Ageism Among Psychotherapists

Two colleagues and I recently published an article about what we’re doing to endure ageism at work (Fox, Karson, and Erickson Cornish, 2022). A few points we made about psychotherapy may be especially of interest to Psychology Today readers.

Consultation and "Real Therapy"

The background for these points involves the recognition that there are two kinds of therapy, which I’ve been calling consultation and “real therapy.” In consultation, you meet with a therapist who gives you ideas about your life, your family, and your problems. Good consultants excel at pattern recognition and give you ideas that improve your life. Bad consultants are formulaic, sympathetic, and validating, and they give you ideas that usually make you feel good about your therapist and disappointed in your friends, romantic partners, and family.

Real therapy is done when your personality patterns are getting in your way. By “personality patterns,” I mean idiosyncratic responding, confirmation biases, transferences, peculiar reinforcement history, and typically unproductive ways you have of reacting to various kinds of situations. Real therapy evokes these problematic patterns in the therapy where they can be worked on in real-time. The distinction is easier to see in couple’s therapy, where a consultant might teach or give advice and a real therapist has the couple engage in their problematic interactions right there in the sessions. Of course, there’s a limit to this; for example, the vast majority of sex therapists work on how the couple communicates about sex and don’t ask them to have sex in the office.

Older Versus Younger Clinicians

In the article, we note that, while, of course, some older people have just stopped learning, we believe the best older clinicians are better than the best younger clinicians. The best older clinicians understand real therapy, and they know that 100 years of research have shown that what works is a strong alliance around setting mutual goals, agreeing on how to achieve them, and fostering the relational bonds that develop when people collaborate. What doesn’t matter much at all is the brand name of the therapy or its techniques. The ageist part is that older clinicians are dismissed as not keeping up with new developments in the field, rather than honored for sticking with the tried and true.

Unlike many forms of discrimination, such as racism, there really are differences between the elderly and the younger, mainly infirmity and expertise. In line with the Dunning-Kruger effect, the elderly often underestimate their own expertise because, like younger therapists, they are swayed in their assessment of the elderly by signs of infirmity that have little to do with expertise.

Indeed, Shedler (2015) has pointed out that, given the demands of a research-oriented career, top researchers are unlikely to have much clinical experience. Labels like “evidence-based treatment” do not mean that the therapy has been shown to be effective; they mean that the treatment has been studied, whether it is effective or not (Norcross and Wampold, 2019). Throwing around three- and four-letter acronyms for new types of therapy in clinical discourse can feel like an ageist microaggression, signaling that experience doesn’t matter.

Another point we make is that straight, white men are disproportionately represented in the population of older clinical faculty. This is partly because the feminization of the field has made it less appealing to men. (Freud said he was a conquistador; now it’s a helping profession.) It’s also because schools are very reluctant to hire young, straight, white men, partly because of social forces, partly as an effort to balance past biases, and partly because of the idea that the faculty should look like the students. The result is that honoring the wisdom and expertise of older faculty can look like deference to straight, white men.

The risk to the profession is hard not to liken to global warming: It’s already happened, and it may prove fatal. Therapists reject the wisdom of the profession because it is largely embodied by people from whom it is not fashionable to learn. Therapists want to jump the gun and claim expertise, leaning on some new three- or four-letter acronym. Your therapist may have gone through an entire training program without once hearing the difference between “building rapport” and building a working alliance, between helping people feel better and helping them get better, or between talking about the problem and doing something about it in the therapist’s office.

If younger therapists insist that they are already expert clinicians, it may keep them from becoming one. Ironically, the mindset of having much to learn is precisely the mindset you need your therapist to have with respect to your uniqueness. Because of this, even beginning therapists can be quite good at it, as long as they are curious and trying to understand, rather than defensively claiming expertise they don’t have. For the same reason, someone who seems to be a lot like you may make comforting assumptions about your similarities rather than engage you with the curiosity that makes therapists effective.