Interviews.

The interviews were conducted by the first author (AB) during the period spanning July 2020 to September 2021 and audiotaped. Using a semi-structured interview, participants were asked to reflect on their experiences with young therapists. We used a problem-centred interview approach to capture and compare individual experiences as well as the subjective perceptions of the participants [17]. The interview guide (see S1 File) included four dimensions with open-ended questions concerning the participants’ experiences of the therapeutic relationship, transference phenomena, and both opportunities and challenges of working with younger therapists. In each interview, participants were encouraged to openly share their perspectives. Coverage of all dimensions and adjustments to allow for a coherent flow of the conversation were considered. Based on the grounded theory approach, we used theoretical sampling and collected new required data in parallel to the data analysis. The sample compromised of 12 participants as theoretical saturation was observed after completing the 12th interview. At that point, further data collection was unlikely to add any substantial new insights or information to the comprehension of the tentative theory (cf. [18]).

The interviews lasted about 80 minutes on average. Because the interview period took place during the Covid-19 pandemic, ten interviews were conducted at the participants’ personal residences and two interviews took place at psychotherapy training institutions, depending on the individual wishes and needs of the participants.

Grounded theory data analysis.

The methodology of Grounded Theory, initially formulated by Glaser and Strauss (1976), centres around an inductive analysis process which means that the constructed theory is derived in the data. At its core is the manual coding, categorisation, and comparison of collected data [18]. Rather than testing a theory against the data, the theory is inductively generated from the data, with data collection and analysis as a joint task [19,20]. Different approaches to Grounded Theory have evolved over time. For our research, we followed the constructivist approach as put forward by Corbin and Strauss [15].

The interviews were transcribed verbatim and the analysis was conducted using the MAXQDA 2020 software (VERDI GmbH) as well as manual processing of the manuscripts. Given the relatively small existing body of research on this topic, a qualitative theory-generating approach was chosen. The grounded theory and an interpretive design were used to gradually deepen our understanding of the participants’ individual experiences and behaviours (cf. [21]). This approach is characterised by a process of discovery, induction, constant revision, and comparison of the interview material (e.g., differences or general patterns) [18].

We analysed both the manifest, explicit data material, as well the latent, preconscious content of the interviews. We assumed that the latter would most likely provide insight into the participants’ unconscious experiences. Based on the grounded theory approach, the following three systematic steps formed the basis of the data analysis for each interview: open coding, axial coding, and selective coding [15]. No predefined sequential order was followed when analysing interviews and coding the data. Throughout the analysis, we produced memos to collect our reflections, questions, and ideas on how the codes were connected to form categories. The data analysis was performed as described in Boschann et al. [10]. Briefly, the relations of the categories were differentiated using information derived from our memos to conceptualise a tentative theory. Open coding was used to derive inductively formulated codes that were subsequently categorised, after which axial coding was applied to develop a category system by reorganising the data. The core category, which is related to all main categories, was identified during selective coding.

In our data analysis, we adhered to the constant comparison method, also referred to as “comparative analysis”, which serves as a strategic approach for theory generation (p. 39) [22]. Following the initial segmentation of data into manageable units, we assessed these units for shared patterns and distinctions. Those units displaying similarities were grouped together under the same conceptual headings. As the analysis process advanced, these concepts were grouped into overarching themes and categories, which were then refined in relation to their distinct attributes and dimensions. Finally, we integrated various categories around a core category (i.e., the primary theme). This core category, combined with the properties of the other categories, formed the basis of our Grounded Theory [15].

Each interview was initially analysed separately by two researchers while the other team members subsequently reviewed the codes and categories of each interview at a later stage. To minimise interpretation errors, we compared the interim results, developed the tentative theoretical model and discussed our findings and the researchers’ process of analysis in regular team meetings [23].

Martha–outpatient example of a positive child transference.

Martha, a 74-year-old woman, came to see her young therapist due to depressive symptoms and conflicts with her daughter. There was little contact with her daughter and her desire for a grandchild remained unfulfilled. Martha described initially feeling sceptical because of the therapist’s gender and young age:

The problem was that I had always had a female therapist and was looking for one again but then it turned out to be a man this time. And then the other problem was that he was much, much younger than me. He could have been my son.

