Introduction
Older adults’ demand for psychotherapy has increased dramatically in recent years (Laron et al., 2022). Several factors have contributed to this transformation, including changes in the stages of aging, shifts in the cultural perceptions of aging populations, and the enduring impacts of the COVID-19 crisis (Aisenberg-Shafran, 2022). Today, more older adults seek therapy at the urging of family members.
Social and emotional life changes as we age. Among the prominent factors emerging among aging individuals is the increased importance of social relations. This includes a greater investment in meaningful relationships, with close ties becoming crucial to a person’s sense of meaning. On the other hand, social networks are inclined to narrow, leading to a sense of loneliness. Negative emotions, especially anxiety and depression, become more frequent, and social roles change. Often, self-understanding increases and emotions become more predictable and less labile (Charles & Carstensen, 2010; Charlesworth, 2022). Some researchers have found that older patients respond well, sometimes even better, to psychotherapy than working-aged patients (Charlesworth, 2022; Laake et al., 2021; Saunders et al., 2021).
Though research consistently finds that therapist-patient similarity can contribute to the therapeutic alliance (Wampold & Imel, 2015), this becomes impractical in many cases, such as among older patients. Older patients find themselves face-to-face with a notably younger therapist, or as patients often remark, “younger than my granddaughters.” However, the therapist’s age is also subject to meaning ascribed to age by the patient. This often takes the form of the therapist’s and patient’s perception of the therapist’s lack of “lived experience,” which will be addressed below. The therapist’s age, as reflected in their appearance, is thus a form of inferred exposure that brings about challenges that should be defined and addressed.
We widen the common discussion of self-disclosure to consider cases where therapist-patient age differences are substantial and in which therapist’s self-disclosure is not a matter of utterance or choice, often transpiring from the very first minutes of the encounter. We propose the term ״inferred exposure״ to denote situations in which the client acquires inferential knowledge or belief derived from the therapist’s appearance. This is present, to some extent, in almost all therapeutic encounters, but we wish to show that it presents itself distinctively in instances of a young therapist and an old patient. Our focus is not so much on age as on possible meanings that may be ascribed to it. These factors interact with the young therapist’s own emotions while working with senior patients.
During training, I (…) encountered a woman who greatly influenced me, whom we’ll call Hanna. She was in her late sixties, and she hated me at first glance. I was young and anxious. Her husband was depressed, and she sought therapy to help her cope with living with him. Upon entering the room, she went to the seat I was planning to use and kept asking to switch chairs the entire session––switching chairs six times in total––then returned to the original seat only to switch again. She accused me of being young, pretty, and unable to understand her sorrow. My anxiety took off, and I commented on her (and my) discomfort. My comment made her burst into anger. Truthfully, it was not easy for me to understand Hanna, perhaps because I was single then and maybe because we were both so scared. She asked to be transferred to a more experienced therapist, and her request was granted.
This example illustrates the complexity of the encounter between an experienced senior patient and a novice young therapist. We argue that the determining factors in avoiding such mishaps are the therapist’s ability and openness to mentalize the meanings of the exposed personal information. That is, the young therapist should conceptually address the potential pitfalls embedded in the situation and manage them through supervision. Each therapeutic dyad finds its way of putting words to these experiences. We propose conceptualizing “inferred exposure” as a concept overlapping with but distinct from self-disclosure for constructing a template to facilitate these interactions.
Self-Disclosure
Literature on self-disclosure refers to its verbal forms that involve a choice regarding the level of sharing (Hill & Knox, 2002). Weiner (1972) and Knox and Hill (2003) mapped out several forms of self-disclosure: here-and-now emotional reactions, attitudes (feeling responses), opinions (judgments about a situation or an event), and formulations (the product of one’s conscious thought, associations, fantasies, and personal experiences). The question of the role of the therapist’s self-disclosure in psychotherapeutic treatment has accompanied psychoanalysis from its inception. Freud (1915) ruled out self-disclosure, claiming that it would limit the patient’s ability to make use of therapy and thus distinguished therapy from educational settings. However, it seems that in practice, his treatments often incorporated it (Tzur Mahalel, 2020).
