In Praise of the Older Therapist

Probing the Heart of Clinical Wisdom

In Praise of the Older Therapist

This article first appeared in the January/February 2005 issue.

Even in the field of therapy–where emotional maturity and wisdom supposedly count for something–the enthusiasm, bravado, and pure physical energy of youth sometimes trump the sobriety, scepticism, caution, and, well, fatigue afflicting those of us who’ll never see 40–or 50, or 60, or even 70–again. Sometimes, brash young Turks instinctively do brilliant therapy that their older teachers and mentors couldn’t or wouldn’t dare to do, even after four cups of coffee and two shots of ginseng extract. n That said, there’s nothing like experience–the slow, steady accretion of millions of new neural connections–for teaching us how to do something well, and that can only come with time and age. When I first entered a master’s program in marriage and family therapy, it seemed hardly possible that I’d ever master the sheer amount of knowledge I needed to be a competent therapist, let alone acquire the inner confidence and authority to use it well. Early in that year, I asked one of my professors, who seemed to carry his knowledge and wisdom with effortless ease, what the learning curve was like in becoming a therapist. What I really wanted to know, but didn’t ask outright, was when, if ever, I could expect to embody the kind of expertise and calm assurance he demonstrated.

He looked at me kindly and said, “In your first 25 hours of face-to face, you develop your basic skills. By 100 hours, you’ve begun to develop templates about certain types of cases and learned to appreciate the theories you’ve been taught. Next is 1,000 hours, when you’ve begun to develop consistency in the quality of your therapy. At 10,000 hours, you’re a seasoned therapist in the eyes of other seasoned therapists.”

The point he was making is undeniable–that time and practice, practice, practice count as much or more than formal instruction in becoming an expert at therapy or just about anything else–medicine, law, carpentry, fire-fighting, or violin-playing. The longer you’ve been at it, the more deeply knowledgeable and skilled at the work you’re likely to be.

He didn’t suggest, however, that all this seasoning–years of marinating in the spicy, bubbling broth of daily practice–would make me also wise, only more professionally competent in the eyes of my peers. Clearly, simply planting one’s butt in a therapy chair for 30-plus hours a week over a span of years doesn’t, by itself, make a great or even good therapist–ask anybody who’s ever suffered from burnout.

The real advantage older therapists have–and it’s an advantage, young Turks notwithstanding–is the brute fact that they’ve simply lived longer, engaged in more relationships, weathered more emotional ups and downs, discovered more about who they are and what they want, learned more about the world and the nature of reality. Of course, some people prove immune to this sort of life education and seem to take only ignorance and willful blindness from the rich stuff of experience. But like so many truisms bordering on the trite, age is often accompanied by maturity and even a little wisdom, whether we like it or not. One of my favorite statements used by pro football coaches every year when the NFL draft comes around is “We’re going to pick the best athlete available. You can teach technique, but you can’t teach speed.” When it comes to therapists, I’d paraphrase that: “You can teach technique, but you can’t teach old.”

So, first in line of Lowe’s Laws for Codger Therapists is:

Our Age and Life Experiences Allow Us to Understand a Wider Range of Clients.

All the major life passages that older therapists have experienced–marriage, perhaps divorce, rearing children, juggling two jobs or working rotating shifts, coping with economic stress, illness, aging parents, death–means that they’re likely to know with firsthand knowledge what their clients are feeling. The older you get, the less shocked or thrown for a loop you’re likely to be by a client’s dilemma, having handled quite a few of your own dilemmas. In the very best sense, you’ve already been there, done that.

Given that you have, or have worked to attain, a fairly well-balanced psyche of your own, your familiarity with life’s conundrums breeds, not contempt, but a certain confident unflappability. If you’ve taken charge of your own life, your own marriage, your own teenagers, chances are you’ll be better able to exert compassionate control in the therapy room with angry spouses, defiant adolescents, and families in which everybody talks furiously over everybody else and all at once. You’re no longer afraid, as young therapists sometimes are, to give orders–tell the overbearing husband to be quiet or the teenager to quit cursing her mother–and make it happen. And, with clients who are going through particularly tough times–a death or other severe loss–simply the fact that you’ve no doubt suffered your own losses enables you to convey the understanding and comfort of one who really does know what they’re going through.

