Cozolino Books Never, never for the sake of peace, deny your own experience 1-No matter what happens in therapy, don’t panic 2-The client is more nervous than you are 3-If you don’t know what’s happening, keep quiet until you do 4-The client will assume you know what you’re doing 5-Just make it through the hour Many of us strive to be more than human When we egin training, we embark on two journeyes: one outward into the professional world and the other inward, through the labyrinths of our own psyches True focus is on the personal and emotional aspects of these issues as they affect the therapist Don’t seal off your inner world and stay “above the neck” in the hope of avoiding their own feelings and emotions. Unfortunately this intellectualizing denefsne handicaps both personal growth and the development of good therapeutic aabilities. It is not mastering the academic material, it is summoning the emotional couage tto move through the inner space that leads to knowing oneself. We all see the world from our own perspective and through the prism of our unconscious assumptions Our vision of reality and sense of conciosu control are mere illusioisn We are guided and directed by multiple unconscious processes of memory and emotion The private personal world of the therapist is, in fact, one of our most important tools. What we don’t know about ourselves won’t just hurt us, it will negatively affect the therapeutic relationship. Countertransference is distortion of th therapy relationship that occurs because of th therapist’s unconscious. Usually is traced to common human struggles with shame, attachment, and fear of abandonment Therapists will inevitably feel uncertainty, confusion, and fear when first starting out. Shutttling requires that weramin flexible in order to move between our minds and bodies, thoughts and feelings, and between oourselvs and our clients Becoming a competent therapist takes many years, being a great therapist takes a lifetime Chapter 1: What have I gotten myself into? We all need to become aware of our pain and uncertainties and hten grow through them. Personal courage—the courage to face one’s fears, limitations, and confusion makes one a good therapist The awareness of your ignorance could be construed as wisdom Give yourself the permission not to know. Include your limitations and allow for honest exploration. Reinforce your strengths and what you are able to accomplish. Instead of comparing yourself to teachers or master clinicans you see on tap, use an internal yardstick. Compare where you are now to where you were 6 months ago. There’s infinite room for improvement and selfcriticism It’s not about knwoign what your client should do, rather it’s about provding a relationship for them to discover themselves Take yourself out of the expert position. Be a thinking, feeling, and available human being Retain a stance of not knowing by asking yourself: 1. Do you feel certain that what you are doing is the right thing 2. Do you continue to bringa client back to an interpretation again and again even if she rejects it 3. Do you feel passionate about the truth of your form of psychotherapy 4. Do you find youself dismissing your supervisor’s ideas if they differ from your own 5. Do you feel like a failure if you do’t have an acceptale answer for your client’s question? Don’t miss opportunities to learn by not being able to say “I don’t know.” Adherence to a certain system may cost the authentic connection with a client Because uncertainty makes us so anxious , we look for quick, clear, and definitive answers. Work with the best people you can find regardless of orientation and get training in a variety of perspectives. Knowledge of a variety of persepctives is the best defense against a false certainty. Ask yourself this question: is my devotion to a theory or technique reflective of my own personals truggles, or is it a rationally chosen theoretical oreitnation that is actually helpful for the person sitting acros from me. Ourbeliefs guie our behavior but our beliefs may be wrong. Imagine that while you’re preaprign someone for some future therapeutic succues somewhere else, another theeapist is doing the groundwork with a future client of mine To accept our clients, we have to first learn to accept ourselves Your openness, curiousty, and convern are convey through focused attention and tone of voice. All of a client’s interactions with you are a part of their experience of therapy What buttons is your client pressing? Are they really attacking you or is it your own insecurity and vulnerability that makes you fel that way. Take five minutes to get centered before a session Schedule breaks for rest, reading, and social contacts Don’t’ overbook your week—avoid emotional and physical exhaustion Little people pay attention to one another. Your presence and attention are powerful agents of cure Listening questions 1. Are you able to turne out distractions 2. Do you avoid interrupting your clients 3. Do you communitcate interest thorugh your body language and facial expressions 4. Do you read between the lines and hear the emotions behind the words Reaction to eye contact as a form of implicit memory reflectingsomething that is potentially important about past experiences. Don’t react when a client ahs a strong negative reaction to you gaze—it may be a person you remind them of, a past experience, or their own thoughts, feelings, and fears Placing chairs a t aslight angle maes it easier for alcient to disengage from eye contact Therapy works best I fyour client oscillatesbetween low and moderate levels of arousal The things people need