Hour of the Heart

1. Aging, Memory, and the Shift to Single Sessions

Now, as I sneak up on age ninety-three, perhaps concerns such as my death and the need to pass on hard-earned lessons truly are pressing.

Facing decline. As memory fails and age advances, the author transitions from long-term therapy to single-session consultations. This shift is born of necessity, acknowledging diminished capacity while still desiring to be helpful and share accumulated wisdom. It represents a poignant confrontation with mortality and professional identity.

New format, new reach. The single-session format, often conducted via Zoom, unexpectedly expands access to people globally who couldn't afford ongoing therapy. This allows the author to connect with a wider range of individuals, offering brief but potentially impactful encounters. It transforms the practice from traditional private sessions to a series of intense, time-limited interactions.

Motivation and purpose. Despite the challenges of aging and grief, the desire to contribute and teach remains a powerful driving force. These consultations provide a new adventure and a way to stay engaged in the world, offering insights gleaned from decades of practice. The project becomes a means of both helping others and processing personal change.

2. The Therapeutic Relationship Heals

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.

Core of change. The most crucial factor in effective therapy is the strength of the relationship between therapist and patient, known as the therapeutic alliance. It is through this genuine human connection, built on empathy, warmth, and trust, that transformation occurs. This alliance is more impactful than specific techniques or interventions.

Building trust quickly. In single sessions, establishing a strong, trusting relationship rapidly is paramount due to the limited time. Sharing vulnerability and being authentically present can accelerate this process, creating a safe space for the patient to open up. Patients often benefit simply from feeling seen, heard, and cared for.

Beyond technique. While theoretical knowledge and clinical skills are important, they are secondary to the quality of the interpersonal bond. Patients often respond more to the therapist's humanity and willingness to engage honestly than to brilliant interpretations or strategies. The relationship itself provides a corrective emotional experience.

3. Focusing on 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.

Present moment focus. The here-and-now approach emphasizes the dynamic unfolding between the therapist and patient during the session. Problematic interpersonal patterns, defenses, and emotions that hinder relationships outside therapy are likely to manifest within the therapeutic interaction itself. Examining this immediate dynamic provides direct insight.

Social microcosm. The therapy session serves as a miniature representation of the patient's social world. By observing and discussing how the patient relates to the therapist, both can gain valuable understanding of the patient's typical interaction styles and their impact on others. This allows for immediate feedback and exploration.

Efficiency in brief therapy. This approach is particularly well-suited for single sessions as it doesn't require extensive historical exploration. Focusing on the present interaction allows for rapid identification of core issues and provides a tangible experience of relating differently. It leverages the immediate reality of the encounter.

4. The Power of Therapist Self-Disclosure

On the contrary, my self-disclosure always seems to bring me and my patients closer together and to improve the course of therapy.

Building intimacy. Sharing personal experiences or feelings, when done thoughtfully and in service of the patient, can significantly accelerate the development of trust and intimacy. It humanizes the therapist, making them feel more relatable and less like a distant authority figure. This vulnerability encourages the patient to be more open in return.

Modeling openness. By revealing aspects of their own struggles, doubts, or emotions, therapists model the very behavior they encourage in patients. This demonstrates that vulnerability is not only acceptable but can lead to deeper connection and understanding. It counters the traditional "blank screen" approach.

Strategic sharing. Self-disclosure is most effective when it is intentional and directly relevant to the patient's process or concerns. It should not be used for the therapist's own needs but to illuminate a point, normalize an experience, or deepen the therapeutic bond. Examples include:

• Sharing personal grief to connect with a grieving patient.
• Revealing past struggles with shame to help a patient with similar feelings.
• Discussing challenges in relationships to explore a patient's relational patterns.

5. Navigating Patient Resistance and Defenses

You want connection but make it impossible for others to connect.

Understanding resistance. Patients often present with defenses or resistance that hinder their ability to open up or engage deeply in therapy. This can manifest as vagueness, deflection, intellectualization, or an inability to identify feelings. These behaviors, while frustrating, are often protective mechanisms developed in response to past pain or fear.

Identifying the pattern. The therapist's task is to gently identify and explore these patterns of resistance, often by pointing out how they are occurring in the here-and-now interaction. Understanding why the patient resists is crucial, as it often reveals core fears or beliefs about intimacy and vulnerability. Examples include:

• A patient who avoids talking about their marriage by changing the subject.
• A patient who intellectualizes emotions rather than feeling them.
• A patient who gives vague, non-committal answers to personal questions.

Patience and persistence. While time is limited in single sessions, navigating resistance requires a balance of persistence and patience. Pushing too hard can increase fear, while not pushing at all leaves the patient stuck. The therapist must find creative ways to invite the patient to look at what they are avoiding.

6. Confronting Trauma and Early Life Wounds

Antje, please trust me when I say that early history is not forgotten.

Lasting impact. Traumatic experiences and difficult childhoods leave deep imprints on the psyche and nervous system. These early wounds, even if seemingly "long past," continue to influence present behavior, relationships, and emotional well-being. They can manifest in various ways, including anxiety, difficulty with intimacy, or self-sabotaging patterns.

Uncovering the roots. Effective therapy often involves exploring these early experiences to understand how they shaped the individual. This is particularly challenging when patients have developed strong defenses to avoid the associated pain, shame, or fear. The therapist helps the patient approach these "dark corners" safely.

Beyond cognitive fixes. Trauma is not merely a cognitive issue; it is deeply embedded in the body and emotional system. Addressing it requires more than just changing thought patterns. Approaches that integrate somatic work or EMDR alongside talk therapy can be crucial for processing and healing these deep wounds.