Of course, as a member of the geezer set, you’ll also be in a much better position to “join” with your older and middle-aged clients around ancient cultural lore that would completely mystify young therapists. For example, I’ve gotten closer to these clients by sharing memories of such arcana as the U.S. hockey team’s victory over the Soviet team in the 1980 Olympics, the pressure on parents to buy Cabbage Patch dolls in 1983, the early James Bond movies starring Sean Connery, pre-cable television, rotary telephones, and how mail got delivered before there were ZIP codes.

There are other advantages that come with age. For example, we’ve learned, usually through hard experience, that we can’t make everything perfect, either in the world or for our clients. Sometimes, we’re lucky if we can just get them to be a little bit better. This painfully acquired lesson inspires Lowe’s Second Law:

We Don’t Confuse What Clients Want Us to Do With What We Can Do.

Let me illustrate. Elizabeth, 45, a part-time waitress at a truck-stop restaurant, and Frank, 50, a sheet-metal worker, came in to therapy to get help for their 19-year-old daughter, Francine, who’d recently dropped out of college and, according to Frank, “gone completely out of control and moved in with a 25-year-old, Negro, drug dealer.”

Elizabeth objected to this description of their daughter, saying that Frank had no proof that the Negro in question was a drug dealer, and furthermore that the young man had a steady job at Auto Zone, a local auto parts store. “I seriously doubt that a drug dealer would keep a 40-hour-a-week job. Don’t you agree?” she asked me. Before I could respond, Frank said, “Listen, Elizabeth. You see the way the boy dresses? The baggy pants, the gold chains? The neighborhood he’s from is full of drugs and gang-bangers. You’re living in a fantasy world.” Then, turning to me, he said, “You know what I’m talking about, right? My wife’s always trying to be a good Christian, thinking the best of everybody. I try to be a good Christian, too, but I’m also realistic. You know what I mean?”

Had I been half my age when this couple came into my office, I would have suffered extremely high anxiety, if not a stroke of therapeutic paralysis. One cause of my anxiety would have been that the daughter had refused to come to the session, and yet her parents expected me to “fix her” in her absence. A second source of discomfort would have been that the parents defined their disagreement, at least superficially, in religious terms. A third source of anxiety would have been Frank’s obvious disrespect for his wife. But the source of my greatest anxiety would have been that, as an African American, male therapist, I was dealing with a white, male, blue-collar worker who described his daughter’s 25-year-old partner as a “boy” and a “Negro drug dealer,” and expected me to agree with him.

But at age 57, I had few such anxieties. I’ve learned–to adopt another sports term–to “stay within myself,” meaning that you don’t try to do more than you can do. Unlike what I would have probably done at age 26, I didn’t address the issues of religion, sexism, or racism, because I felt that those were red herrings with this husband and wife–baits that they hung out on a sharp treble hook in hopes (even if unconsciously) that I’d swallow them instead of insisting that they figure out a way to get their daughter into therapy.

I knew that somewhere down the line we might have to deal with religious, gender, and racial issues. But when you’re an older therapist, one of the lessons you’ve learned is to break down therapy into digestible bites–morsels that you and your clients can chew on for a while without either of you getting psychic indigestion. You can more easily set your own personal and political views aside, at least temporarily, and, as you were taught many years before, focus on process rather than content.

I asked Frank only one question in regard to their daughter’s boyfriend. “Frank, what’s the young man’s name?”

“Who?” asked Frank, somewhat puzzled.

“Your daughter’s boyfriend.”

“Marcus,” replied Frank.

“Marcus,” I repeated. Frank and Elizabeth nodded.

Having thus moved this young man from the general categories of “Negro” and “drug dealer” into the realm of a human being with a name, I was ready to put into effect the next Lowe’s Law:

Older Therapists Aren’t Afraid to Perturb Clients with Demands or Limitations That, in the Long Run, Will Help Us Do Better Therapy.