A major concern regarding therapist self-disclosure is the risk of shifting the focus away from the client. Audet (2011) argued that excessive or inappropriate self-disclosure can distract from the client’s issues, burden them with the therapist’s personal information, and disrupt the client’s ability to project their own meanings onto the therapist. Zur et al. (2009) warned that self-disclosure can blur the line between personal and professional roles, creating role confusion for the client.
Although controversial, a therapist’s self-disclosure has been increasingly considered to also have a positive effect in therapy. Appropriate self-disclosure can strengthen the therapeutic alliance by fostering trust and rapport between therapist and client (Knox & Hill, 2003; Goldfried et al., 2003), normalizing clients’ experiences, reducing feelings of isolation or shame (Henretty & Levitt, 2010), model effective behaviors and coping strategies (Goldfried et al., 2003).
Self-disclosure can be especially therapeutic with patients experiencing high mental stress at the beginning of the session, making clients feel more comfortable and encouraging open communication (Alfi-Yogev et al., 2021; Audet, 2011; Lee, 2014; Levitt et al., 2015).
The effectiveness of self-disclosure depends on the content and timing of the disclosure, the client’s personality and expectations, and the strength of the therapeutic alliance (Henretty & Levitt, 2010). This encompassing evidence for and against self-disclosure indicates that patients are greatly affected from what they know of their therapist and that the therapist’s presence as a person has meaningful implications, which should be considered and managed.
Billow (2000) noted how therapists can reveal information concerning their life outside of therapy, including illness, loss, sexual orientation, and childlessness. The therapist’s age overlays all of these themes: It is in the here and now, related to personal experience, and concerns the therapist’s life outside therapy. Thus, in all cited sources, the discourse centers on what could be a therapist’s constructive choice.
Another facet concerning self-disclosure is its timing. Weiner (1972) and others following him have made the oft-cited assertion that self-exposure should be held in abeyance until the therapeutic alliance is formed. Hoffman (1994) articulated the dialectic process in which therapist self-disclosure attains meaning as it is subtly compared against the backdrop of the therapist’s initial anonymity. However, the young therapist’s self-disclosure is enacted instantly, before the therapist has had a chance to cultivate a therapeutic alliance, as the therapist cannot hide their age. Thus, the therapist can never pose a blank screen but always has a real human presence.
Although self-disclosure remains the commonly used term, a large segment of the literature actually deals with information that was revealed, exposed, or inferred nonverbally rather than by sharing propositional knowledge.
Inferred Exposure
Aron (1996) drew our attention to the fact that (some) patients have considerable knowledge about their therapists and that it is present in the consulting room, whether discussed or avoided. As individuals react not to reality but to their construction of it, patients interpret information (that they know or assume) about their therapist (see also Crastnopol, 1997; Wachtel, 1980). The patient may acquire several aspects of knowledge about the therapist without the therapist’s deliberate self-disclosure, such as physical appearance and disabilities and wearing jewelry or tattoos. Some of these features may even be concealed by the therapist, and some information may be gleaned from social media. Constructing information about the therapist involves inferential thinking by the patient, an inclination even more prominent when the therapist is of a different social group. In the latter case, inferred exposure is inevitable, beyond the therapist’s discretion. We will discuss the ascribed meaning of age gaps and the patient’s recognition that the therapist has a different ‘lived experience’ These perceived gaps can impact how the patient perceives the therapist’s competence and the prospects of receiving adequate treatment.
Addressing the inexorability of therapist self-exposure, Weiner (1972) claimed the following:
Every action of a therapist involves some degree of self-exposure. The question is not, then, how to attain total exposure or avoid exposure altogether but how to help the therapist become aware of the ways in which he is exposed and how to maximize the therapeutic impact of both deliberate and inadvertent exposures (p. 42).
The following discussion will focus on cases where older patients become immediately aware of the therapist’s younger age at their initial meeting. This exposure evokes inferences about the therapist’s age and affects many aspects of therapeutic interaction that need to be understood.