to learn in therapy are realted to attachment, abandomnet, love, and fear Quickly get to the pint and stop. Compare “I’m sorry your’e feeling sad today” with “You wish your father could just love and accept you” Th. Unhelpful communication styels such as an overly intellectual approach, ocnstnat interprepation, or diagnosising every move a cleitn tmakes to protect us from our own uncomfortable emotions do little to help our clients. Keep things client-centered Am I helping the client or myself? It is far more difficult task tot taek the time necessary to get o know someone in order to discover what they might need. To realy know someone else means being wiling to go where they need to go regardless of how it makes us feel. Letting go of the belief that my own defense and strategies work for everyeone The emotions of therapy, the complexity of the clients’ experience, and the sheeer amount finformation to process makes applying theory in clinical situations diffciult. A clear and concise way of thinking about therapy really heps All orientations models are designed to lessen suffering, reduce symptoms, and increase a clients abilty to cope with the stressors of life Everything you do should go back to theory First is rapport and connection/relationship Understanding is a hollow victory. Three things that will guide you through therapy: (1) case conceptualization (road map), (2) treatment plan, and (3) case notes. Will ground you in your understanding of the process of therapy, how the theory applies to your client, and wwhat to focus on from session to session. Consider failures to be experiments providing valuable information Encourage your supervisor to be firm on keeping notes specific to a theory Anxiety is the enemy to rational problem solving Don’t panic. Maintain mboundearies. If a client has it, it doesn’t mean you should have it too. Strong emotions usually stay for a few minutes. Stay calm Provide structure—give them relaxation techniques Provide hope Discuss strengths and resources Go for the root, not the fruit/symptoms Encouraging clients to review their past accomplishments, positive relationships, interests hoobies, and passions will actually lift their spitis. Hving them reconnect with activities of interest asap can also enhance their receptivity to what is focused on during sessions. When people feel sad and guilty, they are usually depriving themselves of positive experiences. Your admission of ignorance, geunuine questions, and desire to learn about your client is most often experiences as interest and caring, not incompetence. Consider the definition of a word and how evyerone’s got one. Allow clients who are culturally different form you to tach you about their culture before you draw any conclusions about their problems or psychological conditions. Ask them to describe ehow some of their behviaors are seen and understood by their family and understood within their culture 1. In what ways is it hard for you to make people of my culture understandyou 2. Do you try to correct my mistakes sbout your culture or do you let them go 3. What do I understand about your culture and what do I seem to miss 4. Do our diferentces make it hard for you to correct my mistakes 5. Do I take culture into account enough in trying to understand you? 6. Do I overemphasize your culture in our discussions or in my understanding of you? Being culturally sensitive means that you accept your ignorance, find the information you need to do a good job, and continue to test what you have learned. When your client is from a culture other than yours, try not to worry about appearing stupid because you are asking to be educated. Most members of mniory groups are accuostmed to dealing with misunderstanding and prejudice. Your interest and admission of ignorance will amost always be experienced as a breath of fresh air. It will dmemonstrate oth yoru desire to getto know your clients and your confidence in yourself Imiportant learning occurs in the hours and days right after your first session while the experiences are still fresh in you r mind and obdy. The stress can prie your brain to growin in an accelerated fashion. That’s why listening to taped session and seeking consultation in the early months of training and supervisors are improtnat Doubt is a sign of an active mind nd can keep us experimenting with new approaches When reviewing a session begin by thinking about what you did right. 1. Did I show up on time, rested, centered, and prepared for the session 2. Review the relevant case notes before the sessioin 3. Communicate a sense of caring and concern for my client 4. Actively listen 5. Allow my client to express herself without being interrupted 6. Deal with emergency concerns appropriately 7. Establish an emotional connection Why Didn’t I 1. Say more 2. Say less 3. Ask certain questions 4. Say certain things 5. Keep quiet 6. Not interrupt Telling someone he’s not making sesnse is far less helpful than helling him you don’t understand. Help me to understand what you mean What do you mean when you say that Coud you say that again? I didn’t quite follow I’m confused The Process of therapy is more circular than linear If an issue is important, it is bound to return Surrender to your imperfection Stay flexible and don’t be married to a gameplan Help your client move in the direction of psychological health If I fail to adequately manage my defensiveness, I run the risk of arguing, debating and bcomign attached to my positive. Being silence in the presence of another is often awkward and usually means something is wrong with us or the relationship. Thus, silence is equated with shame and incompetence, which both evoke anxiety. What does silence evoke for my client as well as for me? In doing so, clients will provide you with information about the architecture of their unconscious world. Consider allowing silences to go past your level of comfort and explore your feelings and associations. 