I told Frank and Elizabeth that I couldn’t complete an assessment of their daughter unless their daughter came into therapy. “If you can’t get her to come in,” I said, “there’s no point in continuing. I can’t help her if I can’t talk to her. Can you two somehow convince her to come for your next session?”

When I told Frank and Elizabeth there was no point in continuing therapy if they couldn’t bring their daughter in, I was risking the possibility that they wouldn’t come back. This would have been almost impossible for me to do as a young therapist just starting out. I would have been terribly afraid to end the first session with a nonnegotiable demand, to immediately set such a limit for a new client couple, because if they didn’t show up for the next appointed session, I would have felt that I’d made a terrible mistake and was a miserable excuse for a therapist. But now, with the confidence of maturity and years of practice, I knew my primary obligation as a therapist was to do the best work I could, which meant putting the clients’ long-term interests ahead of my momentary discomfort. I also believed, with the intuition that a therapist gains over the long run, that Frank and Elizabeth knew they needed help and would probably return. And I was right.

At our next session, Frank and Elizabeth brought in their daughter. It wasn’t lost on me that Francine’s name was a feminine version of her father’s name, and I could have hypothesized quite a number of things from this: he saw her as a female extension of himself; there was a battle between Frank and Elizabeth over whom Francine “belonged” to more; Francine felt smothered by her father, and was rebelling against him by choosing a lover whom her father would find objectionable; Francine was covertly expressing some of her mother’s rage at her father by dating a “Negro”; etc.

But at my age, having parented a son and a daughter through their tumultuous teen years into adulthood, I also realized that one way or another, Francine had to grow up. She’d have to make her own choices and, regardless of the reasons she made those choices, learn to live with the consequences, as would her parents. This orientation provoked the first question I asked Francine during this second session.

“Francine,” I said, “I’ve heard a little bit about what your parents want for you. What do you want for yourself?”

“She doesn’t know what she wants,” Frank interrupted.

“Let her answer the question, Frank,” Elizabeth interjected.

“She’s not old enough to know what she wants,” Frank shot back. Meanwhile, Francine folded her arms, sighed, and stared somewhat disgustedly across the room at the open window behind my back. At this point, as a young therapist, I would have felt stuck in stalemate–Francine sullen, Frank belligerent, Elizabeth exasperated, and me wondering what to do next. In an effort to get them off dead center, I would have rifled through the standard textbook options still fresh in my head from graduate school, looking for an escape route.

I might have tried to block Frank and Elizabeth’s bickering and repeat my question to Francine, putting her at center stage. From a narrative point of view, I’d be restricting her parents’ dominant stories and empowering her subjugated story. From the Milan System’s point of view, I’d be demonstrating my neutrality in preparation for a round of circular questioning. From a structural point of view, it would have been a potentially powerful unbalancing move. It also might begin to bring the family’s racial issues into bas relief, if not high resolution.

Or I might have directed the question I’d asked Francine to her mother. Giving Elizabeth center stage would also have been an unbalancing move, possibly opening the door to her transgenerational issues, while at the same time being a proactive way to counteract the apparently unequal division of power in her relationship with Frank.

Finally, I might have asked Frank what he now wanted from his life. But when I was younger, this would have seemed too risky–giving Frank even more power than he already had, and making Elizabeth and Francine feel I’d decided to take his side of things. I’d have felt shaky enough about my ability to handle Frank already, without giving him an opening to take over the entire therapy.

In any event, if my small list of approaches didn’t work, I’d have felt sunk–my repertoire was still pretty limited in those days. This leads us to another of Lowe’s Laws:

Older Therapists Can Sift Through More Options in 30 Seconds than Younger Therapists Can in 30 Minutes.

No sooner had these three options flashed through my mind than they set off a whole new chain of possibilities that I never would have thought of 25 years ago. Now, it suddenly occurred to me that, rather than asking each member of this family what they wanted from life, it might be more interesting to ask the parents what they’d have wanted from their lives when they were 19 (Francine’s age), and to ask Francine what she’d hope for her children if she were as old as her parents.

In addition, I quickly decided to do the exact opposite of what I’d have done as a young guy, and address the question first to Frank. “Frank,” I said, “When you were Francine’s age, what would you have wanted from your life if everything you wanted was miraculously guaranteed to turn out to your complete satisfaction?”

