A Day in the Life of a Very Old Therapist

• Jerry: What’s Not to Like?!
• Born of Necessity: One-Session Therapy
• Susan: Trying Out My New Strategy

The day had not started well. I woke at 3:00 a.m. with leg cramps that wouldn’t go away. I quietly got out of bed, careful not to disturb my wife, Marilyn, sleeping deeply next to me. To relieve the pain, I took a hot shower until it turned lukewarm, then dried myself and returned to bed. The heat had soothed my muscles, and the cramps had subsided somewhat. I tried hard to go back to sleep. But when it comes to sleep, “trying hard” is always doomed to failure. Insomnia has been my kryptonite for decades.

I had been tapering down my use of sleeping pills, reluctantly, as my doctor suspected they were accelerating my memory loss. I tried some breathing exercises. Time after time I inhaled, whispering “calm,” and exhaled, whispering “ease,” a meditation practice I’d learned years ago. But it was to no avail—the slight calming brought on by the utterance of “ease” soon morphed into anxiety, another old nemesis. I shifted my attention and focused on counting my breaths. A couple of minutes later I realized I had forgotten about counting and my ever-restless mind had wandered elsewhere.

A year earlier Marilyn had been diagnosed with multiple myeloma, an insidious cancer of the blood plasma. She was in the midst of a series of chemotherapy treatments, which had yet to result in any significant improvement. Her warmth and the sound of her breathing were so familiar, my beloved bedmate for many decades. But now something new had joined us, this sinister illness, doing battle within her.  

I was pleased to see her resting peacefully that night and gently traced the lines of her face in the dim light. We’d been together, inseparable, since middle school. Now I spent the majority of my days worrying about her and trying to enjoy the time we still had together. Nights I spent worrying about a life without her. How would I pass the time? With whom would I share my thoughts? What loneliness awaited me?

Noticing that my mind had strayed so thoroughly, I gave up the idea of getting back to sleep. I checked the clock and noted, to my surprise, that it was already 6:00 a.m. Somehow, when I wasn’t paying attention, I must have nodded off for a couple of hours.

Jerry: What’s Not to Like?!

After breakfast, I looked at my schedule. I had only two appointments that day. The first was a termination, the final session with Jerry, a patient whom I’d been seeing for one year. Jerry was a successful lawyer in his 40s who had come to therapy seeking answers after his girlfriend of two years had left him, the third in a string of failed relationships. “I can’t see why,” he’d said during our first meeting. “I’ve got a great house, a great job, tons of money. What’s not to like? I mean look at me.” He’d gestured at the well-tailored, clearly expensive suit he was wearing.

Jerry was not what you’d call warm or reassuring. He was demanding, and often critical. He groused about my fee, suggested I get a better gardener to tend the plants along the walkway to my office, and, once inside, disparaged the artwork on the walls.

He had come to me, he told me repeatedly during our first few meetings, because he’d heard I was the best, and he deserved the best. This was soon accompanied by a look of disappointment in his eyes that I hadn’t swiftly cured him of his troubles. Clearly, that look said I wasn’t the best after all. And yet, over time, we’d had success. What had worked? We had two important factors going for us. First, Jerry was highly motivated to make change in his life. Despite his prickly exterior he realized that he was in some way contributing to his relationship problems, and he was eager to put in whatever work was needed to address this. I had to slow him down, let him breathe, and see that part of the problem was the immense demands he placed on himself and me to magically “fix” him.

“Imagine being your girlfriend for a few minutes,” I suggested. “What if you weren’t ‘the best,’ if your garden path weren’t expertly tended, if you didn’t look perfect on Jerry’s arm? Would Jerry love you and support you nonetheless?”

“I doubt it,” he said.

“Instead he would criticize you constantly, and you’d end up feeling crappy about yourself and your relationship. And . . . ?” I left the question hanging in the air. Jerry considered for a moment.

“And you probably wouldn’t stick around,” he said finally.