10-15 seconds of silence should not be unusual in therapy Asking your client “Are you aware you are silence” or “what are you feeling” regains verbal contact Be keenly aware of your feelings and use them in my work. Sometimes preparation does not match erformance like ideally does not match reality. With most clients, the biggest challneg is helping them become open to change Are the labels you’re using with clients really helping them? Slow progress is the norm and backsliding periods should be expected When stagnation happesn, it is time to be cuirous, ask questions, and seek answers I’ve noticed on a number of occasions you have rejected some of my thoughts only to bring them back later as good ideas. I wawondering if you are aware of this and, if you are, can you tell me what thoughts and feelings you have about it? Fill your own well before you can fill other’s cups See clients as people Fear of confrontation may be expressed in 1. Setting fees too low 2. Running overtime 3. Not brining up diffuclt topics 4. Making too many interpreatations Resistance may be better descried as implicit and procedural memories from early relationships or traumatic experiences. Identify, understand, and communicate these patterns to the client. Collaborate! When a client resists, they are really thinking, “Can I trust you?” or “Can you really help me?” If clients aren’t ready for therapy, they won’t stay Success in therapy may push people back to old ways Strong countertransference with a client may be a good reason to refer. Supervisorscan help turn countertransference reactions into personal growth and positive therapeutic experiences for our clients. Address fees of therapy from the start When clients say they can’t afford the fee, ask them to bring in their tax return to discuss the issue. One month of missed payments should be the cap Making an interpretation is essentaily calling someone on their act Absorb client’s transference, not get defensive and intterpet what you consider to beteh emotional process taking place. Care and patience always trump strength and aggression. Be patient with yourself. This is an extremely compex and delicate process requires a lot of patience By naming my feelings, I was able to help the client feel his and recognize a defense against them. Shuttling is necessary because two fundamental weaknesses in our expepiernece of ourselves and others. (1) Sensations, emtions, and bodily states are capable of disconnecting from concisou awareness and (2) we influence one another in many unconciosu wys Shuttling down requires a shift in attention from thoguhts to emotions and bodily states. Shuttling up to your conscious rational self allows you to then think throughwhat is happening within yourself fand your client, remind yourself of your road map and Rx paln and make decisions as to how to think about what you are experiencing in your body. It is an ongoing process that is carried out whie you are attending to what your client is saying When you are feeling distracted, bore, or tired during a session, (1) begin the process of shuttling in order ot explore any manifestations of countertransference and (2) think of external reason that may be causing you to do so. (3) shuttle down into your body to find if you are angry, hurt, disappointed, or frustrated and (4) ask yourself whether your client has done anything that may have triggered theose feelings. Join with your clients, but avoid the drama. You’re their friend, not their therapist. A barrage of words is not openenes and vulnerability Stay centered. Some people learn during childhood that it is dangerous to think ologically and see the world clearly. This is espeicaly treufor people who grew up with abuse, addition, and neglect. Their scattered attention and sue of language have been shaped to keep them from gaining a celar experience of reality. The disorientation and disorganization that results from this defenseive strategy is pat of the storm they brin got therapy If I can’t understand something after an hones effort, there is a good chance the words are hiding crucuial information. 1. Ask yourself what the client may not want to sayor feel 2. Check for countertransference 3. Ask for help to understand 4. Ask the client to repeat what they just say. Talk less, say more 1. Model comfort with silence from the first session by remaining relaxed uring pasues in the diagloue 2. Inquire about feelings, thoughts, fanstasies, and memeories that may emerge during the silence 3. Discuss the role of worlds and silence in the client’s FOO 4. Ask the client to sit in ilence and state single “feeling words” about every 10 seconds, switching from narratives to basic feelings 5. Intreprte the defseenevie nature of the cleint’s talk by saying “sometimes talking can distract us from difficult feelings” or long and compleciated stories can hide simple truths Reamin as open as possible with your supervisor Bring in other members of the system for additional insight The therapists’ job is to be aware of what judments, attitudes, and feelings he or she might evoke and include this awareness in working wth clients. First awareness, second growth. Keeping secrets is difficult. Strict with themselves about confidentiality tas to heighten their awareness of its importance and difficulty Countertransference: doing what you would do to relieve your inner feelings while ignoring the needs of the client Unconvering countertransference takes time, work, a good supervisor, emotional honesty, and courage Pay less attention ot your cleint’s problems as you shift to a focus on your experience. 