However, she described how this feeling quickly subsided in the course of the therapy, which became a very positive experience. Martha emphasised that her therapist had always been “very professional”, but had once “crossed a line” when he told her he had recently become a father. Following this, Martha developed considerable interest in her therapist’s baby and explained: “I have the feeling that he could have been my son, so I was obviously interested in the baby, you see?” Martha would have been “extremely pleased if he had told [her] a bit about his child” and often asked her therapist for baby photos. At first, he had shown Martha baby photos, but when his reaction seemed distant at a later time, she strategically waited for several sessions before asking him again, to avoid potentially annoying him. Martha had had a “replacement grandchild” before and referred to her therapist’s baby in the same way: “I had the same feeling again. He could be my son and now there is a grandchild, as it were. Because I don’t have one”. Martha had “imagined her therapist as a father” and imagined “how lovingly he interacted with the baby.” Martha developed fantasies of “meeting him outside with the pram”:

If he had said ‘I am going to be in the park on Sunday afternoon’, I probably would have been in the park as well and would have bumped into him by accident (laughs).

Martha stated that she did not discuss “sexual issues” with her therapist because she is “probably too old-fashioned”.

Daisy–outpatient example of a negative child transference.

Daisy was a 71-year-old woman, suffering from anxiety and post-traumatic stress disorder. As a child, she was sexually abused by her father and was also abused by a male therapist in a children’s home. As an adult, Daisy was a political prisoner in the GDR and her baby was taken away from her. She often referred to her young male therapist as “the boy” and stressed that he was “pleasant” but “like a child” to her. Their first meeting already got off to a “bumpy” start and Daisy had difficulty telling him about her traumatic experiences. She recalled it being “unbelievably difficult” to tell a young therapist about the abuse she suffered and that she had the impression that he felt “uneasy”. Daisy stressed: “He was really sweet. He would have made a lovely son-in-law. But not my therapist.” She indicated that she finds it “easier” to speak to older people about her experiences and explained that the reason she felt “sceptical and distant”, “definitely had something to do with [his] age. He might be very competent, I’m not denying that, but he was just confounded by my experiences, poor kid.” Daisy also recounted that the therapist seemed “disbelieving” when she told him about the sexual and physical abuse and her experiences in prison. She related this to the young age of the therapist, as well as their different socialisation experiences:

He probably had no idea about the sort of things I experienced (…) What I experienced is so unbelievable. I grew up in the GDR and even an East German would have difficulties believing the things I went through. A West German would have no idea.

After having “this feeling”, Daisy stopped seeing this therapist: Something happened then which happened to me a lot as a teenager and a child: I had the feeling he didn’t believe me. That is a very, very hard feeling for me to have.

When I had this feeling, it was over for me. I no longer went to see him.”

Afterwards Daisy switched to a young female therapist with whom she felt a “very strong relationship of trust.” This young therapist was “really very empathetic, really sweet” and they would tailor the therapy sessions to her needs. The relationship that developed between them was “almost like a friendship.” Nevertheless, Daisy would not talk about sexuality with young therapists.

Rosie–outpatient example of a grandchild transference.

