“What Makes Therapy Work?”: Dr. Michael Dulchin

As the opening part of an ongoing series, we thought it would be interesting to ask the different providers at Union Square Practice for their thoughts on the simple question: “What makes therapy work?”, starting with our co-founders Dr. Jonathan Fader and Dr. Michael Dulchin. Here is Dr. Dulchin’s reflections:

Michael Dulchin, MD:dulchin-bio-img

What makes therapy work? It’s a very interesting question.

Most studies cite the relationship between patient and therapist as one of the biggest components of success. Some of the older studies even say that you can predict whether or not therapy will work by measuring how much you like your therapists.

That being said, it’s also certainly possible that people just happen to like therapists who are using a particular form of therapy which is helpful to them. There are dozens of therapy styles, but in general, you can organize them into three schools of thought. There are the psychodynamic therapies, the cognitive therapies, and the behavioral therapies. (more…)

Afraid of Flying?

Learn How Cognitive Behavioral Therapy Can Help You Manage Those Flying Phobias.

As a clinical psychologist, I help people manage fears, or phobias, that interfere with life.  Many people are afraid of flying but are able to overcome these fears with help.  Below are fictional “dear diary” stories to illustrate how many people feel when facing a Boeing 747 followed by specific ways that therapy can help you get your feet off the ground.

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Dear Diary,

I must be coming down with something…my stomach has been upset for the past two days, and I keep breaking out in sweats. I hope it’s not a stomach virus.

Or maybe it’s a respiratory thing? I notice I can’t catch my breath lately. And my heart is beating so fast! Maybe I should see a cardiologist.

Or maybe I hit my head? I’ve been getting sort of dizzy and noticed some tingling in my hands and feet. Which doctor helps with that? A neurologist? I don’t know.

I can’t figure out why this is all happening now. And just before Thanksgiving! I’m supposed to go visit the family, and my flight leaves on Wednesday.…You don’t think that this has anything to do with the terror I feel at the thought of getting on an airplane…right?

Yours truly,

Ms. Jittery

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Sound familiar?  

For many of the 45+ million Americans who fly at Thanksgiving, the anxiety of flying sets in days in advance. For some, it might ruin their whole week. Whether the fear began after a particularly rough flight or has been around as long as a person can remember, the physical symptoms that come along with a fear of flying can be very uncomfortable, and often scary.

Some people experience full-blown panic attacks while in flight, and others feel little waves of anxiety every time they think about flying. Whether the feelings come on intensely all at once or build up slowly over a period of time, physical symptoms are a core experience for those with a fear of flying.

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Journal,

The car is almost packed. I have 23 hours of new podcast material to listen to, which should last me the entire drive. I’ll need another 23 for the ride back at the end of the week, but I’ll deal with that later.  Sure, flying would get me there more quickly. And yes, the rest of the family will be catching up for a day and a half before I even arrive. And yeah—I am missing a bit more work than I should (not to mention that huge meeting I won’t make it back for on Monday) but that’s okay. Everybody—from my family to my coworkers—knows that I don’t fly. I mean, I never have before—why start now?

Signed,

Mr. Evader

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How about this?

Most of us know at least one person who will go to great lengths (in a car…) to avoid flying. Avoidance can seem to help with a fear of flying in that you don’t have to experience the anxiety of getting on a plane.  However, avoidance can actually make things worse in the long run. By continuing to avoid airplanes, a person never gives himself the chance to learn that he actually can manage his anxiety and that flying actually is relatively safe. But, as any avid evader knows, avoidance can be addictive!

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For my memoire –

That’s it! I just landed, and I swear I will NEVER fly again—and this time I mean it! These airlines nowadays don’t seem to care about passenger safety. With all of the noises that plane made, I was certain that something was wrong. But the worst was when the noise stopped! I swear heard the engine stop working entirely. And the turbulence! I’m telling you—that plane dropped 500 feet in 5 seconds. It’s a miracle that we didn’t fall right out of the sky. I just know that one of these days, my plane will crash. Or even if it doesn’t, I’ll feel so uncomfortable that it might as well crash.

Until next time,

Mrs. Uninformed X. Thinking-Traps

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And finally, this?

