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


 As part of an ongoing series, the staff at Union Square Practice will be sharing their thoughts on an important question: What makes therapy work?” This week, Dr. Michael Dulchin shares his thoughts.

What makes therapy work?

That is 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 the success of therapy can be predicted most by how much the patient likes the therapist. That being said, it’s also possible that people like the therapists who are getting them better. There are also studies that have shown certain types of therapy to be better than others in particular clinical situations.

So, is it the therapist or the particular type of therapy that makes therapy effective?  There are many schools and styles of therapy, but in general, you can organize them into three– the psychodynamic therapies, the cognitive therapies, and the behavioral therapies.

Psychodynamic Therapy focuses on past experiences and how they shape a person’s life with the thought that once someone understands the underlying unconscious motivations for their behavior the less-than-desirable patterns of behavior will be easier to change.  Cognitive Therapy asserts that while it can be very difficult to directly affect your mood and anxieties through will alone people can directly affect their thoughts and thought patterns. Finally, Behavioral Therapy suggests that willpower is best used to alter behavior directly, often with a series of incremental changes over time.  Cognitive and Behavioral therapy are often used in conjunction with the hybrid approach known as Cognitive-Behavioral Therapy (CBT). 

Therapists often gravitate to the style that feels most right to them in regard to underlying beliefs about understanding, action, emotion, responsibility etc. Many therapists will have been trained in more than one type of therapy and will then use therapy that they think will most benefit a particular patient based on the difficulties a patient is having and the style that the patient is most comfortable with.

But there is still no simple answer to what makes therapy work. In fact, therapists who are strictly adherent to a psychodynamic model or to a CBT model will often see the aspects of the model they believe in the actual practice of the model they don’t.

For instance, psychodynamic therapists will often focus on the relationship between the patient and the therapist in order to explore many aspects of a patient’s early development, early experience and current behavioral patterns. Cognitive behavioral therapists focus more directly on changing thoughts and behaviors.

I have been at conferences and witnessed dynamic therapists listening to the process of a cognitive-behavioral treatment and insist that the effective part of the treatment was actually based on dynamic principals and that the CBT therapist, by navigating and maintaining the therapeutic relationship, was actually doing dynamic therapy. Similarly I have seen CBT therapists observe the process of a dynamic therapy and feel that aspects of the treatment—allowing for alternative possibilities of thought and alternative responses to situations—are the actual effective aspects of the therapy, not the attention paid to the past or the therapeutic relationship, and it is in fact the dynamic therapist who is actually doing CBT.

So to answer the question, while there are many therapies that have been proven to be effective, it’s harder to determine which aspects of the therapy are actually the effective components. I believe that in some cases it is the support of the therapist in others it is the specifics of the therapeutic theory, and in most it is a combination of the two. Or maybe it’s just a nice smart person sitting in a room with another person, thinking about behavior, thought and emotion with an underlying intellectual explanatory structure that helps people understand themselves and change their behavior.

If you have any questions about how therapy works, get in touch with me on Twitter @drdulchin!