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The Making of a Therapist Notes by Cozolino

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
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
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
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
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
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
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
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
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.
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
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
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
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
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
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
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.
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