This realization, that being demanding and often unkind severely impacted his relationships, clicked for him. He could see the role he was playing and started to change. In the weeks that followed, he set about in earnest to improve. He began to catch himself whenever he was overly critical of me and whenever he complained that others in his life were inadequate. He took more responsibility for the way people, especially potential romantic partners, responded to him. And he set about curbing his sharp tongue. Jerry’s fierce drive to change himself was essential to the progress he made, but it was not something I could control.

I could influence another factor, however: the powerful relationship he and I developed. From the beginning, Jerry had tested me: Why wasn’t my taste in art better? Where was my fancy car? Why hadn’t I been able to fix him all the way yet? Through all these barbs, I’d stayed in there with him. I’d been empathetic and warm, and also willing to push back when it seemed a challenge would do him some good. Gradually he softened up and stopped competing with me. As our relationship grew, his bristles felt less like attacks and more like witty, playful jabs that I could parry or call him out on. Little by little we built a strong connection, a “therapeutic alliance” as we call it in the field.

This alliance, building it and using it, is the most important factor in my therapeutic approach. In what now seem like countless lectures, and numerous writings, I’ve stated that “it is the relationship that heals.” What drives change is not a worksheet that the patient fills out, a brilliant question the therapist poses, or a behavioral change the patient must chart daily. In my approach to therapy the honest connection between the therapist and the patient is the medium through which we discover, learn, change, and heal.

Jerry and I had made excellent progress using that relationship over the course of the year we had together. He became friendlier, and when he occasionally still snapped at me with a disapproving comment, I would point it out. He learned to apologize and then, bit by bit, catch himself before saying something acerbic, and often, quite endearingly, replace such comments with attempts at compliments: “The lemon trees beside the path are looking much better this week” or, “You know, that statue of Buddha on your bookshelf is actually more interesting that I thought.”

I looked forward to our weekly meetings and would be sad to say goodbye when today’s session ended at 11:50. But, for reasons that will become clear, we had agreed upon a one-year time frame at the beginning of his therapy. He had certainly made the most of it, and we were both hopeful that his future relationships, romantic and otherwise, would be richer and more satisfying.

Born of Necessity: One-Session Therapy

The second session on my schedule that day would be very different. It was with a woman named Susan, whom I planned to see only once. Only once!? How could I do anything resembling effective therapy in a single session? And why would I want to try? To explain, I need to rewind my timeline a bit to provide context.

About five years before this, when I was in my early eighties, I noticed that my memory was starting to fail. I had always been a bit forgetful, misplacing my appointment book, glasses, or car keys with regularity. This was something different. I began to encounter people I recognized, only to have their names elude me. Occasionally I’d stop in the middle of a sentence, stuck searching for a familiar word. And, more and more frequently, I would lose track of the characters in movies Marilyn and I were watching.

As this progressed, I began to think that, perhaps, I was no longer able to offer the long-term therapy I had for nearly 60 years. Instead of open-ended therapy that sometimes lasted three or four years, I decided to set a 12-month time limit, agreed upon in advance, for all new patients, hence my agreement with Jerry. I approached this new framework with some sense of loss, as it represented a major shift in my work, one derived from necessity, not desire. But soon curiosity, and my wish to continue being helpful, won out.

Ultimately, I found this to be an agreeable solution. If I chose my patients carefully, I was almost always able to offer a great deal during our year’s work together. With some patients, in fact, there was an increased sense of urgency, and thus motivation, thanks to the time limitation. This had worked well, both for me and for my patients, for the last five years. Then around the time I was 87, I started to find I was more and more reliant on the summaries I recorded after each session to remember the details of my patients and that, even with these notes in hand, their faces and problems occasionally seemed alien. I was faltering, and I began to question the value of the care I was able to provide. I felt I still had much to offer, but it was clear that I could not, in good conscience, engage in ongoing work with patients, even limited to one year.