For lots of people, their fear of flying is perpetuated not only by misinformation, but also by “thinking traps” that work against them when it comes time for a flight. Erroneous concepts such as the existence of “air pockets” and airplanes “dropping” in the sky contribute to people’s experience of fear when it comes to flying.

Furthermore, fearful flyers often overestimate the likelihood of risk on a flight.  They also imagine unpleasant flying experiences to be much more intolerable than they actually are. Both of these common “thinking traps” keep people stuck in the experience of fear when it comes time to travel.

How can Cognitive Behavior Therapy help?

So—are fearful flyers doomed to lives limited by the distance one can reasonably drive in a car? Definitely not!

Cognitive Behavioral Therapy (CBT) is a therapeutic approach that shows great success in managing fears, or phobias, such as the fear of flying.

But how? Through a combination of:

  • Education
  • Breathing skills
  • Thinking skills
  • Graduated exposure to flying-related scenarios
  • Mindfulness

CBT can help people conquer their fear of flying and expand their experiences and lives. Information about flying itself as well as information about the body’s response to fear can go a long way in managing anxiety. Slowed, deep breathing skills quiet the physical reactions of fear, and learning to think from an evidence-based and measured perspective helps to bring big fears down to size.

As with any phobia, exposure to the feared situation itself is key. The creative use of videos and virtual reality exposure therapy (VRET) help familiarize a person with the airplane environment, and, as we all learned during 4th grade piano lessons: practice makes perfect! Finally, from a mindfulness-based perspective, practicing observing one’s own experience of fear without feeling totally consumed by it can help a person navigate the very uncomfortable experience that is fear of flying.

Whether you’ve avoided flying your whole life or just started avoiding it last year, you don’t need to go through another holiday season with the same level of dread that you have in years past.

To learn more about how CBT for fear of flying can work for you, contact us here.

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Julia Vigna Bosson, PhDBosson Rounded
Clinical Psychologist
Julia Vigna Bosson, Ph.D. is a licensed clinical psychologist. She has worked in various medical centers, including multiple VA hospitals, in private practice, and for the NYU Posttraumatic Stress (PTSD) Research Program. Dr. Bosson has a specialty in treatment of anxiety and trauma disorders, ranging from the effects of daily stressors on physiology and immunity to PTSD and other post-trauma reactions. Dr. Bosson is a Certified Provider of Cognitive Processing Therapy (CPT) for PTSD.

The Puzzle of Adult ADHD (And How Neuropsychology Can Help Solve It)

Do you find it extremely hard to focus?  Are you continuously distracted?  Do you have dozens of unfinished projects? Does it take you significantly longer than other people to complete tasks? Do you have debilitating procrastination habits?  Are you unusually restless, impulsive, or impatient?

If you answered a resounding “YES!” to many of these questions, then you may want to read on and learn more about ADHD in adulthood.

Most people know of ADHD as a childhood disorder. But few people are aware that ADHD can continue into older adolescence and even well into adulthood. In fact, there are adults who remain undiagnosed and untreated, suffering from its effects for years or even decades.

The good news? If you are properly diagnosed – and an accurate diagnosis is essential – there are many treatment options that can help.

Meet Mr. Inattentive

Mr. Inattentive is an adult with undiagnosed ADHD who has trouble concentrating, finds himself daydreaming during work meetings, and forgets important details from conversations.

His wife describes him as forgetful and feels that he doesn’t listen to her.

His boss frequently tells Mr. Inattentive that he doesn’t seem to apply himself or reach his full potential, which is something he’s been told by teachers and bosses throughout his entire life.

At this point, Mr. Inattentive’s symptoms have led to major problems in his career and marriage.

People like Mr. Inattentive will recognize this familiar pattern: problems with attention have likely plagued them throughout their education and early careers. Those failures, in turn, create a cycle of emotional distress.

People like this may gravitate towards tasks that are more positive to reduce their level of frustration – like starting an interesting new project instead of finishing that boring task your boss keeps asking for – not realizing that it will hinder their productivity even further.

Repeat this cycle over the course of years, and they often develop chronic distress, hopelessness, poor self-esteem, and other symptoms analogous to depression. Often people who suffer this way then seek psychotherapy in response to emotional distress, not realizing the cognitive deficit underlying much of their issues.