A woman therapist’s pregnancy, an illustration of inferred exposure, can introduce a multifaceted impact on the therapeutic relationship; however, therapists usually have some discretion about when to reveal personal information and so can consider the patient’s emotional construct when revealing it. An age gap differs in that it is usually noted at the onset of therapy.
Pregnancy highlights age differences to the patient, eliciting comparisons and personal thoughts relating to the patient’s life stages and their own history. An oft-cited theme in this regard is the patient acknowledging that the therapist is in a sexually intimate relationship with a spouse and that the spouse (and the fetus, which is also in the room) are of foremost importance to the therapist in ways that the patient would never be (see Etchegoyen, 1993; Penn, 1986). The patient may address their perceptions of the therapist or actively avoid them.
These themes are played out even differently when the patient is older. In one such dyad, we supervised a case of an older patient who could not get pregnant in her youth and had adopted a daughter. Unsurprisingly, the therapist was apprehensive of upsetting the patient with her pregnancy. Through supervision, the young therapist learned to openly discuss and disclose her pregnancy with the patient, taking into consideration the complexity of the situation. This helped the patient move away from speculating about the therapist’s physical appearance and toward developing intimacy, which had been a lifelong challenge for her. Contrary to the therapist’s expectations, the patient expressed concern and empathy, returning to therapy after the therapist’s maternity leave. In the phone call prior to their reunion, the patient asked about the baby, remembering that it was a girl and asserting that she was also involved in the pregnancy. In this example of inescapable exposure, the patient became more deeply involved with the therapist, enhancing the patient’s capacity to form closer, more nurturing relations. We believe these outcomes were fostered by the therapist’s openness and willingness to engage in such a relationship with the patient.
The discussion of inferred information about the therapist is often accompanied by some self-disclosure, as illustrated in our example. Fonagy and Allison (2014) asserted that the ability to mentalize––the capacity to understand others’ and one’s own behavior in terms of mental states––is crucial for establishing epistemic trust in the therapeutic relationship. Mentalization includes assumptions about one’s and others’ self-states, requiring a nuanced perspective to distinguish between what is known and what is fantasized. One of the benefits of therapy is that it provides a space to practice mentalization, using the therapist as a subjective other. However, Aron (1996) held that the permission to think about the therapist as a person requires the therapist’s willingness to expose something of themselves.
As illustrated in the pregnancy example, we believe that the active avoidance of discussing age differences hinders the therapist and patient from finding their metaphorical seats and may also exacerbate anxiety. As the therapists-in-training are often young and are still in the process of forming their therapeutic identity, the supervisor’s role is crucial.
The question to be addressed in supervision, then, is not whether to disclose but how to deal with the exposure in a non-defensive, curious, and playful manner. The supervisor’s task would be to keep the young therapist’s anxiety in check, helping them distinguish between themselves and what is projected onto them, i.e., the patient’s fantasies of them. Fostering the playful realm would allow maneuvering between discussing age and focusing the therapeutic work on the client’s subjectivity, not the therapist’s.
Aida was a beautiful woman in her late sixties, a widow, a mother of three, and a cosmetician. Her husband died from a degenerative disease about two years prior to her arrival. He had been physically and psychologically abusive to her, and she tried to leave him many times. She came to treatment asking why she could not get over his death and begin her long-anticipated life. Aida was curious about herself and her female therapist. She asked about the therapist’s age and then spontaneously guessed it exactly to the month; the therapist was embarrassed. Aida did not like her age, the therapist being so much younger than her daughters (and neither did the therapist in that context), but it was a talkable matter. She thought they looked similar despite their age difference, and they made a strong alliance built on both being blond women determined to work hard on forging a life, though looking privileged on the outside. She wanted to take on the role of the experienced woman who could teach the therapist about her life. Despite this unusual positioning and uncomfortable feelings, the therapist followed her lead. Aida taught her a lot about being married to a man, what to do, and what to look out for. She gave examples from her life, thinking about how little choice she, Aida, had and how differently she wanted things to be. The therapist often wondered who they were discussing when talking about the therapist’s imagined-to-be life with a husband. Technically, it was the therapist’s life, but as Aida later said, she was consistently talking about herself. In a deeper sense, Aida was mourning the life she had and the loss of the life she should have led, with the therapist being an avatar of her.