I didn’t ask this particular question because it made obvious theoretical sense, or because I was following some clinical guideline, or because I had some structural, strategic, or narrative goal in mind. I asked this question mainly because it fascinated me and I was personally very curious to know how he’d answer. As young therapists, we play pretty strictly by the rules, following the clinical narratives we were taught to follow, afraid that if we don’t, we’ll be cornered by something unexpected for which we don’t have a response. As older therapists, however, many of us have the confidence that we’ll be ready for just about anything that happens. We may be surprised by what our clients do or say, but we’ll rarely be shocked, and not very much that happens in therapy will leave us gaping and, literally, at a loss for words. We can think on our feet, shift direction in an instant, and track any trail that opens up suddenly, even if it’s off the beaten path.

Frank briefly contemplated my question, and then replied with a chuckle, “I think all I wanted out of life was a really great tattoo, and to make enough money to buy a brand new Harley, and to marry Elizabeth.”

“And Elizabeth,” I asked, “how much money did you expect Frank to earn before you’d consider marrying him?” She laughed. ” I didn’t care how much money he made. But my parents did, especially my father.”

As Elizabeth further explained, her father, a second-generation Pole who worked in one of the local steel mills, didn’t approve of her dating Frank for several reasons: “because Frank didn’t have a job at the time, because he had an earring–my father said it made him look like a ‘queer’–and because he was Italian. My father and mother wanted me to marry a good Polish boy, and my father used to say that marrying an Italian was almost as bad as . . .,” here Elizabeth paused and looked at me somewhat sheepishly. I said nothing, but nodded to her to finish the sentence. “Well, as bad as marrying a black. I’m just saying that that’s the way hefelt, you understand,” she hurried on. “I mean, he was very old fashioned. I, I mean Frank and I, don’t, haven’t raised our kids to be like that. That’s not the Christian way. Jesus said we should love everyone. Isn’t that right, Francine?”

Her daughter sighed impatiently, “Yes, Mom, that’s what you’ve always said. But I don’t think you and Dad practice what you preach.”

“Francine, how can you . . . ,” Elizabeth began, but Frank cut her off.

“This has nothing to do with Marcus’s race!” he said, “It has to do with you making some dumb choices that you might regret!”

“What kind of choices? What, exactly, am I going to regret?” Francine shot back.

“Moral consequences! Legal consequences! Consequences for your personal safety!” Frank blustered on.

I interrupted them. “Whoa! Hold on here a minute, Frank,” I said. “I can see you really love your daughter, although she may not see that. And, Francine, I see that you’ve inherited your parents’ independent and strong personalities. But I just need you guys to be quiet a minute to let me think about how I can help you. It’s somewhat of a puzzle to me right now. Do you mind if I take a moment to think?” And here, I took full advantage of another of Lowe’s Laws for Golden-Oldie Therapists:

We Recognize the Power of Silence and Feel Comfortable With It.

The family fell silent, and I sat there for at least a full minute, with my elbow on my knee and my fist under my chin, like Rodin’s sculpture The Thinker. To a young therapist, a prolonged period of silence in a session can be excruciating because it implies that he or she doesn’t know what to do or say. Older therapists, by contrast, have learned to live with silence and enjoy it. They’ve known the welcome silence that comes when their small children are asleep; the profound silence in which they’ve offered prayers for a sick parent or close friend; the joyful silence that fills the therapy room when clients leave at the end of a particularly good session. More important, they’ve acquired the inner freedom to actually be able to sit quietly and think, even with an audience of clients somberly looking on. They’ve discovered that silence not only helps them put their thoughts in order, it functions as a calming interlude for their clients.

So I sat in silence, thinking.

Indeed, several things had happened that required some thought. For one, my question to Frank about what he wanted when he was Francine’s age had very quickly brought several potentially explosive issues–racial, religious, and transgenerational–into the session. Furthermore, the high level of reactivity from father, mother, and daughter could easily lead to repeated rounds of accusations, counteraccusations, and negative feedback loops. In short, nothing would change unless I did something to change these dynamics.