7. Existential Fears: Death, Isolation, Meaning

Existential psychotherapy focuses on patients’ inner conflicts that arise from confronting the givens of human existence—death, isolation, meaning in life, and freedom.

Universal concerns. Beneath many presenting problems lie fundamental human anxieties related to the inescapable realities of existence: the certainty of death, the inherent isolation of consciousness, the search for meaning in a meaningless universe, and the burden of freedom and responsibility. These concerns impact everyone, often unconsciously.

Death anxiety. Fear of death is a core existential anxiety that can manifest in various ways, from avoidance of life to thrill-seeking behaviors. The author's personal experience with grief and aging provides a new perspective on this fear, suggesting that fewer regrets about how one has lived can lessen death anxiety. However, this connection is not always straightforward.

Isolation and connection. The terrifying reality of ultimate isolation drives a deep human longing for connection and intimacy. Therapy, particularly group therapy, can serve as a powerful antidote to this isolation, providing a space to feel truly seen and connected to others. Interpersonal relationships are a primary salve for existential loneliness.

8. The Therapist's Own Journey and Self-Awareness

Knowing oneself as deeply as possible is essential, and exploring one’s faults, strengths, and dark corners as a therapy patient is the best way I know of honing one’s perceptions in service of providing one’s patients the most effective therapy.

Self as instrument. The therapist's most important tool is their own self. Deep self-awareness, gained through personal therapy and ongoing self-reflection, is crucial for recognizing one's own biases, blind spots, and emotional responses (countertransference). This allows the therapist to use their reactions as valuable data in the therapeutic process.

Personal therapy is vital. The author strongly advocates for therapists undergoing their own therapy. This provides firsthand experience of being a patient, fostering empathy and understanding of the patient's perspective. It also helps the therapist work through their own issues, preventing them from interfering with the patient's process.

Continuous learning. The journey of self-awareness and professional growth is lifelong. Even at an advanced age, the author remains curious about what works in therapy and how to be more effective. Mistakes, like accidentally sending notes or misinterpreting a patient, become opportunities for learning and refining one's approach.

9. The Unexpectedness and Nuance of Human Connection

It’s funny how often my missteps provide excellent openings.

Unpredictable paths. Therapy is rarely a linear process, and breakthroughs often occur in unexpected ways. A therapist's planned intervention may fall flat, while a spontaneous comment, a shared personal story, or even a mistake can open up crucial avenues for exploration and connection. The therapist must be open to these unpredictable moments.

Beyond the surface. Patients may present with one set of concerns, but deeper, often unarticulated issues lie beneath the surface. The therapist's task is to listen not just to the content of what is said but to the underlying emotions, patterns, and unspoken messages. This requires intuition honed by experience.

Nuance in communication. Human communication is complex and layered. A patient's words may convey one message, while their demeanor, tone, or non-verbal cues suggest something entirely different. The therapist must attend to these nuances, recognizing dissonance (like serenity masking anxiety) as important clues.

10. The Value of Honest Feedback and "Tough Love"

I believe this is because most of us never get truly honest feedback from others.

Honesty in the relationship. Providing honest, direct feedback to the patient about how they are experienced by the therapist can be a powerful catalyst for change. This feedback, delivered with care and empathy, offers the patient a rare opportunity to see the impact of their behavior on others in real time. It breaks through social politeness and defenses.

Confronting difficult truths. Sometimes, helping a patient requires delivering "tough love" – confronting them with difficult truths about their behavior or situation that others may avoid. This is particularly necessary when a patient is in denial or engaging in self-destructive patterns. It must be done with genuine concern for the patient's well-being.

Risk and reward. Offering honest feedback, especially in the here-and-now, carries a risk of the patient feeling hurt, defensive, or misunderstood. However, when done skillfully within a developing trusting relationship, it can lead to profound insights and motivate the patient to make significant changes they might otherwise avoid.

11. Experimenting with Role Reversal

What questions do you have for me?

Shifting the dynamic. Inviting the patient to ask the therapist personal questions can be a powerful technique, particularly when the patient is struggling to open up or feels intimidated. This reverses the traditional power dynamic, giving the patient agency and control in the interaction. It can break through resistance and foster intimacy.

Patient's curiosity reveals. The questions a patient chooses to ask can be highly revealing of their underlying concerns, fears, or desires. For example, asking about the therapist's friendships may highlight the patient's own loneliness, or asking about the therapist's struggles may indicate a fear of imperfection. This provides valuable diagnostic information.

Modeling openness. By answering the patient's questions honestly and vulnerably, the therapist models the desired behavior of openness and self-disclosure. This can make the patient feel safer and more comfortable revealing their own inner world. It transforms the interaction from an interrogation into a mutual exploration.

12. The Enduring Need for Connection

One of the great drivers of existential anxiety is our condition of being alone in the universe, such that we can never completely share our experience with another.

Fundamental human drive. The longing for human connection is a primary force motivating people to seek therapy. Whether presenting with relationship problems, depression, or anxiety, patients often struggle with feelings of isolation and a desire for deeper intimacy. Therapy aims to help them develop the capacity for meaningful connection.

Therapy as practice. The therapeutic relationship itself provides a safe space for patients to experience and practice intimacy. By learning to open up, share vulnerabilities, and navigate the dynamics within the therapy session, patients can develop the skills and confidence needed to build richer relationships outside of therapy. It's a rehearsal for life.

Beyond the session. The impact of a single session, or any therapy, extends beyond the hour itself. A moment of genuine connection, a new insight, or a feeling of being truly seen can resonate with the patient long after the session ends, influencing their interactions and choices in the world. The goal is to empower them to seek and create connection in their own lives.

Last updated: May 4, 2025