This vignette illustrates the importance of making use of the inferences the client is making about the therapist’s age through awareness and discussion. It is not just that the client is drawing such inferences; it is also that the therapist is willing to talk about them. The fact that the therapist looks young, and the client is reacting to it is just part of the matter. There is the issue of how to self-disclose in the sense of sharing propositional knowledge about oneself, not simply exposing one’s young body to a client. Thus, the therapist can use self-disclosure following inferred exposure to facilitate an understanding of the patient and promote treatment.
Though young therapists may feel uneasy discussing themselves with a patient, it is sometimes necessary for them to do so Openness to sharing and receiving support from supervisors who can help them navigate this while keeping the focus on the patient’s inner world, that is how the patient understands the therapist and not the therapist as a person – is vital. This awareness can create opportunities for the patient to discuss difficult topics with their therapist.
However, even with the benefits of therapist self-disclosure, therapists and their supervisors should be aware of the potential complications that could ensue. We elaborate and explain these gaps and complications in the section below.
Gaps and Complications
In this section, we describe some common gaps and accompanying complications common in the treatment of older patients. We unpack the situation in treatment and its ascribed meaning and suggest how age differences can be met in the therapeutic setting via conceptualizations stemming from the discussion of inferred exposure.
Gap #1. Age Differences and the Therapist’s Lack of Personal Experience of Aging
One of the possible meanings of the age gap when the therapist is younger than the patient is the therapist’s lack of “lived experience” regarding issues concerning the patient’s life. Life expectancies, a sense of urgency due to late life, death anxiety, and depth of experience may be considered by the patient to be part of their identity. Since the therapist has not experienced most of them, the therapist may be perceived as not being fully competent to treat them. Whereas these patient concerns may be more pronounced when dealing with age-related treatment issues, they can also be detected subtly in many therapeutic dyads.
The potential of challenging competence can be viewed as both a shortcoming and an advantage. The therapist’s lack of lived experience can cause the patient to feel not understood. On the other hand, as each person’s experiences differ, psychotherapy highlights the need to examine the patient’s unique life experience. Such situations help the patient and therapist acknowledge that the patient has a unique life experience to share, an advantage in the joint voyage. We found that the scenario of recognizing the patient’s expertise regarding their external reality with the therapist assuming a curious stance allows the patient to explore possible meanings of their life experience. Furthermore, the therapist’s reactions may also serve to recognize and acknowledge the patient’s experiences, fostering the patient’s self- and other understanding, i.e., mentalization.
Gap #2. The Cohort Effect on Life Experiences
Older patients may not only be significantly older than the therapist but have lived out their lives in different eras. In certain populations, it is common for older adults to have experienced profound historical events and societal changes. These may include living through major global conflicts, Holocausts, the aftermath of wars, significant geopolitical shifts, the formation of new nations, and the challenges associated with immigrations. Such experiences can shape their worldviews, values, and psychological needs in ways that younger therapists must strive to understand and address sensitively.
Whereas these differences stem primarily from growing up in different conditions, engendering a cultural gap, they are also reflective of the person’s internalized mental construction of their place in the world. For instance, an older patient who lived with an abusive husband and blames herself for not leaving him may struggle to communicate her situation to the therapist. She might feel that the therapist would judge her choices due to a lack of understanding of the societal norms prevailing during the period when divorce was considered a failure and was perceived as poor parenting.
This relevant knowledge emphasizes the importance of therapists’ training regarding multiculturalism across life spans. Even a younger therapist can actively listen and reflect with the client, notwithstanding their age gap. For instance, a younger therapist could respond, “…So you must have felt so alone, even being afraid to tell others about what you were going through since they would judge you…”. Such a reflection could help validate the client’s feelings and build trust, notwithstanding the age gap.
Gap #3. The Fantasies and Opportunities Gap
When working with older patients, comparisons become unavoidable. Some comparisons place the young therapist in a superior position than the patient, health-wise, options-wise, living-wise, and other domains. These comparisons can lead to complex emotions and dynamics within the therapeutic relationship. The youthful therapist represents life’s horizons, experienced or forsaken.