And yet, and yet . . . the thought of no longer practicing was dizzying. Sharing with my patients, aiding them through their darkest thoughts, and joining them on journeys of discovery—for the majority of my life this had been my daily work and my calling. Who would I be, if not a psychotherapist? Truth be told I was angry and deeply frightened. I was not ready to feel this old, this useless. The thought of leaving therapy behind felt like resigning myself to rapid decline, followed soon after by my inevitable death.

I pondered this dilemma. I had to put my patients’ needs first, so doing long-term therapy was out. But after so many decades of practice and research, I knew I had developed levels of insight and expertise that were rare, and still potent. Plus, I felt the personal need to continue contributing in some way. How could I offer something—enough to be helpful to patients, enough to keep myself engaged in the world—while also not endangering anyone? I came up with an unconventional idea. Perhaps I could meet with people for one-time, one-hour, consultations. During that hour I would offer everything I could—insight, guidance, a warm accepting presence—and then, if appropriate, refer them to a colleague who seemed well attuned to their particular challenges for ongoing treatment.

The idea of such short-course therapy was profoundly foreign to me. I have always seen therapy as a longer-term endeavor—not the endless years of old-school psychoanalysis, but often several years, long enough to help patients search for better understanding of themselves and make meaningful change in their lives. The question of how I might be effective in single sessions could be an interesting experiment, if nothing else.

For some time after coming up with this idea I vacillated between skepticism—Was this just a way of forestalling my own decline rather than offering anything truly beneficial to the patients?—and excitement—I knew I had skills honed to an uncommon degree and had been helpful to many, many struggling people, which undoubtedly had some value. I took the time to stare carefully at my own feelings. It was possible my pride would resist accepting this lessened importance. And yet I knew that, at some point, I would need to accept my decline and pass the torch fully to the next generations. I honestly did not know what this experiment would yield, which itself was intriguing. Thus, I began a new adventure of short therapeutic encounters, and investigation of what might be most helpful in a far briefer time frame for creating change than I had ever before conceived as effective.

I announced my retirement from ongoing therapy, and my offer of these single-hour consultations—either in person in my Palo Alto office, or online—on my Facebook page. Within hours, requests for appointments started to pour in, far more than I’d expected. They came from all over the world, English-speaking countries of course, but also many other places, too—Turkey, Greece, Israel, Germany—as Zoom had collapsed the barrier of space. And they came from people in many stages, and to some extent many walks, of life. This single-session format, I quickly realized, would allow me to work with many people I had never been able to reach otherwise, people for whom ongoing therapy with me was prohibitively expensive. It was clear this would be a very interesting shift from the relatively traditional private practice I’d led from the lovely Spanish-style cottage in our backyard over the previous 20 years, and for decades before that working in the psychiatry department at Stanford University. Would it be effective for the patients? Would it feel satisfying for me? Only time would tell. It would certainly be new, and at my age, newness was nothing to scoff at.

This, then, was how I found myself on that particular morning contemplating my first single-session consultation with Susan. I was excited yet concerned. I am not always filled with second-guessing, but after a restless night spent with my darker thoughts about Marilyn’s failing body and my own weakening mind, I had my doubts. How much good would I be able to do, really, in these short encounters?

I had several things going in my favor, I reminded myself. First, my particular therapeutic approach has always been heavily focused on using what I refer to as the here and now. By this I mean that the interactions the patient and I have in the moment are the essential tools of change. Whatever problematic tendencies a patient has—their insecurities, their neuroses, the things they do that get in the way of their relationships with others—these are all likely to show up in the therapy sessions, through their interactions with me. Jerry, who had to have the best therapist, is an excellent example. Even though he came to me for help, and thus presumably began our work with a positive opinion of me, he constantly criticized me in many ways. Time and again I brought his awareness to this tendency. At first, he attributed the comments to my inadequacies, that I was overly sensitive and jealous of his financial success. But little by little Jerry began to see that he behaved this way elsewhere in his life as well, and that it impacted his relationships, and his happiness.

