeutic experience for a patient as it is to learn any particular therapeutic approach. Allen (2012) conveys a superb blending of melding new conceptual models while retaining basic ...

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