Discussions about relationships, weddings, or starting a family may stir feelings of envy or jealousy toward the therapist. In such instances, the therapist faces the decision of whether to disclose their personal circumstances. For instance, the therapist may choose not to divulge their upcoming wedding when counseling a patient who is struggling to find a relationship.
While the primary focus in therapy centers on the patient, the therapist’s full presence and the potential for comparisons that arise need to be acknowledged. A recurring theme emerging when working with older patients is the sharp disparity between the patient’s sense of mourning for lost possibilities and the therapist’s potential for new beginnings, including embarking on a different career path, exploring the prospect of sexual relationships, and contemplating other life choices, ambitions, and opportunities that still appear attainable for the therapist. When the comparison becomes hurtful for both parties, skirting the issues constrains the dyad’s discussion of the relationship.
Complexity #1. Therapists’ Awareness and Processing of Ageism
Therapy with older adults often evokes personal experiences and emotional responses in the therapist. Managing these reactions, collectively referred to as “total countertransference,” has been closely linked to improved therapy outcomes (Gelso & Hayes, 2007; Hayes et al., 2011). Implicit biases, such as ageism, often emerge in such countertransference and can significantly influence therapists during therapy. Lederman and Shefler (2022, 2023) stressed the importance of therapists acknowledging their ageist attitudes and biases. Moreover, they recommended that therapists continue identifying and managing triggers and manifestations of ageism within the therapeutic process. Plotkin (2000) also claimed that countertransference difficulties tend to cluster around therapists’ unresolved conflicts related to their own and their parents’ or grandparents’ aging, death, and health issues, which are likely to be revived when treating older patients. In his discussion of the prospects of total countertransference with older patients, Plotkin (2000) emphasized those relating to illness and loss.
Along with the older patient’s wistfulness related to the age gap, ageism can evoke negative emotions regarding the therapist, both in transference and in the total countertransference. For example, a patient who was compelled to retire due to his age against his will felt that the therapist did not understand the intensity of the insult, with the latter primarily addressing the financial consequences. Discussing his forced retirement, the patient felt that his expertise was not recognized and was ignored disrespectfully by the young professional who fired him. In the transference, the disrespectful and offensive experience was projected onto the therapist in the role of the young professional who forced the patient to retire. Exploring the therapist’s attitudes in supervision toward the older population, the therapist could boldly acknowledge his beliefs that older people should not work. Following that, the therapist and supervisor noted that the therapist avoided inquiring about the patient’s former job, perhaps unconsciously perceiving it as no longer relevant. This, in turn, aroused the therapist’s curiosity, acknowledging to the patient that he did not know much about the patient’s former work and wanted to know more. We believe the shift occurred both because of the therapist’s willingness to acknowledge his ageism and because of his openness to empower the patient to teach him about the patient’s life.
As seen in this example, ageism might constrain the therapist’s ability to spot different transference positions, especially those related to generations and a life experience gap.
Agism may also have the limiting effect of seeing the person as defined by their age. This can also lead to assuming that the patient is the older one in the transference (as in the example below) or not being alert to erotic transference.
The understanding of sexuality is an issue often clouded by ageism. Some younger therapists might assume that older clients are unconcerned with sexual matters, explaining why the patient appears to avoid the subject. Changes in perceived sexuality also relate to observable changes in appearance and attractiveness that contribute to stereotypes of decreased sexuality at older ages. These stereotypes interact with actual changes in sexuality in older age that the young therapist may not perceive as sexuality. While research claims sexuality to be important throughout life, even authors assuming a decrease in the sexual drive in older people (often mediated by health issues) find that sexuality still comprises an important life domain during aging. Therefore, avoiding sexuality in therapy restricts the potential benefits of being in touch with one’s life forces (for sexuality in older age, see Gott & Hinchliff, 2003; Taylor & Gosney, 2011).
A young male therapist was treating an older lady. It took considerable work on the part of his supervisors and himself to perceive the erotic transference, and, as a result, the patient flourished. When perceived, additional processing was needed to find a constructive therapeutic attitude.