1. Start by picking a challenging client 2. Begin to jot down your personal thoughts and feleings in a countertransference journal 3. Tape record two sessions a few weeks apart 4. Review your tapes and journal entries to see if you can identify any manifestations of countertransference 5. Transcribe th tapes verbatim from start to finish 6. Find 2-3 underlying countertransference issues to analyze Don’t be surprised you’ll find avoidance strategies such as cleaning, eating, shopping, or playing computer games far into the night Don’t ask yourself “How can I be the person he will ike.” Rather, “how can I be the person he might need Society teaches us to hide wour weakesnesses and play to our strengths in countless ways It si not arandom choice to become a therapist. Innnate dispoitions combein with environmental and parental influences to determine which children grow into caretakers. Carried out dpends on our attachment pattersn history of trauma and loss, family dyanmics, and the challenges we faced while growing up. The motivation to help others comes from the combined needs to regulate others and heal ourselves The psychotherapist has a strong conscious and unconscious need to: 1. Be perfect 2. Be liked 3. Avoid conflict 4. Not have negative emotions 5. Prtoetct others from negative feelings 6. Have few needs and no strong opinions These are expressed in therapy by 1. Feeling total repsonsiblitiy for the cleint’s improvement 2. Diffciluties coping with selilence 3. Needing to be liked or be a firend to the client 4. Siding with the client against others in his/her life 5. Inability to tolerate the clients affect 6. Keeping interactions at an intellectual leve 7. Giving advice Pay attention to your level of energy, stamina, and mood as affecte dyb your scheulde. Talk to practicing therapists to find out about hteir lives and think hard about your personal needs One borderline client at a time—only. Chornically depressed clients are also extremely difcult to work with Good therapy should be healing and energizing for bothclients and therapists. You and your clients are growing from the therapeutic process If therapy feels laborious, stressful, or painful, something is wrong. Make sur eyou take lunch and exercise because it makes a big differenc on your outlook. Overwork signs may be not engaging in enjoyable activites, isolatingyourself from family, finding it difficult to stop, and not relaxing. Also theres are depression signs. Protect yourself by not internalizing clients’ struggles. Seeing clients at places other than the office or bartering are not worth the risk Have a good idea what insurance company and professional board standards are as well as state laws. Know yourself, your career options, and foster a good match between the two Choose a job or future that’s right for you Get solid training in at least two methods of psychotherapy and select the best aviallbae supervisiors regardless of orientation. The inttelliguence, maturity, and wisdom of good supervisors arefar more important than whether they prefer a specific model Therapy is only as useful as the client takes it. Be aware of medications and their effet Use everything that is potentially helpful to your clients Work: hospitals, private practice, community mental helaht centers, schools, clinics, industry, supervision, case evaluations, case managemen. A successful privatepractice requires self-organization, motivation, and a strong entrepreneurial speirt. Best way to martk has bene to give talks and provide people with information and resources. Foster a few specialty areas Private practice 1. Selling yourself and promoting yoru practice 2. No paid vacation 3. Difficulty in getting time off 4. Payng for your own medical insturance, malpractice insurane, an dretirement benefits 5. Starting from scratch if you morve somerwehre else Consider all tehse things carefully before decising on private practice. If decide yes, have collegauges you can tell anything to while maintain confidentiality. These realtionships and honest feedback are esesetnial to wherever you practice. Charging $100/hr is more like $40/hr after rent, phones, insurance, taxes, and overhead Institutaions offer a social structure, backup,a nd shared “on-call”coverage if you like to turn your phone off on weekends. However, you don’t have enough control of your work, there is demand for conformity, mountains of paperwork, and inherent limitations of systems. Keep in mind that the venue is all about fit. Accepting ourseves with our limitations is very ifferent from self-acceptance Therapy is more a stateof mind tha an activity or accomplishment The key to a good therapist is self-awareness Pyschotherapy is not to be thought o fas a profession, but a calling, a lifestyle, and a vehicle for personal growth Despite all the difficulties, risks, and challenges, being a therapist can be incredibly rich and meaningful. Although one of themost difficult professions to nagvvigate intellectually and emotionally, it offers the opportutnity to help others while simultantously discovering ourselves, stretching us to our full human potential. Helping people connect with oe another, bringing hope to people without hope, and being a ctalyzt for victimized clients to become empowered helps Cozolino elieve his life has meaning.