Louis Cozolino on the Making of a Therapist

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). 

Beginnings in Psychotherapy

As the days of August tick rapidly by, and the fall semester looms on the horizon, I am eagerly reading any number of books that I can get my hands on, including Mary Jo Peebles-Kleiger, Beginnings: The Art and Science of Planning Psychotherapy (Analytic Press, 2002). Both the title and the timing are apt as I am beginning a clinical practicum later this month, and am very excited about that. 

The book has many good insights, though in my reading of it these are largely confined to the first six chapters. 

Begin as You Mean to Go On:

The author begins with what might seem obvious, but can get overlooked: If therapy is to end properly it must begin properly. She notes that what goes on in that first hour very often communicates our theory, our views of patients and their problems, and how the process will play out.

She reiterates what I have seen said time and again in many books in the past year: the role of the therapist's personality and our "competence, hope, and humanity...will minister strongly (or, some would argue, more strongly) than the particular modality we eventually select" (p.1).

Wearing Diagnoses Lightly:

I have seen others whom I respect note that one cannot and must not be hidebound about diagnostic labels. Peebles-Kleiger says that one may often start with a diagnosis, but one can equally start with a case formulation--a narrative that goes beyond symptoms and causes to be grounded in history of relationships, taking a wider view. I very much incline towards this latter. In any event, one must recognize, as she rightly puts it, that "no system of diagnosis is fully comprehensive....diagnosis is ongoing" (p.4).

Early on, her approach is to put together a clear picture of the patient that takes account of and has some idea of:

1) History, including that of relationships
2) Patient's capacity for forming the therapeutic alliance
3) What functions do the symptoms serve?
4) What is psychological cost of change?

Having accounted for these, one can proceed to step 5): Form what she calls a "blueprint" for treatment that focuses on "connection, focus, joint activity, prioritization, and choice" (13).

Later on she offers further recommendations on the taking of a patient history (cf. Nina Coltart, discussed elsewhere on this blog, about the huge importance of getting this done as comprehensively as possible early on), noting that it is best to take history "which flows out of the investigation of current emotions, behaviors, and ideas" (52). Indeed, some of those current emotions and behaviors will show up in the consulting room, and careful observation of the patient and his or her activities will often give clues of an historical nature which should then be examined together. E.g., she refers to a patient who always came precisely 15 minutes late to every session. This obviously had a history behind it needing to be explored, as they did. 

The Therapeutic Alliance:

In her second chapter, Peebles-Kleiger offers a helpful reminder that the alliance is beginning to be formed (or thwarted!) the moment you walk into the waiting room and make eye contact with the new patient for the first time. Here and throughout your entire time working together, she says that "respect, even reverence, is the order of the day" from first greeting patients to the end of their treatment. I like that "reverence" here for each person's unique dignity. 

She notes something often seen in other books based on wide-ranging research: building the alliance repeatedly shows the crucial importance of the therapist's "ability to show empathy, sincerity, and unconditional acceptance of the patient" (16). This allows her to note, moreover, that other
"research has documented that if a patient feels accepted, understood, and liked by the therapist early in the relationship, then therapy tends to be successful" (14). This, she says, is pantheoretical. 

She differs--rightly in my view--in not following early psychoanalytic techniques and requirements aimed at "curbing spontaneity and remaining unresponsive" because doing so  "could actually have a negative impact on the relationship" (17; cf. Coltart again). She does, however, agree with the formative experience and expectation--going back to the early days of psychoanalysis--that insisted on the therapist also being in therapy, if not as a prerequisite then as a concomitant to his or her own clinical practice: "There is empirical evidence for a positive correlation between having had personal therapy oneself and being better able to facilitate a positive alliance in treatment" (23). (I am, frankly, amazed that this is not still a widespread requirement today of prospective clinicians.)

Naked Logic:

I really liked her counsel to avoid appearing or trying to be some kind of aloof expert handing down recommendations from on high. This is not original to her, of course, but goes back at least to Carl Rogers. In any event, she rightly says that transparency in the therapist's thinking--taking off the outer later to see the logical gears working underneath--can be very important. This "invites the patient to be a diagnostic partner and to reason along with you. The end result is that the patient not only knows how a particular treatment recommendation was arrived at, she also feels that she helped critique and shape its construction" (22). Such collaboration helps the alliance.

Goals and Treatment Plans:

As someone whose entire experience thus far has been psychoanalytic, I found her third chapter, Focus, helpful. She begins by noting that some people (I confess I incline towards this) are suspicious of too much attention on focus, on goals, on treatment plans because they fear this will undermine the capacity for spontaneity, creativity, and above all free association. To us she says it may be helpful to see our role as similar to a personal trainer: advocating for a repeated focus on attaining certain goals for improvement in the patient's life. She says that the research is clear: focus and goals across modalities are key to successful therapy. And, she insists (though this needed much more development), focus and goals are not at cross-purposes with free associating. Nor are they aimed only at symptom relief. You can be doing several things at once in therapy. 


The author's sixth chapter, What Material Is Important?, poses some important questions and offers some not terribly original answers that are nonetheless still important to underscore. 

One of the really obvious things she says to pay attention to is "repetition (of phrases, themes, behaviors, sequences, mannerisms, emotions).... The more repetition the more attention is warranted" (p.69). I have learned this from reading the great child therapist and psychoanalyst Adam Phillips over the years, but I first learned it from what is perhaps my favourite of Freud's technical papers, "Remembering, Repeating, and Working Through." 

In addition, do not fail to note strong emotions, idiosyncrasies, and especially dramatic losses of control or wildly singular behaviors--even if they only occurred once and were never repeated, they may offer a deep vein of significance to be explored. 

Jumping, finally, to Peebles-Kleiger's nineteenth chapter, on the Psychological Costs of Change, I found much gratifying material here, too, which reflects my own attempts at rethinking "resistance." I've come to the view that resistance must be seriously respected, not merely scorned as something to be gotten rid of, or around, as quickly as possible. This, too, comes out in Freud's paper mentioned above: the resistance plays a role, and the clear-eyed clinician must try to see what role that plays. As Peebles-Kleiger notes here, symptoms can be bothersome but also productive and useful. Some symptoms may protect from grief or hold anger in check. Some may be resistant to change until and unless (as Winnicott might say) the patient learns that it is okay to hate the therapist. 

Though she doesn't mention him here, I had another of Freud's works in mind here, the centenary of which is this year: Beyond the Pleasure Principle, with its controverted theory of the death drive and the less controverted and I think more clinically abundant phenomenon of the repetition compulsion. The repetition of symptoms, and of resistance, must be examined and taken seriously by, inter alia, asking what the plan is for their replacement. As she notes, lots of therapy without such a plan will falter: you can't remove something and leave nothing in its place for most people. You must replace something pathological with something adaptive. 

Anyway, such were some of my thoughts in reading Mary Jo Peebles-Kleiger's useful book, Beginnings: The Art and Science of Planning Psychotherapy