How to manage countertransference in therapy

Countertransference, a therapist’s cognitive and emotional reactions to a patient, is now recognized as a phenomenon that can arise in virtually any form of psychotherapy. Rather than something to avoid, psychologists today view countertransference as an important facet of therapy to notice and manage, as well as an opportunity to harness for the patient’s benefit.

“Countertransference doesn’t mean you’re doing something wrong. In fact, it regularly happens during therapy,” said Kirsten Lind Seal, PhD, LMFT, a psychotherapist in private practice in Minneapolis, Minnesota, who leads CE workshops on countertransference. “The main thing is acknowledging and understanding its power to help and possibly harm, then deciding what to do about it.”

If countertransference is not addressed, a therapist may act out their own unconscious patterns with a patient, such as meeting anger with defensiveness or detachment. But with proper preparation, including training on self-awareness, self-disclosure, and emotion regulation, therapists can learn to recognize countertransference when it arises. In some cases, engaging countertransference during a session can even advance the goals of treatment.

“Patients communicate their wishes, fears, and longings to us in all sorts of ways that are not verbal and not conscious,” said Tamara Feldman, PsyD, a clinical psychologist who practices individual and couples therapy in Wellesley, Massachusetts, and has published on countertransference. “Tuning in to countertransference—the feelings you experience with and about the patient—is essential to truly understanding them.”

In the psychoanalytic tradition, countertransference is best defined in relation to transference, a patient’s unconscious projection of feelings about other people in their life (such as a parent or spouse) onto the therapist. The mirror of transference, countertransference describes the therapist’s resulting feelings, thoughts, and reactions, which relate to their own experiences and triggers. Psychoanalysts view both as key tools in the therapeutic process, offering a window into the patient’s inner self and relationships that often transcends what is spoken aloud in session.

In other forms of therapy, countertransference describes any feelings and reactions of the therapist toward the patient. That may include everything from anger, dread, or excitement to distraction and boredom. One example: When a longtime patient of Lind Seal’s continued to avoid social gatherings that he had originally decided to attend, after they had worked together for years on managing loneliness, she noticed she felt frustrated.

“I realized I was becoming irritated in a way that I imagined other people in his life had also become irritated with him,” she said.

Countertransference can also manifest as positive feelings toward a patient, such as a maternal or protective instinct, said Janina Fisher, PhD, a licensed clinical psychologist and trainer of clinicians who delivers trauma-focused treatments. Though less often seen as problematic, these feelings are important to recognize, she said, because they can compromise a therapist’s boundaries and objectivity.

While countertransference can arise in any form of therapy, not all practitioners are equally prepared to handle it. Training differs widely between graduate programs, courses, and supervisors. Research suggests that therapists trained in certain theoretical orientations, such as psychodynamic therapy compared to cognitive behavioral therapy, are more likely to expect and attend to countertransference during sessions. That is due in part to the strong emphasis psychodynamic training places on a therapist’s emotional awareness as a tool for understanding the therapeutic relationship (Gordon, R. M., et al., Clinical Psychology & Psychotherapy, Vol. 23, No. 3, 2016opens in new window).

Unexamined countertransference can lead to missed opportunities to help a patient or—even worse—replicate the harmful dynamics that led them to therapy in the first place.

In a series of meta-analyses conducted between 2001 and 2018, psychologists Jeffrey Hayes, PhD, and Charles Gelso, PhD, explored what happens when therapists react behaviorally to feelings of countertransference, such as scolding a patient after feeling personally attacked. They found that patients had worse outcomes when their therapist showed more behavioral reactions toward them, compared with when the therapist reacted less. But several therapist traits, including self-awareness and anxiety management, were associated with fewer countertransference reactions and better patient outcomes (Psychotherapy, Vol. 55, No. 4, 2018).

“The good news is that we don’t have to be perfect,” said Hayes, a professor of education and psychology at Penn State University. “We can be human, we can make mistakes, and all hope is not lost when we manifest countertransference behavior.”

Early psychologists saw countertransference as a sign that the psychoanalyst needed more therapy. “But the idea that a therapist could maintain a benign, physician-like attitude all the time with all patients has not been clinically supported,” said Nancy McWilliams, PhD, who has published extensively on psychoanalysis and has a private practice in Lambertville, New Jersey.