As I pondered the situation, it occurred to me that if I could strengthen my bond with Frank, he might feel safe enough to be less reactive toward his daughter and wife–perhaps even allow himself to become more vulnerable to them. If this shift occurred in Frank, it would help melt the family’s frozen communications patterns. But how was I to get closer to Frank without alienating his wife and daughter? I thought back to what Frank said he’d wanted when he was 19 and how neither of his parents had supported him as the person he was then and wanted to be. Now Frank was just repeating the same pattern with his daughter. He had no idea how to support her as the person she was and wanted to be at 19. Meanwhile, the family was sitting silently, waiting for me to tell them how I was going to help them. What I decided to try was, I think, unexpected for all of them. But then, that’s another advantage of being an older therapist:

There’s More Than One Way to Skin a Cat: We Aren’t Afraid to Act on Our Hunches (as Informed by Accumulated Wisdom).

We sometimes act on hunches based not upon on our emotional identification with an individual case, but rather upon our previous experiences with other, similar, clients. I call that accumulated wisdom. When we’re young, we tend to stick to doing what we’ve been taught and tamp down our intuitive hunches for fear they’ll be proven to be disastrously wrong. But if we pay enough attention, age can bring the almost unconscious ability to recognize and act on subtle emotional cues, which might have escaped us entirely earlier in our careers.

“Elizabeth, Francine,” I said, “I’d like to talk with Frank alone for a few minutes if you don’t mind.” The two women looked at each other and then at Frank, who shifted uneasily in his seat and frowned at me.

“What do you want to talk to me about?” he asked.

“Just something between you and me,” I said mysteriously. “Something private.”

This was an interesting moment, because, in a peculiar way, I think Frank saw this invitation to talk to me alone asboth a potential threat and a challenge to his courage. I think his wife and daughter also felt this. Glancing sharply at him, Elizabeth said, “It’s fine with me. Come on, Francine.” As mother and daughter left the room, I sensed that a shift had already taken place in the family dynamic. For one thing, Elizabeth had always pretended to side with her husband while being secretly in alliance with her daughter. By sending her out with her daughter and keeping Frank with me, I had, by implication, made her alliance with her daughter overt instead of covert, and at the same time made Frank’s sense of isolation from his wife and daughter overt.

As Frank sat before me with his arms folded across his chest and his knees crossed in a protective posture, I moved my chair closer to him and said, “This is no big deal, but I just wanted to ask you about the tattoo you wanted. Did you ever get it?”

“The tattoo?” he asked, seeming somewhat confused.

“You said that when you were 19, one of the things you wanted most was a really great tattoo. Do you remember saying that?”

“Yeah,” he said, smiling slightly for the first time since coming to therapy. “I’m surprised you remembered that.”

“Well, did you ever get it?”

Frank leaned forward, clasped his hands together and chuckled. “Yeah, I got it. I got more than one, as a matter of fact.”

“Did you get it at Rob Boy’s?” I asked, mentioning the name of a prominent local tattoo parlor.

“Yeah,” he said with a surprised smile, “How do you know about Rob Boy’s?”

I shrugged. “Everybody knows they’re the best in this area. Did Rob do it or his wife?”

“His wife. Damn, I never expected that you . . . ,” he now looked truly amazed. I shrugged again.

“I’ve had other clients who got tattoos from Rob Boy’s,” I said, which was both true and an excellent example of how having seen hundreds of clients multiplies the reference points for an older therapist and a new client. “It’s a beautiful art form, but I think that a lot of people don’t recognize it as such.”

“You’re damn right it is,” he said forcefully. “A great art form. It’s like your whole body becomes a canvass, you know?”

For the next 20 minutes, we talked about the art of tattooing, Tattoo magazine, and even Ray Bradbury’s famous short story “The Illustrated Man,” which Frank and I had both read when we were teenagers.

By now, we were reaching the end of the session time, and I took one more chance.

“Frank,” I said, “I’d understand if you don’t want to do this, but I’ll be honest: I’d really like to see your artwork. I bet it’s damn good.”