Ageism can be a delicate issue for both therapist and patient in the therapeutic situation, encompassing both transference and countertransference. We believe that the role of ageism should be continuously explored in supervision, as will be expanded in the recommendations section below.
Complexity #2. Reversed Transference and Countertransference
Patient G, a grandmother, initially expressed doubt to her young therapist about the therapist’s capacity to truly grasp her inner world. From the first meeting, she expressed a great desire and need for a mature figure to lean on. The age gap made it more difficult for her to see the young therapist as someone who could help her.
Countertransference, once viewed as the therapist’s unconscious emotional reaction to the patient, has evolved into a concept that can both aid and challenge therapy. Initially seen as an interference with objectivity, countertransference is now widely acknowledged to be a valuable tool for understanding the patient’s inner world, provided it is managed effectively (Gabbard, 2020; Gelso & Hayes, 2007; Hayes et al., 2011). Clinicians now recognize that countertransference offers important insights, as the therapist’s emotional responses can reveal key dynamics in the therapeutic relationship and as a way to enhance empathy. However, countertransference can present risks if not carefully monitored, as it involves the therapist’s subjectivity, which may cloud their judgment. The key is in balancing awareness: using countertransference to enhance understanding while maintaining reflective control to avoid losing objectivity. In this way, countertransference becomes a powerful tool when employed thoughtfully and with supervision (Prasko et al., 2022).
Countertransference in a young therapist-older patient dyad presents specific challenges. Therapists are often perceived as parental figures; however, when the therapist is substantially younger than the patient, a “reverse transference” or “reverse countertransference” may emerge. That is, the therapist can be seen as the older patient’s son, daughter (Yesavage & Karasu, 1982), or even grandchild. This facet of transference can be conflictual for therapist and patient alike. The patient might feel that their “inner child” and their longing to be cradled is inappropriate and inapplicable in such a situation. The therapist might feel threatened, as it is an unfamiliar and possibly awkward position for her to take a parental role toward an older person. As most young people’s encounters with older adults are with family members, grandparents, or professional experts, expressions of reverse transference and countertransference may arise, making the therapeutic encounter more awkward and challenging.
Complexities #3. Ambivalence, Inferred Exposure, and Self-Disclosure
Ambivalence toward therapy is a common phenomenon, often deriving from the patient’s desire to avoid experiencing hurtful emotions. However, for older patients, ambivalence can often take different forms: Therapy sometimes has a financial cost, and this may induce ambivalence as many have limited resources. Some older persons deliberate carefully over each expense. For others, family members who are potential inheritors examine their parents’ expenses, often compromising their parents’ privacy, even questioning whether the therapy is essential. Others may fear being overtaken and try to control the situation. Among some older people, diminished standing among family and friends, difficulties in understanding the changing world, and the feeling of being taken advantage of could trigger paranoid reactions (Abraham et al., 1980). Older patients may be reluctant to “talk badly” about relatives, especially deceased relatives, as a cultural practice. However, when the patient understands that talking about close relations can play a central role in therapy, ambivalence ensues. Intrapersonal and interpersonal difficulties and suffering such as these might promote a position of self-reliance and a diminished willingness to trust others and expose hardships.
An additional source of ambivalence derives from the tension between the older patient’s perceived seniority and the increased dependency that accompanies aging. Growing dependence can produce an existential conflict, intensifying ambivalence and complicating therapy.
Young practitioners are often anxious and may interpret their patient’s ambivalence as a reflection of their incompetence or a signal that therapy is unnecessary or unsuitable for the patient. As their newly established sense of being a therapist is still fragile, they may have difficulty articulating and processing these complexities. They may perceive ambivalence as rejection and, combined with their own ambivalence, shy away from exposing themselves. The young therapist might also try to combat their sense of unworthiness by offering complex academic or otherwise inappropriate interpretations to demonstrate their professionalism, which typically only makes the patient more anxious or feel misunderstood. Some young therapists respond by rigidly adhering to rules, avoiding personal disclosure, fearing it might drive the patient away.