Instead, countertransference is increasingly seen as a process co-created by therapist and patient—a unique dyad with its own dynamics. That relational perspective informs psychologists’ recommendations for identifying and addressing it.

To determine whether countertransference is at play with a given patient, Lind Seal suggests a series of questions for therapists to explore. During a session, do you feel irritated? Bored? Anxious? Surprisingly sad? Is this a feeling you have often, or is it limited to sessions with this particular patient?

“If the feeling is uncharacteristic and the exact trigger is not immediately obvious, that’s the time to really investigate what’s happening inside yourself,” Lind Seal said.

Consider, for example, a female trainee treating an older male patient, said Beatriz Palma, PhD, a staff psychologist and groups coordinator at the University of Virginia’s Counseling and Psychological Services (CAPS) who has done research and trained extensively in countertransference and how to manage it. The trainee, who comes from a culture with strong patriarchal norms and respect for authority figures, has become increasingly agreeable with the patient, keeping quiet during sessions and challenging him less than her other patients.

“In supervision, the trainee can explore where those behaviors stem from, any fears about what might happen if she ‘rocks the boat,’ and whether and how the dynamic should be discussed with the patient,” Palma said.

Research by Hayes, Gelso, and others has helped identify a series of factors that can prepare therapists to navigate countertransference when it arises. First and foremost is self-awareness.

“Be in your own therapy, with the aim of knowing as much about yourself as possible, including what buttons are pressed for you with different kinds of patients,” said Joyce Slochower, PhD, a private practitioner, professor emerita of psychology at the City University of New York, and faculty member at New York University’s postdoctoral program in psychotherapy and psychoanalysis. For example, if you know you tend to become more active when a patient behaves passively, you can more quickly realize when that occurs in a session, Palma said. That, in turn, can help illuminate the client’s own dynamics.

Strong emotion regulation skills, including those developed through mindfulness meditation, have also been shown to reduce countertransference reactions among therapists (Hayes, J. A., et al., Psychotherapy, Vol. 55, No. 4, 2018). Palma suggests grounding techniques (sensing your feet on the floor, taking a deep breath before responding) and cognitive strategies (“this is just a thought”) to help manage intense reactions (including emotions, thoughts, and somatic responses), in the moment. These approaches help therapists pause and create space so that internal reactions do not translate into external behaviors.

A firm understanding of appropriate boundaries and self-disclosure is also key. If a therapist experiences countertransference, they may sometimes react impulsively—for instance, by sharing personal information to explain or justify their feelings. While self-disclosure can be helpful in certain contexts, it is not always the best solution. For example, a therapist might disclose their trauma history in hopes of building rapport with a patient. But if that disclosure is driven by the therapist’s own emotional needs, it can shift focus away from the patient’s experience. A 2018 study found that when therapist self-disclosure was unsuccessful, it was usually preceded by a countertransference reaction (Pinto-Coelho, K. G., et al., Journal of Counseling Psychology, Vol. 65, No. 4, 2018).

Lind Seal’s advice: When in doubt, sit quietly.

“If you’re very activated, it’s probably a good general rule not to do anything right in the moment,” McWilliams said.

The art of managing countertransference lies in knowing whether, when, and how to address it with a patient. The choice between expressing or containing, Slochower said, requires drawing on your clinical judgment. Is this person capable of hearing how you see them? What are the chances they might shut down, leave, or otherwise suffer?

“Sometimes, you really have to name the elephant in the room,” Slochower said. “Other times, you just have to make space for the patient and wait for another moment to name what you see.”

Small self-disclosures can move therapy along for some patients, said McWilliams, such as a therapist who says: “I find myself to be really sad as you talk, and yet you don’t seem to be processing any sadness.”

A more direct challenge, in the case of Lind Seal’s patient who skipped multiple social opportunities despite his loneliness, might sound something like this: “I’m feeling like you’ve got a lot of excuses here, and I wonder if other people might feel the same. What do you think?”