He looked at me for only a moment, then grinned. Without a word, he stood up, removed his long-sleeved shirt, and turned his back to me. I must admit that, although I’ve never had a tattoo or even been a big fan of tattoos, the one on his back was impressive. It was an intricate scene of naked women, wolves, a horse rearing and gnashing its teeth, demons, a shower of swords, flames, clouds, and the moon.

“It’s Armageddon,” he said. And then he turned around for me to see the front of his body. His chest and stomach were shaved, and the scene there was one of souls flying up to heaven, where cherubs, angels, sunshine, and flowers awaited them. “Judgment Day for the saved,” he explained.

“Awesome,” I said. “Awesome.”

When he put his shirt back on, his body language was entirely different. He leaned toward me as I leaned toward him. He continued to smile and make eye contact, as if with a friend, a supporter. I told him that I’d leave it up to him if he, his wife, and daughter would be back for another session.

“Well, I can’t speak for them,” he said, “but I’ll be back even if they don’t want to come in. I just gotta learn how to talk to Francine better, so she doesn’t tune me out.” I told him that was a fine goal.

At that moment, it suddenly seemed to me that we’d passed a critical fork on the therapeutic road. For the first time, I could see the general form of the next few sessions: how the family would change, and what I needed to do to help them change. As an old-fashioned structural therapist, I could see Frank’s softening leading to a stronger alliance with his wife, more permeability in the boundary between his daughter and himself, and, overall, greater inclusion for him in the family system. And I knew that I’d need to encourage him to be vulnerable, and also that he’d keep trying because he trusted me as a man with whom he’d shared the supernatural destinies of the saved and the damned etched upon his flesh. And Frank, I felt deeply, wanted to be among the saved.

At that moment, the case suddenly felt like, if not a piece of cake, a nice slice of sweet potato pie. Enough had transpired between me and the members of this family to convince me that progress could be made, even if Frank hadn’t taken off his shirt to show me his tattoo. And that’s another odd and wonderful thing about having thousands of hours of experience in the therapy room:

When a Case Reaches a Fork in the Road, We’re Not Afraid to Follow Either Fork, as Both Paths Are the Roads More Traveled. And That Makes All the Difference.

The other day, I was talking with a colleague and puzzling over the well-established, if somewhat discouraging, empirical finding that seems to indicate that experience level doesn’t make therapists any more effective, despite everything I’ve been saying in this article. “Walter,” he said, “I know older therapists to whom I’d never send someone I care about in a million years.” Then he added, “And I also know other older therapists with whom I’d trust my children’s marriages–or my own. Maybe it comes down to their being two groups of older therapists–the really great and the really lousy?”

So what’s the difference? To be sure, experience, by itself, doesn’t guarantee anything. Maybe it’s as simple as this–there are older therapists who’ve reached a point in their careers where doing therapy is nothing more than a rote exercise, a dull repetition of the same ideas and techniques recycled from case to case. The appreciation of the uniqueness of each case, each family, or each couple has diminished with each passing, boring, but expensive, minute. They’ve lost the attentiveness to the little hints and clues clients drop in passing, or as afterthoughts that could potentially open the gates to creative ways of understanding and solving their problems. In short, they’ve lost what Buddhist meditators call beginner’s mind, a sense that each case is a fresh, one-of-a-kind event, requiring one-of-a-kind thinking. Good older therapists are the ones who still have a novice’s reverence for people, a sense of wonder at being in a position to help them, and a twinkle in their eyes, combined with all the years of experience, both in therapy and in life.

Maybe there’s a fork in the road for experienced therapists, a point at which they either begin to truly grow old, both intellectually and spiritually (and by old, I mean tired, bored, uncreative, and perhaps even jaded), or somehow find a way to renew their fascination with the art of therapy and the vigor to do it not only well, but even better than before.

It’s the older therapists in that second group, however they got there, that I’ve come to praise.




Walter Lowe

Walter Lowe, MD, is Chairman and Professor of the Department of Orthopaedic Surgery at the University of Texas Medical School at Houston, Edward T. Smith Professor and Chair, and the Chief of Orthopedic Surgery at Memorial Hermann – Texas Medical Center and LBJ General Hospital. He is also the Medical Director of the Memorial Hermann Sports Medicine Institute.