Young therapists may be disinclined to self-disclose due to other aspects of ambivalence. Thus, some therapists will eschew self-disclosure when sensing the patient’s ambivalence because they feel that the patient will be more reluctant to stay if they perceive the therapist to be inexperienced. The therapist may then believe that sharing even minor details would lead to the patient revealing other information that they may not be comfortable sharing.
The therapist’s youth can also be an asset to the therapeutic process, as patients may find their young therapist less intimidating than older therapists. Additionally, the therapist’s status as a student can foster a constructive and reciprocal therapeutic alliance. Inferred exposures, when approached with awareness and purpose, can further strengthen the therapeutic relationship, especially when followed by intentional self-disclosure or appropriate responses.
Conclusion and Implications for Clinicians and Supervisors
As supervisors, we identified four supervisory factors that help therapists use their vulnerabilities to the patient’s advantage: (1) Help the young therapist consider the patient’s vulnerabilities at an emotional level by using countertransference as a real-time source of information. (2) Help the young therapist find playful ways to use therapist-patient gaps non-defensively. (3) Help the therapist trust and use the patient’s experience of what had been effective in the past. (4) Help the young therapist maintain a focus on the patient even in the face of a possible slackening of the focus that can result from inferred exposure.
The following two sections elaborate on these recommendations for clinicians and supervisors:
Recommendation for clinicians:
1.
Using: We believe that using countertransference can help the therapist understand what information and how much information the patient needs, thus serving as a guide for the patient’s needs. Understanding countertransference can help the therapist not only feel empathic about what the patient would like but also understand the patient’s needs in the relationship. An example from our supervision experience is a young therapist who felt sorrowful when her patient, a woman in her seventies, became aware of having sexual feelings. The young therapist felt that the slimness of the patient’s prospects of experiencing a mutual sexual relationship and her losing the opportunity for this basic life experience was heartbreaking. With the aid of supervision, the therapist used her countertransference to understand the severity of the woman’s lack of vitality and vivid experience. From that stance, the therapist could find gentle and subtle ways of connecting with the patient’s mourning of what would likely never be experienced. When working with older patients, countertransference may sometimes be very powerful or seem even unrelated to the themes that the patient brings. We thus stress that supervision should be used to seek these feelings in countertransference and encourage the young therapist to share and process them with their supervisor.
2.
Finding playful ways to address the gaps: Playfulness and humor can help deal with difficult subjects gently and suggestively. Levity can also help neutralize aggression. For example, an older, anxious woman told a young therapist that she was so young that she still had “milk on her lips.” The therapist responded with a mock wiping of the lips, asking, ‘Is this better?’ This humoristic response shows that the therapist was not skirting the concern of the age gap and dealt with it openly and with acceptance. They then brought up the question of whether they could overcome it.
Age gaps may raise anxiety and ambivalence from the therapist’s position; however, the role of the supervision should be to normalize the anxiety, making room for naïve and even humoristic interactions discussing the gaps and their meaning within therapy.
3.
Trust the patient and use their experience by applying a two-expert partnership model. A relevant working model has been suggested by Laidlaw et al. (2016), calling for adjusting cognitive behavioral therapy for use with older adults. This strengths-based approach model proposes recognizing the presence of two experts in the therapy room. The first expert is the therapist, trained to provide psychotherapy for the patient. The second expert is the patient, with their expertise derived from the wisdom they have achieved throughout their life. Wisdom, according to Baltes and Staudinger (2000), is not a consequence of age but an outcome of multiple experiences of coping with difficulties and living in ambiguity. Thus, wisdom is rich “knowledge about the fundamental pragmatics of life” (Baltes & Staudinger, 2000, p. 125). Following this understanding, the young therapist should not eschew acknowledging differences, among them age disparities, but embrace them, as they can facilitate a deeper knowledge and experiential platform for exploring and revealing the patient’s unique self. Through investigating disparities and similarities, the dyad can hold the tension between the universality of the patient’s emotions and their uniqueness. Accordingly, we suggest that young therapists invite old patients to share the responsibility for promoting treatment by providing examples and exploring sources of feelings and thoughts based on their life experiences.