Rosie, a 69-year-old woman, came to see a young therapist because of a psychosomatic disorder and anxiety symptoms with depressive components. Rosie had “relived traumatic experiences after surgery that threw [her] off track” and was “very happy and grateful” to have a place with her young therapist. Rosie “immediately saw [her] granddaughter sitting in front of her” who had “also wanted to enter this profession”. The “chemistry was right from the start” and it was “love at first sight”, something she had only experienced with her husband before. Rosie had “known it would work out with her [the young therapist]” from the first moment. According to Rosie, a deep bond of trust developed “very quickly” and the therapist is “an important support and was always there” for her. Although her expectations had been low due to past negative experiences of therapy with older therapists in the GDR, this time she did not feel “any fear or inhibition” and stated “I don’t feel afraid of being hurt in some way when I’m with her. (…) I feel good with her.” The relationship with her young therapist is “harmonious” and she encourages Rosie in what she has “already achieved and accomplished.” In comparison, Rosie had “suffered” through “a lot of conflict and a lot of confrontation” in her earlier therapies. Rosie likes the fact that her young therapist usually emphasises her strengths and successes. Rosie described a strong relationship with her granddaughter, with whom she is very close (“she’s my sweetheart”). She spoke about having an affinity for young people and enjoying being with them: “I just like young people. I don’t really like spending time with older people (laughs).” Rosie was pleased that both her granddaughter and her therapist were interested in her life “despite being an older woman” and that both of these relationships are harmonious. Sometimes her stories about her granddaughter and therapist became mixed up during the interview so that Rosie would laugh and clarify: “My granddaughter! I am talking about my granddaughter!” Rosie admitted to not wanting to talk to her therapist about her sexuality, although this played a major role for her: “That is an impediment if I’m being honest. I couldn’t talk to her about that.” She added that she would not talk to her granddaughter about her sexuality either. When her youngest son and his partner broke up, Rosie also imagined her therapist as her daughter-in-law.

Richard–outpatient example of an erotic love transference.

Richard, a 79-year-old man, suffers from depressive moods, panic attacks, and anxiety about his pacemaker. He mentioned that he often feels lonely and longs to find a partner. Richard spoke enthusiastically about his young therapist and emphasised how attractive she was. He emphasised their “wonderful talks”: “It is so great. I really enjoy speaking to her and having a conversation. That’s something I miss. I miss that at the moment.” From his first meeting with his young therapist, he said, he was “gobsmacked by this woman” and described:

Such a lovely, sympathetic, pretty woman. (…) Such a charming and attractive woman, that was the first impression. Moreover, we have such nice conversations, such nice chats.

Richard related that he also meets “other women as well” but that his therapist is “special” and “appeals” to him as a woman. Richard finds it difficult to leave when the sessions come to an end: “When I go home, I am only thinking of her, I always look forward to the next session.” Richard spoke of having given his therapist flowers and described the therapy process with the words “we have been together for a while now.” He admitted being attracted to her:

You always have to think about that a bit when you are an older man sitting opposite a young, pretty woman. (…) That’s just the way it is, these feelings, you can’t just dismiss them and say ‘No, I’m just a cold block of ice, aren’t I’?

Although Richard worries about the end of his life a lot, it “hasn’t come up in therapy”. Instead, he often talked about his search for a partner and would, for example, also bring newspaper clippings of partner adverts to the therapy sessions to discuss them.

(a) Conflict avoidance.

During the interviews, it was noticeable that some participants did not initiate discussions concerning conflict in the interviews. The majority of the participants emphasised how good the psychotherapeutic treatment and the relationship with their young therapists had been. When asked about possible difficulties or interpersonal tensions, most participants denied having had a conflict with their young therapists. For example, Richard stated that there had “never been any conflict at all” and it had “always been harmonious”. Harriet also vehemently denied experiencing any conflict with her therapist and stressed that her therapist “always did everything well”. Similarly, Grace explained that while there were “never any conflicts of any kind” with her young therapist, they “might have had constructive discussions sometimes.” Violet mentioned “sometimes having a conflict or a discussion” with her therapist, but “that everything was always back in balance” next session.

Analysis of the material for latent content also indicated conflict-avoiding behaviour among the participants toward young therapists. Richard, who suffers from a fear of death connected to his heart disease, did not raise this issue with his therapist. Instead, they would have “joyful and pleasant conversations” in which he spoke about his search for a partner. Similarly, Martha described keeping interpersonal conflicts out of the therapeutic relationship. For instance, although she was sometimes annoyed by her therapist, she never communicated her frustration and “practically always dealt with the conflict alone”. Instead, she praised her therapist in the next session for challenging her on purpose. When having a conflict with her young therapist, Violet thought to herself: “well, let him talk (laughs), at some point, this [conversation] will be over anyway.” She would become “completely quiet” and her therapist “senses that something is not right and changes the topic”.

