“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.

A rough way of thinking about these is that Psychodynamic Therapies focus on past experiences and how they shaped a patient’s life. They believe that, once people understand these underlying motivations, self-knowledge helps them both to feel better and to change their behavior. Meanwhile, Cognitive Therapy asserts that while it can be very difficult to directly affect your mood and anxieties through willpower alone you can directly affect your thoughts and thought patterns. Finally, Behavioral Therapy says you should use your willpower to change your behavior directly, often with a series of incremental changes to your actions over time. It’s also worth noting that many therapists today combine elements of both Cognitive and Behavioral therapy into a hybrid approach known as Cognitive-Behavioral Therapy. 

What’s really interesting is that different therapists see these things differently. Many therapists will say that different types of therapies are appropriate for different people. I believe that myself. But people who strictly adhere to one form of therapy above all others will often look at others who are practicing differently and instead see aspects of their own form of therapy in disguise.

For instance, Psychodynamic Therapy will often focus on the relationship and feel that examining the patient-therapist relationship will reveal many aspects of a patient’s early development, early experience and even current behavorial patterns. Cognitive behavioral therapists will not start off with that approach and instead will focus on changing thoughts and behaviors.

So a Psychodynamic therapist might see a Cognitive-Behavioral therapist at work and say: “Oh, look at all these things you were doing! When you were treating the patient, they were thinking about the patient-therapist relationship–about their early experiences and how they related with others, and how to see things and even see you differently. You’re actually doing psychodynamic therapy all along.”

And Cognitive-Behavioral therapists will respond by saying: “Hmph! On the contrary, you think you’re doing psychodynamic therapy, but look at what you did with your patient. You paid attention to their thinking and their behavior patterns. You’re actually unwittingly using components of cognitive behavioral therapy!

So to answer the question, while there are many therapies that have been shown and proven to be effective, it’s harder to determine which aspects of the therapy are actually the most effective. It may be that it’s the overlapping aspects of each. Maybe it’s just a nice smart person sitting in a room with a patient, thinking about behavior, thought and emotion with an intellectual structure–and that’s the basic aspect of therapy that works regardless of the particular theory.