We believe that the two-expert approach makes use of the patients’ experience but also carries specific benefits in the young therapist-older patient context. In this approach, the therapist’s lack of life experience is transformed from liability to strength, and the patient’s wisdom is acknowledged and valued.
4.
Maintaining the therapeutic setting and overcoming challenges raised by inferred-exposure using self-disclosure.
4a. Ambivalence in therapy can be acknowledged and managed by exploring the transference and actively working on the real relations. Age differences challenge compliance to therapy, often marking the young therapist as unsuitable (in the patients’ fantasy) for the role of an authority (e.g., parent, expert). However, this ambivalence should not be sidestepped or eliminated from psychotherapy. Young therapists should allow their older patient to express their ambivalence and relate to it with openness and curiosity: We do not know what the dyadic interaction will bring, and we are interested in all its forms. For Patient G, who expressed a desire to be cradled and clearly doubted the young therapist’s capacity to be her therapist, working with the expressed ambivalence resulted in considerable benefit. The young therapist, keeping this ambivalence in mind, offered a more balanced position, addressing this concern when it arose while avoiding emphasizing it when it didn’t.
As their therapeutic journey progressed, gradually fostering a more open and authentic connection, an intriguing transference dynamic emerged. This transference was marked by a profound outpouring of compassionate care and support, akin to what the patient identified as “grandmother transference.” That is, the young therapist was perceived as the patient’s grandmother in the room. This emotional connection vividly evoked memories of the nurturing relationship the patient shared with her grandmother, a stark contrast to the strict and distant relationship she had with her mother.
4b. Ensure that the therapeutic setting is made explicit to the patient to counteract the loosening of boundaries that may follow inferredexposure. The combination of the therapist representing a child in the patient’s view, the patient’s great need to be heard, and the lessening importance of time frames, rules, and role definitions can be particularly challenging in the therapeutic setting.
We suggest conducting an explicit and implicit discussion of the therapeutic setting. Explicitly, the therapist should review the schedule, the seating arrangement, payment, and timetables. Implicitly, the therapist should adopt a routine that may include opening the sessions with a direct question to the patient (e.g., “What would you like to discuss today?”) and signal the conclusion with recognizable statement (e.g., “See you next week”). All these elements define the framework where the therapist determines the treatment’s structure, but the patient may bring any content they desire. Reinforcing the setting in the counseling room allows the therapist’s self-disclosure to remain in the appropriate context of focusing on the patient. The young therapist-old patient dyad bears unique complexities, and we highlight the unique situation and the exceptional benefit of self-disclosure in such a dyad.
Recommendations for Supervisors
Supervisors working with early career and young therapists as they treat older adults should be aware of the unique challenges inherent in this situation. The therapist’s natural anxiety, exacerbated by the age gap and by the patient’s referencing it explicitly and implicitly, should be acknowledged. Supervisors need to encourage young therapists to attend to the complexities, ambivalence, and sometimes strange countertransference they feel and bring them to supervision, even at the cost of shame or embarrassment.
Anxiety can be managed and reduced by maintaining the setting and understanding the value of countertransference for promoting treatment. Psychoeducation needs to be a part of supervision, referring to professional literature to learn about the aging process, sexuality in older individuals, relevant life experiences, age gaps, and other complexities. This psychoeducation, recommended here for the young therapist, also appears to be needed nowadays for the supervisors.
We conclude with a patient’s remark to one of our young therapists. At the end of a session, the patient said to the therapist: “That was really good; I am surprised. You are really young, and I am old; how could you understand me”? The young therapist then replied: “You taught me well. Thank you.” In our minds, this exchange sums up in plain language most of the issues discussed in this paper: the recognition of the age gap and the older patients’ perceived ineptitude of their young therapist; the willingness to discuss the age differences as a potential for strengthening the therapeutic alliance; the willingness of both parties not to know and be surprised, which we claim to be essential in therapy; and the positioning of the patient-therapist relationship in a non-hierarchical fashion with the therapist acknowledging the patient’s expertise.
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Conflict of interest
On behalf of all authors, the corresponding author states that there is no conflict of interest.
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