(b) (Fantasised) therapy discontinuation.

Daisy, whose experience with a young male therapist had been negative and involved interpersonal conflict, stopped her psychotherapeutic treatment as a result. She then found a young female therapist who was “really very empathetic [and] very sweet,” who gives her a lot of freedom and responds to her personal needs (e.g., a more flexible setting and frequency of the sessions). Daisy described “this current kind of therapy” as “absolutely perfect”. Some participants were hostile to potential conflict situations (i.e., having an argument) and threatened to discontinue their therapy as a result. Grace said: “To be perfectly honest, if I had noticed any kind of conflict at all, I may well have said goodbye.” She explained that she did not want to have any interpersonal conflicts with her therapist because she had enough conflicts “outside.” Similarly, Harriet said she would have had to “stop” if there had been a “bad atmosphere.” Mary also stated that if a conflict had developed, she would “probably have been done” with the therapy, while Violet reported she would have “dropped” therapy or considered a “change of therapists” if she did not feel comfortable with her young therapist.

(c) Adaptation / Subordination.

Many participants described feeling a strong motivation to commence therapy, such as Grace, who explained she “really wanted” therapy instead of being “forced” to find it. Some participants made it clear how seriously they took their psychotherapy and that they were annoyed, for example, when other less motivated patients disrupted the group therapy session. Only a few participants spoke about resisting psychotherapy at the start. Phil explained that he had “quite considerably resisted” during the first few days in the day-care hospital and that he “hadn’t made things easy”. However, he had transformed into a patient who was very motivated and committed to participating and even had “fun” at the sessions. Many participants felt grateful and expressed a desire for their young therapists to help them, as illustrated by Rosie who emphasised that she would “never have got her life on track alone” and “often wouldn’t have made it”. Some participants said that they saw young therapists as being people worthy of respect and commanding authority (“They were authority figures for me”–Phil). For Jack, the young therapists were experts and that is why he “accepted their opinion regardless of their age (…) Because [he is] the one looking for help.” Relatedly, Richard commented that his therapist is “the person, who is there to help me” that he would “defer to her completely and expects her to recommend things,”

(d) Solidarity, support, and protection.

On the one hand, many participants particularly focused on the skill level and professionalism of their young therapists, which they mainly attributed to the many years of study and training to become a therapist. Reflecting on her young therapist in training, Rosie mentioned that she did not notice “any differences from the ‘qualified therapists’” she had had in the past and stated: “I would have thought she was already a fully qualified therapist.” Martha also emphasised how professional her therapist was and that she had the feeling that “he had only prepared for me that day. He was completely focused on me and knew exactly what we had discussed in the previous session.” George referred to his therapist’s professional experience:

Obviously, she is very young, but she had already had experience in the day-care hospital (…) It wasn’t an issue for me because I really found her to be very, very competent.

On the other hand, most participants also described feeling a sense of solidarity with young therapists or feeling supportive or protective of them. Some participants emphasised that young therapists had a “difficult job” (Richard) and thus they showed compassion (“They don’t have it easy”–Grace). Rosie mentioned that she enjoys going to her young therapist, “because we need the next generation and that’s why it was important to me”. Relatedly, Violet explained that “young people have to be encouraged and have to learn somehow”. Phil had the “strong and distinct” feeling of being “in the same boat” as young therapists. In general, he felt a “need to help” young therapists and to “support” them in the group therapy sessions. He explained that he saw working with a therapist as a give and take: “Because they were nice to me, I was nice to them (…) That’s why I then wanted to help these therapists as well.” Violet described feeling overwhelmed by an exposure exercise but continued doing it for her young therapist anyway so as “not to disappoint” him:

He tries so hard and then I always think: ‘No, you have to pull yourself together.’ (…) When someone tries so hard and then the person, you’re trying so hard for just says: ‘No, I don’t want to.’ Well, that’s a crushing blow.