This here-and-now approach is largely ahistorical, meaning that it does not rely a great deal on patients’ personal histories. Rather than spend great amounts of time digging through patients’ backstories, time which I would not have in these single sessions, I focus on the present, tuning in closely to every word and gesture they offer, as well as those that they omit. I was confident this approach would allow us to get into the serious work quickly. It also had the great benefit of dove-tailing nicely with the limited capacities of my faltering mind: remembering the past was increasing challenging, and recalling copious details about each patient was beyond me. But being present right here and right now, I could do very well.

A second thing I had going for me was that nearly all of the people who requested consultations had some knowledge of me in advance. Over six decades I have written many books, including influential textbooks for student therapists, philosophical novels, and books of stories like this one that aim to demystify the process of therapy. Through these I have had the good fortune to become a well-known figure in the field, and most of the people who had requested consultations thus far had mentioned reading at least one of my books. It was clear from most of their emails that they saw me as having some amount of wisdom and power. I took this with more than a few grains of salt, knowing that we all sometimes seek reassurance from silver-haired elders. In fact, there was a small voice inside me, adolescent and rebellious, that wanted to shout out “I’m not that old yet!” and cancel this whole undertaking. But for the most part I was happy to play the role of guru on the mountaintop, realizing that I might be able to use the wisdom with which people imbued me and leverage that power to help them change.

Susan: Trying Out My New Strategy

Such was my state of mind as I settled into the chair in my office and opened a Zoom window to speak with Susan, a 50-year-old schoolteacher from Oregon who was deeply depressed. We quickly greeted each other, and I explained that I would only be able to see her one time, as noted in the Facebook posting, and that I hoped to be as helpful as possible. It felt very strange saying all of this, and I think I was laying out the groundwork as much for myself as for her. She nodded, then launched into her tragic story. Two years ago, at about 10:00 on a Thursday night, she had opened the refrigerator and noticed that the large cherry pie she’d made was nearly gone. She had planned to serve it the following evening to close friends who were coming over for dinner, but now it was reduced to a sliver of crust oozing deep red filling.  

What had happened to the pie? It was no mystery: no doubt Peter, her husband, must have eaten it. It wouldn’t have been the first time.

“That gluttonous slob!” she exclaimed, bursting into tears. The fate of her cherry pie was too much. The last straw. She had to be at work until 5:30 the next day, an hour before her dinner guests would arrive. She would barely have enough time to get dressed and set the table, let alone bake another pie. The disrespect!

Brimming with anger, she’d stomped upstairs and confronted her husband, who was already in bed. They argued for 10 minutes. Tempers and voices rose. He told her he had always been the main support for the family (not true! she protested) and that he’d eat any pie he damn well pleased. She retorted that he was an obese hog who was going to gorge himself to death.

He told her to sleep on the couch and pushed her out of the bedroom, slamming and locking the door.

“Fine,” she yelled. “The last thing in the world I want to do is to share the bed with a selfish glutton.”

The next morning, her hard knocks on the bedroom door and loud calls to her husband were returned with silence. Finally, she and her two daughters broke into the room to find him lifeless in bed. They called emergency services, and when the medics arrived, they declared he had been dead for several hours. When police officers arrived, they sealed off the house and searched every room. Susan and her daughters were interviewed at length—clearly the police were considering the possibility of foul play, going so far as to infer that the pie might have been some sort of weapon. “How awful,” I said. “And how much have you recovered from your husband’s death?”

“I’d say zero,” Susan replied. “No recovery. None at all. Perhaps I’m getting worse. I miss him so much, and I am racked with guilt about what I said to him that last night. And I’m also mad at him for leaving me. I cry all the time and now I’m the one who can’t stop eating and I’ve gained 60 pounds. I saw a psychiatrist here recently and he said that I was, in some way, identifying with my husband. What help was that? I’ve developed terrible skin problems and I can’t stop scratching myself. I can barely sleep, and when I do, I keep dreaming of Peter. When my daughters leave for college in a month, I’ll eat by myself in restaurants and people will look at me and, I’m sure, pity the dumpy fat woman eating all alone.”

