I don't remember exactly how I came across Louis Cozolino's The Making of a Therapist: A Practical Guide for the Inner Journey, but I am very glad and grateful that I did. He has written an extremely useful book in a cogent and accessible fashion. I would be very tempted to use it if I ever teach a course on, say, introductions to counselling and therapy.
He begins by noting that would-be therapists need to be encouraged not to "stay above the neck" in how they relate to their patients: "the more fearless we become in the exploration of our inner worlds, the greater our self-knowledge and our ability to help our clients" (xvi). Such inner exploration is necessary because that world is a crucial tool: "the private personal world of the therapist is, in fact, one of our most important tools" (xviii). The fact that this is so little taught today, Cozolino says, is a great loss to all concerned. And we mustn't resist doing this, for, as he says a little later, "to accept our clients, we have to first learn to accept ourselves. This can be the biggest challenge of all" (15).
His first chapter reiterates what I have seen so often, and recently written about, in Nina Coltart: the therapist, for much of the time, must live with not knowing, not being certain, not having clear ideas of what is going on. This is not to be shunned or feared.
Arranging the Consulting Room:
Chapter II has some very practical tips on getting centred in order to get started. He says that one must pay attention to one's consulting room and its set-up to ensure a comfortable, calm, mindful environment for you as well as your patient. I wrote rather at length about such matters here. He says it's best not to have chairs directly facing one another, and to give people options for sitting, asking them from time to time about how they feel being in the consulting room with you. He also says there's nothing wrong with modifying arrangements if people need or request it.
Communicating:
As you are going about your day, schedule yourself to allow for breaks and to ensure you are not rushing. Equally or even more important: do not rush to fill in gaps, but allow for silence. When you do talk, keep it simple and short. This good advice, much confirmed by my recent supervisors, led me to adapt something I heard in another context:
- Be blunt
- Be brief
- Be quiet.
Maintaining the Tension:
Good therapy, Cozolino says, is always going to find itself stretched between several poles:
- Nurture and Challenge
- Comfort and Stress
- Affect and Cognition
In addition, it should have the goal of increased affect regulation and the creation of new narratives about the self.
Treatment Plans:
These will flow out of your theoretical orientation, he says, and are constructed backwards, from goals to interventions. Keep them clear, straightforward, and open to revision in dialogue with your patient.
Notes:
Keep them very short and say nothing critical that you would not want the patient to read.
Loving Defenses, Patiently:
What Cozolino writes about appreciating the role of resistance and defenses puts me in mind of Auden's poem "In Memory of Sigmund Freud," which I love, especially these lines:
he would have us remember most of all
to be enthusiastic over the night,
not only for the sense of wonder
it alone has to offer, but also
because it needs our love. With large sad eyes
its delectable creatures look up and beg
us dumbly to ask them to follow:
they are exiles who long for the future
that lives in our power, they too would rejoice
if allowed to serve enlightenment like him.
One thing I have realized over the past year is that we must come even to love the defenses for they once served a useful purpose that has since become maladaptive. Cozolino says that if patients see your appreciation of their defenses, they "will be more wiling to explore alternative ways of being" (76). All this will be slow-going with, he says, some "backsliding."
Resistances, too, have their rewards, not least because they often point quite clearly and directly to what is most painful and difficult that might hitherto have been closed off to and hidden from us. This may also be true of conflicts in the therapy. Don't be defensive about defenses, about conflicts, about resistances. That will serve nothing and nobody. To launch a frontal attack on defenses is to ensure they deepen.
Negative Therapeutic Reaction and the Death Drive:
Cozolino has clearly been influenced by the psychodynamic traditions, but he wears them very lightly. He raises "the very success of therapy" will unsettle some people and cause regression, or even destruction and early departure. All this is, he says, a "common occurrence" (119). (Freud certainly saw it, not least in Beyond the Pleasure Principle.)
Counter-Transference and the Desire to Sack:
Cozolino offers some helpful advice in sorting out the desire to fire or sack a patient. This may be legitimate--you are a bad fit, or lack the skills for this particular disorder, or are in an impasse. But it might also be caused by the patient who needs to try to get you to fire him or her, creating, yet again, their past experience of abandonment. This requires careful discernment on your part, and perhaps some supervision if necessary.
In his ninth chapter, he introduces the very useful image and concept of shuttling. This is "up into your head, and down into your body" as you monitor counter-transference reactions. You shuttle from mind to body, and then from you to your patient and back again. He offers very concrete guidance here, saying you should do this if you've felt disconnected, or been tuned out, confused by what the patients is said, or fearful or anxious. He often shares the results of these shuttlings, especially if a particular strong feeling or image surfaces. Sometimes these can provoke really stunning responses; at other times they miss their mark. In any case, he allows the patient to "accept, reject, modify, or ignore" the results of the shuttling, saying that if it is rejected, just let it go because hanging on to it will not serve any purpose.
Dreams: The Royal Road to Whose Unconscious?
Cozolino has a brief section on the use of dreams, noting that patient's dreams are of course useful and important, but so are the therapist's. He gives a compelling example of how one dream of his enabled him to pick up on a deeply buried part of his patient's life, endlessly denied, and eventually nudge this trauma out into the open.
Wordiness Should Make You Wary:
Patients will try to recreate other relationships in the therapeutic relationship. One such will be the excessively wordy person who appears to be describing things--even feelings, or traumatic memories--in great, and greatly wordy, detail. This can be a trap and so Cozolino says we must not "mistake a barrage of words for openness and vulnerability" (143).
The Vocation and its Enjoyment:
Cozolino ends this excellent book where he began, saying that your self-acceptance (and self-care, which he stresses in the penultimate chapter) will be key to your flourishing in the vocation of therapy, which must not be allowed to become all drudgery but should be an occasion (as Coltart and before her Winnicott above all said) where patient and therapist can enjoy one another (at least some of the time).
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