Knowing is Better

Indeed, it’s common for individuals with ADHD to experience mood disorders, such as depression or anxiety, at some point in life. There is also a high rate of learning disabilities and substance use disorders that co-occur with ADHD. These conditions can seem like the primary issue for many patients, when in fact they may be rooted in ADHD.

Though, of course, it’s a two-way street. Mood disorders can interfere with cognitive abilities like attention in people who don’t have ADHD.

With so much left unknown about ADHD, particularly as it relates to the course of ADHD throughout the lifespan, it’s crucial that individuals suffering from these symptoms get accurate information, diagnoses, and treatment whenever possible.

“Knowing is Better” – this is the central message right now for October’s ADHD Awareness Month.

In my role as a neuropsychologist, I’m devoted to helping answer those questions. An accurate diagnosis is perhaps the most critical step, and the beginning of how neuropsychology can help.

What is Neuropsychology and How Can It Help?

If you’re not sure what neuropsychology is, you’re hardly alone. I’m asked about it all the time, and not just by patients — other clinicians and mental-health providers are curious too.

Neuropsychology is a specialized area within psychology that focuses on the link between brain functioning and behavior.

In this broad description, behavior refers not just to our actions but also to our underlying thought processes, or cognition, as well as our emotions. Cognition includes skills like learning and memory, attention, problem solving, and how quickly information is mentally processed.

Numerous conditions can interfere with cognition, from neurological problems like stroke or multiple sclerosis to medical, neurodevelopment, and psychiatric disorders.

A neuropsychological evaluation aims to address what is contributing to an individual’s cognitive symptoms; to figure out the degree to which the cognition and behavior are affected; and to determine what can be done about it. I recently joined the team at Union Square Practice as a clinical neuropsychologist to do just that for our patients.

What Happens in a Neuropsychological Evaluation?

When a patient comes to a neuropsychologist, we go through several steps with them:

– First, a clinical interview is conducted. I collect details about the individual’s personal concerns, how their symptoms impact their daily life, and, together with a detailed history, conceptualize this information within a framework of behavioral functions and underlying neural processes.

– The next step is neuropsychological testing. I administer a variety of tasks and questionnaires with the individual; their performance across neuropsychological tests reveals a unique pattern of their cognitive strengths and weaknesses.

–  Once neuropsychological tests are scored and interpreted, the results are summarized in a report. All this information is used to help make a diagnosis or clarify existing diagnoses. Perhaps most importantly, this information determines what recommendations are appropriate for the individual’s ability level to guide treatment planning.

– The deductive process doesn’t end once a diagnosis is reached (or ruled out). The neuropsychologist must bring all the pieces together and suggest possible solutions, or treatment recommendations, to resolve, reduce, or compensate for the individual’s difficulties.

However, the brain is enormously complicated. We have a long way to go before we truly understand its inner workings. This can make it next to impossible to determine a diagnosis with absolute certainty.

To me, the beauty of neuropsychology is that it requires a strong foundation of clinical psychology skills, because it can be as much a therapeutic process as it is a diagnostic one. Combining the two, I strive to understand patients’ concerns from their own unique perspectives in order to best solve their individual puzzle.

One Size Does Not Fit All

Patients with ADHD, whether children or adults, show a lot of variability in symptoms, as well as in response to treatment.

Not only do symptoms vary from person to person, but an individual’s symptoms can also vary throughout the course of life.

For instance, an adult who had combined inattention and hyperactivity in childhood may experience improved activity level and inhibition in adulthood, yet continue to have significant problems with concentration and planning.

Adults with undiagnosed ADHD don’t always recognize, or at least appreciate, the cognitive component of their difficulties until they go through proper testing and diagnosis. More often, they arrive in a clinical setting due to some period of crisis or chaos in life, rather than due to pure cognitive complaints.

Paying Attention to Executive Functioning

Countless adults have asked me if they have ADHD because they lose focus at work or can’t pay attention when their spouse recites them a to-do list. Individuals with ADHD do struggle with these symptoms, yes. But those with ADHD can struggle with a lot more than inattention, while there are several other considerations that could account for isolated attention problems.

Meet Ms. Disorganized

Ms. Disorganized is between jobs and feels lost about what to do next.

Her most recent position, which she quit rather impulsively, was just one in a long string of dead-end jobs.