She caught her breath loudly, perhaps holding back tears.

“That’s it, Dr. Yalom, I’ve unloaded on you. That’s everything. I don’t know what else to say.”  

She slumped back in her chair.

“You know, Susan, I’ve worked a lot with women who have lost their husbands and your account of what you’re going through is not unfamiliar to me. Let me ask you something. You say your husband died over two years ago. Can you compare your condition now with a year ago? Is it different? Is it less painful?”

“No. Just the opposite. That’s what torments me; I think of him more and more, and when I’m alone in the house I’m terrified of being sad and lonely forever. Damnit. It’s not fair.”

“Grief always lessens, but it takes time. Usually, the course of grief goes through a predictable cycle. It’s most keen the first year when you experience the first birthday, the first Christmas or New Year’s Eve, without your spouse. But then, as time passes, the pain lessens. And later, when you go through the cycle of the special days for the second time, it becomes markedly less painful. But that isn’t happening for you. Something’s blocking you and I have a hunch it’s related to your anger.”

Susan nodded vigorously and I asked, “Can you put that nod into words?”

“I have no words for it, but I feel you’re right. It’s confusing. I’ll be drowning in sadness and then, suddenly, all I feel is intense anger.”

“Let’s focus there, on your anger,” I said. “Just let your mind go there and for just a couple of minutes please share your thoughts with me. In other words, think out loud.”

She looked puzzled and shook her head. “I don’t know how to start.”

“It might be easiest to start at the beginning. Think out loud about your very first encounter with anger.”

“Anger . . . anger. The first time I felt anger was with my first breath—at my birth.”

“Keep going, Susan.”

“There was anger when I was born. My mother’s anger. I remember her saying time and time again that she wanted a boy and if I had been a boy, she would have stopped there. She just wanted one child, and it wasn’t me. She let me know about it over and over.”

“So you spent some of your early childhood hearing about how your birth, your very existence, inconvenienced her?”

“Oh God, yes, she made me feel it all the time. Damn her for that!”

“And your father?”

“Worse. Sometimes even worse. His favorite joke, which he never tired of telling, was that the nurse made a mistake when I was born and brought the family the afterbirth instead of the baby.”

“Ouch. Oh, Susan, how dreadful to have your father joke you’re not a person, that you’re a placenta.”

“He thought that was such a funny joke. And my mother agreed. I’ll be honest with you. I know it’s unnatural, but I hated them. Both of them. My father especially. He wouldn’t pay for my college. He wanted me to work as a secretary in his store instead. So, I left home early and had to work my way through school.”

She paused, letting these deep emotions swirl through her. After a moment, while she was still in that open tender place, I pushed her to go deeper.

“And the anger toward your husband? Tell me about that.”

“It wasn’t like my anger toward my father. Certainly not at first. I met Peter after I left home, when I was in college. We were sweethearts and he was good to me. His parents were well off, and he always had money. Whenever I was strapped, he’d help pay my rent or buy groceries. And I’d never had that kind of help or affection before.

“Peter’s father was a politician and wanted him to follow in his footprints. Peter had the charisma—he could be incredibly charming and fun. But he was lazy, a poor student who gambled whenever he could, and eventually flunked out of school. He became a guard at a local bank, a job his father got him. He never made enough to support us or, if he did, he secretly gambled it away. Either way, he made it clear that I always had to work. I never took time off, except three-month maternity leaves when I had our daughters. I could never become myself, never be the kind of mother I wanted to be for my girls. Instead, I worked, worked hard. And you know what? Just a few days before he died, he told me he’d gotten too heavy to be a bank guard, and they’d moved him to office work, which meant a pay cut. He said it wasn’t a big deal, and I got so mad at him because he didn’t even care about his health. And probably I would have to find a second job to pay our bills.”