Offering a forewarning can help soften the blow of a hard-to-hear statement. Slochower sometimes starts by noting, “I’m going to say something you’re not going to like.”

Using language that emphasizes therapy as a two-person process is another way to make such statements more palatable. For example: “It feels like we’re in a place where there’s temporarily a loss of hope” or “It feels like there’s a lot of irritation between us right now.”

“Sometimes when you talk about countertransference in a two-person way, it’s easier for the patient to sign on to,” McWilliams said.

With a patient who was repeatedly angry and devaluing, Fisher found herself thinking, “No matter how hard I try, I can never please her.” The thought brought to mind her relationship with her mother—and helped her snap out of a countertransference reaction: She had been walking on eggshells.

“I realized: I’m the little kid trying to please my mother, and there’s no therapist in the therapy room,” Fisher said.

It took a few tries to find an approach that worked. One day, when Fisher did not respond to an angry remark, the patient demanded, “What’s wrong with you?” Fisher closed her eyes and noticed her internal experience—she felt shaky and worried about saying the wrong thing. She then opened her eyes and shared that with the patient, who seemed surprised and apologized for causing anxiety. Processing the countertransference together ultimately deepened their relationship, Fisher said.

In certain situations, therapists should pause and consider seeking consultation before addressing a countertransference, such as if they feel a temporary hatred or futility toward a patient or if they are feeling very activated emotionally, McWilliams said. Disclosing sexual attraction or fantasies about a patient may need to be addressed in a general way, such as: “Do you feel like there’s a sexualization of the atmosphere between us?”

Caution is also warranted when patients have a history of trauma, Fisher said. Classic psychodynamic approaches to transference and countertransference may not work with these patients, who can interpret a pointed observation as a rejection or be triggered by the high degree of intimacy.

“Transference and countertransference work is very intimate,” Fisher said. “That’s complicated with trauma survivors, who were often abused by the people they were closest to. The closeness, although they yearn for it, can be triggering.”

Countertransference is not something therapists study once and master. Reviewing new clinical research and seeking support from colleagues can help midcareer psychologists sharpen their skills and deepen their impact.

Research by Hayes suggests that reflective practice, a system for exploring and improving one’s actions, offers a helpful framework for approaching countertransference. It involves therapists reflecting on their own thoughts, feelings, sensations, and behaviors during and after a session; forming and testing hypotheses about their underlying causes; and testing and evaluating potential solutions with patients. A preliminary test with trainees in Australia and New Zealand found that engaging in reflective practice helped trainees think more critically about the causes and consequences of their countertransference reactions, as well as how to manage them (Australian Psychologist, Vol. 56, No. 2, 2021opens in new window). Hayes is now conducting a follow-up study at Penn State that includes data on patient outcomes.

Feldman, who works with families and couples, has also studied new ways of looking at countertransference. A therapist’s attitudes toward “important others” in the patient’s life—anger at an insensitive spouse, for example—can also interfere with the therapeutic process (Psychoanalytic Psychology, Vol. 41, No. 2, 2024).

“When a therapist finds themselves feeling a particular way about a person in the patient’s life, we should think about that as countertransference, too,” Feldman said.

At any career stage, seeking support is key in dealing with countertransference. Join a peer supervision group, go for supervisory consults, or talk with a friend in the field, Slochower suggests.

“The challenge never goes away,” McWilliams said. “You always need people you can reach out to, preferably somebody who knows you very well and knows what soft parts of you have been activated.”

Self-care in whatever form works for you, be it socializing with friends, spending time in nature, or listening to music, should not be neglected. Hayes suggests reading Leaving It at the Office,opens in new window a guide to self-care for therapists that covers sleep, diet, exercise, leisure, managing a difficult caseload, and more.

“A lot of experienced therapists say they know this—but how often are we actually doing it? It’s a question we need to be honest about,” said Hayes. Forgoing sleep and downtime may feel like a necessary sacrifice for patients in need. But that sacrifice can undermine a therapist’s ability to stay emotionally regulated, making countertransference harder to manage.

“We need to remember that we are role models for our patients in terms of mental health,” Hayes said. “It’s hard to take care of other people if we’re not taking care of ourselves.”