Employers frequently have trouble with Ms. Disorganized’s behavior and performance at work. She leaves tasks unfinished, is inefficient, and seems to be much slower than others to get anything done.

Adults with ADHD struggle with numerous cognitive, behavioral, and/or emotional symptoms, all of which interfere with their day-to-day life.

The most common problems noted in both children and adults with ADHD involve executive functioning.

Though executive functioning has no agreed-upon definition, most concur that it’s a multi-part system of working memory (the temporary mental storage of information), planning, initiation, regulation, and inhibition.

Executive functioning drives our most complex capabilities — our ability to identify key elements of a problem, develop a solution, monitor performance, and modify our approach as needed.

Put another way, executive functioning allows us to organize and manage our cognitive resources in order to achieve our goals. Thus, when there’s a deficit in executive functioning, an individual can have a hard time getting things done!

Disentangling Mood and Other Factors that Contribute to Symptoms

Just as the symptoms of ADHD can lead to, or exacerbate, feelings of depression or anxiety, it is also possible for mood-related disorders to cause cognitive issues like inattention and poor planning.

Remember, being inattentive does not mean you have ADHD. This is a crucial distinction to make because it guides the course of treatment.

Interventions for ADHD like a stimulant medication might help someone increase their focus temporarily. If the underlying issue is depression, however, then targeting ADHD is ineffective in the long run. This brings us back to the importance of a comprehensive evaluation for the most accurate diagnosis.

Some adults have disabling problems with executive functioning yet don’t technically meet criteria for ADHD — but they also lack other conditions or injuries that explain their symptoms. Despite not fitting into specific diagnostic criteria, they often still respond well to the same interventions as adults with longstanding ADHD diagnoses.

A neuropsychological evaluation can tease apart the often-messy mix of cognitive, mood, and behavioral factors in order to solve the diagnostic puzzle and develop the best treatment plan.

Beyond the Diagnosis

When ADHD is suspected, a thorough assessment of all contributing factors can lead to the most accurate diagnosis and comprehensive treatment approach.

There are many ways to approach ADHD treatment in adulthood, and not just with medication.

  • Growing evidence supports the use of certain approaches to psychotherapy to improve aspects of cognition, like executive functioning.
  • Neuropsychologists can help patients develop specific strategies and compensatory techniques to meet the individual’s unique needs.
  • Innovative new assistive technologies can also help, like apps that guide you through planning and solving problems, help you organize to-do lists, and provide reminders for those easy-to-forget details.

The risks of undiagnosed ADHD are too grave to ignore. For instance, ADHD in adulthood is associated with significant risk for lower academic achievement, more cognitive impairment, lower occupational attainment, and poorer social functioning.

Just like there’s variability in symptoms, there’s also variability in patients’ responses to ADHD treatment. That means figuring out the right path may be a complex process of trial and error. While science hasn’t yet solved all the mysteries of ADHD, I can tell you for sure that there is a realistic chance for significant improvement through the steps we can take together.

Amanda Hahn-Ketter, Psy.D.

Clinical Neuropsychologist

Dr. Hahn-Ketter is a licensed psychologist who specializes in clinical neuropsychology. She has extensive experience working in medical and mental health settings, including Mount Sinai Hospital and the VA. Her expertise entails assessment, diagnosis, and treatment planning with patients who have neurocognitive issues. She also provides cognitive rehabilitation to help individuals compensate for and cope with cognitive difficulties.

Outside of clinical work, Dr. Hahn-Ketter is committed to teaching and leadership in the field of neuropsychology. She also participates on professional committees and is an active member of the American Psychological Association (APA) Division 40 (Society for Clinical Neuropsychology), International Neuropsychological Society (INS), and New York State Association of Neuropsychology (NYSAN), and an affiliate member of American Academy of Clinical Neuropsychology (AACN).

Can You Choose Your Feelings?

When working with couples in counseling, David Pearl’s focus is to help his clients interact with each other intentionally instead of reactively.  An example of a reactive response is when anger gets triggered. Anger is a secondary emotion which shields us from more painful and vulnerable emotions, such as shame, loneliness, or sadness. In relationships, we often use anger as a defense mechanism to  protect ourselves from something hurtful that our partner has said, or something that will effect us in an unwanted way.

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