“I hear lots of anger rumbling, Susan,” I said. “A husband who never recognized all the work you did, who never valued your needs and wants. A cruel father who saw you as either a problem or a punch line. And a callous mother who never wanted you, never offered love. Now they are all gone— mother, father, husband—all gone. And a good bit of your life has gone by as well. Oh, Susan, no wonder you’re angry. Who in your situation wouldn’t be enraged? I know I would be.”

She nodded as I spoke.

“How does it feel to hear me say that, Susan?”

“Hard. Right. But hard.”

“I want to take a moment to look at all you’ve accomplished in spite of them: two loving children, a valuable teaching career, and so much more. You’ve done so well, Susan.”

She swallowed, taking that in.

“I haven’t really been able to talk to anyone about this,” she said. “Everyone wants to remember Peter as a good person, remember us as a good couple. No one wants to talk about the darker side.”

“Thank you for sharing it with me. Your anger is only human. Yet I suspect it presents a big problem. We feel we should never speak ill of the dead, that it’s wrong or somehow disrespectful. Does this ring true for you?”

She nodded, tearing up.

“Well, I disagree. Anyone in your situation, with the experiences you’ve lived, would have the angry feelings you’re experiencing. You’re judging yourself far too severely.”

Susan was sobbing now, and I waited for her to calm down and breathe.

“I don’t know what to do, how to stop it,” she said finally. “I’d like to remember so many other things about our life together. I really did love him. But now I’m just so mad.”

“I suspect that as you accept your anger, accept that it is appropriate and you have good reason for it, those other memories will return. But it will take time.”

“Maybe.” She nodded. “I hope so.”

Then, in my most solemn voice, I continued. “Susan, I’ve listened carefully to everything that you’ve told me, taken it all in and pondered it carefully. I want you to know that I pronounce you innocent. Please hear that: I pronounce you innocent! You deserve a good life. You’ve worked hard, you’ve been a good mother, a good wife, and you deserve some happiness now.”

She smiled through her tears, and I finished the session with a keen sense of having been helpful. I gave her the name of a therapist with whom she might continue. Clearly this old man still has something to offer, I thought on reviewing our meeting!

I received a follow-up email from her a couple of weeks later which confirmed this. She thanked me for helping her, writing:

I won’t forget the moment when you said something like “apparently your mother and your father were not good parents, but even so you’ve done extremely well in life . . . I admire you for that.” You gave me a warm feeling of being seen and respected and supported at the same time. Also your pronouncing me innocent. I will never forget that remark, and the smile on your face as you said it. I will keep the sound of your voice in my mind and my heart.  

Thinking about it later that night, I felt this was one of my best therapy hours ever. I resolved to keep offering these unusual one-hour sessions, to see whom I could help and to glean as much as I could from the process. Equally important, I would share what I learned. Earlier, speaking of my desire to help patients, I left out the other major aspect of my professional life, that of teacher. Most of my work as a writer has been in the service of teaching young therapists and others practicing, or entering, therapy. Furthermore, many of my thoughts have gone against the grain, countering major trends in the field. While psychiatry has increasingly pushed medication as the solution to mental illness, I have championed human connection; while psychotherapists have increasingly been taught approaches that aim at symptom reduction, like cognitive behavioral therapy or solution-focused therapy, I have embraced curiosity and deep personal exploration.

This dedication to sharing what I’ve learned has always been a powerful force driving me forward, and I began to feel that impulse again when thinking of Susan and imagining many rich brief encounters ahead of me. I would undertake this project not only to help those who seek consultation and to remain engaged myself, but also to pass on what I learn. 

Full book available here.

From the book HOUR OF THE HEART by Irvin D. Yalom and Benjamin Yalom. Published on December 10, 2024 by Harper, an imprint of HarperCollins Publishers. Reprinted with permission.