Additionally, Daisy described her own “uncertainty” concerning what she was allowed to tell young therapists. She was “definitely more cautious” and “more restrained” and suggested she did not want to “hurt” young therapists:

Someone is sitting there in front of you who could be your own child. My daughter has already offered to do “inner child work” with me 100 times, but no, never with my children. Never. The age difference makes me more cautious.

Specific features of transference.

It was important to many older participants to be taken seriously and not to feel old when around young therapists. For example, some older patients emphasised that it was important for them to be treated “as a well-rounded and valuable individual” and “not just written off as a granddad”. On one hand, these remarks could be linked to negative views on aging and self-perceptions of the older patients, as well as negative societal perceptions of old age [31]. The presence of such pessimistic self-view and self-deprecating tendencies among older patients might also correlate with symptoms related to depressive psychological disorders [32].

Older patients might become particularly aware of their more advanced age due to the direct contrast between themselves and their young therapists. By taking on an admiring and supportive parental or grandparental role, negative feelings, such as envy and aggression, could possibly be reduced through a reaction formation. Baumeister et al. (p. 1085) [33] explain the concept of reaction formation as transforming “a socially unacceptable impulse into its opposite” to protect the self-esteem by engaging in a behaviour that portrays a contrary trait to the actual undesirable trait. For instance, indications of hostility or intolerance could be met by demonstrating oneself as peace-loving and tolerant. We argue that a child and grandchild transference can therefore serve to stabilise self-esteem, thereby strengthening feelings of self-worth and self-efficacy (cf. [34]). For instance, many older patients described the feeling of wanting to support young therapists.

For older patients, the psychosocial developmental tasks of shaping the next generation (generativity) and accepting the life cycle (integrity) come to the fore [35]. In keeping with generativity, older patients can pass something on to young therapists and avoid dealing with old age and death by unconsciously assuming the role of a parent. Erotic transference and feelings of being in love, as in the case of Richard, might also serve as a form of defence, for instance, to cope with the fear of death or feelings of loneliness by fantasising about a romantic relationship with a young therapist or as a means to maintain power and control of the therapeutic relationship (cf. [36]).

Our results show that positive child and grandchild transferences build trust and can diminish initial fear of entering psychotherapy in older patients. For example, one older patient described feeling less inhibited with young therapists than with older therapists. In general, an interesting contradiction emerged, as most older patients stressed how competent their young therapists were, all while feeling a desire to help them. These results can be linked to a transference dynamic where older patients place their young therapists in the role of their (grand)children and support them. This might enable older patients to maintain influence and preserve their competence. Thus, showing protective behaviour can also be traced back to uncertainty about what young therapists (perceived as children) can endure. For instance, Daisy had challenges in opening up about her traumatic experiences to young therapists (as well as her own children) compared to therapists of an older age.

Another finding concerned how older patients and young therapists dealt with the issue of sexuality. DeLamater and Sill [37,38] suggested that sexual interest remains moderate to high among most women and men in their 70s. However, our results indicated that especially those patients who reported having a child or grandchild transference, did not want to address their sexuality with young therapists. Humboldt et al. [39] identified challenges older adults feel regarding their sexual well-being, as shared in therapy, such as partner unavailability, family issues and physical changes due to aging. In this context, it is important to mention that older patients might feel inhibitions regarding discussions about their sexuality with their health professionals in general. As an illustration, Rosie explained that her therapist’s young age was an “impediment” to talking about her sexuality. Additionally, Martha also expressed her reluctance to address the subject of sexuality with her young therapist. Both patients drew a parallel to their reservations about discussing sexuality with their (grand-)child. This feeling of inhibition could be explained by a general taboo concerning speaking to (grand)children about sexuality. Sharing sexual problems with young therapists could also trigger unconscious feelings of competition and envy leading to avoidance being used as a defence mechanism. On the other hand, it could also be difficult for young therapists to address sexuality with older patients, e.g., for fear of rejection or interpersonal conflict, and Hillman [40] pointed out that negative countertransference, including fear, confusion, contempt, and denial, is usual among young therapists.