What Is Countertransference and How Does It Affect Therapy?

Countertransference is the collection of emotional reactions, thoughts, and impulses a therapist experiences in response to a client during treatment. Originally considered a flaw that compromised therapy, the concept has undergone a dramatic reappraisal over the past several decades. Most clinicians today regard these reactions not as obstacles to be suppressed but as a rich source of information about what is happening in the therapeutic relationship, and potentially about the client’s inner world. Understanding countertransference matters for anyone in therapy, training to become a therapist, or simply curious about how the human dynamics of the consulting room shape mental health treatment.

How the Idea Evolved

Sigmund Freud coined the term in the early 1900s and treated it as a problem. In his view, countertransference was an unconscious, neurotic reaction stirred up by the patient’s own transference, and it got in the way of the therapist’s neutral, objective stance. For decades, the dominant advice was that therapists should undergo their own analysis to root out these reactions so they would not contaminate treatment.¹

That view started shifting mid-century. Analysts like Paula Heimann, Erich Fromm, and Donald Kiesler argued that therapists’ emotional responses were not just noise but signal. They proposed a broader concept sometimes called “total countertransference,” meaning all of the therapist’s reactions to the client, whether conscious or unconscious, whether triggered by the client’s transference or by something else entirely. Under this wider lens, a therapist’s sudden irritation, unexpected drowsiness, or protective urge could all be clinically meaningful data points rather than personal failings.²

This shift was not merely academic. It changed day-to-day clinical practice. Rather than striving to be blank screens, therapists began deliberately monitoring their own feelings in session and using those feelings as a kind of diagnostic instrument. Today, most training programs teach countertransference awareness as a core competency, not just a hazard to manage.

What Countertransference Actually Feels Like

People outside the field sometimes picture countertransference as a therapist “falling in love with” or “hating” a client. Those extremes exist, but countertransference is usually subtler and more varied. Researchers who developed the Countertransference Questionnaire identified eight distinct patterns that therapists commonly report, regardless of their theoretical orientation: feeling overwhelmed or disorganized; feeling helpless or inadequate; experiencing positive warmth; feeling special or overinvolved with a particular client; having sexualized feelings; feeling disengaged or bored; having parental or protective urges; and feeling criticized or mistreated.³

A separate instrument, the Assessment of Countertransference Scale, organized therapist reactions into three broad clusters: rejection (irritation, hostility, boredom, distrust), closeness (interest, affection, wish to help), and sadness (despair, immobility, fear). These clusters showed good internal reliability, and the rejection and closeness dimensions were strongly inversely related to each other, meaning that when a therapist felt more warmth, they tended to feel less hostility, and vice versa.⁴

These reactions can also be physical. Therapists sometimes notice tension in their chest, headaches, fatigue, or a sudden urge to shift in their seat. Nursing literature has documented physical symptoms as a channel for countertransference, showing that the phenomenon extends well beyond emotions that are easy to name.⁵

Why Certain Clients Trigger Stronger Reactions

Countertransference is a two-way street: it depends on both the therapist’s psychology and the client’s presentation. Some clinical populations tend to evoke particularly intense and mixed reactions. Working with clients who have borderline personality disorder is one of the most widely studied examples. In one study examining therapist responses across eight countertransference dimensions, the most strongly endorsed reactions toward these clients were positive and satisfying feelings, parental or protective feelings, and feeling helpless or inadequate, sometimes all within the same session.⁶ That mix of wanting to help and feeling powerless captures why these cases are often described as emotionally demanding.

Trauma work creates its own countertransference landscape. When clients describe traumatic experiences, therapists may find themselves activated in ways that go beyond standard empathic engagement: threat responses, identification with the victim, feelings of helplessness, guilt, anger, or strong rescue impulses. These reactions can overlap with but remain distinct from secondary traumatic stress, a condition in which the therapist develops their own trauma symptoms from repeated exposure to clients’ narratives. The two processes can interact, particularly when the trauma material touches on the therapist’s own personal history.⁷

New therapists are especially vulnerable to being pulled in by difficult clients. One study of novice clinicians working with patients who had negative therapeutic reactions, meaning the patient got worse despite or perhaps because of the therapist’s efforts, found that these patients tended to project their own depressed and guilty feelings into the therapist. The inexperienced clinician, still developing their professional identity, provided “fertile ground” for absorbing those projections without recognizing what was happening.⁸

Does Managing Countertransference Actually Improve Therapy?

This is the question researchers have been chipping away at for years, and the short answer is yes, though the evidence base is still developing. One early evaluation of countertransference management used the Countertransference Factors Inventory, which measures skills like anxiety management, the ability to conceptualize what is happening in the relationship, and self-integration (how well the therapist tolerates their own emotional reactions). The study found that therapists who scored higher on overall countertransference management, and specifically on anxiety management and conceptualizing skills, achieved better outcomes as rated by both the trainees themselves and their supervisors.⁹

This makes intuitive sense. A therapist who can notice that they have begun avoiding a particular topic because it makes them anxious, or who recognizes that their irritation with a client is partly about their own issues, is in a better position to stay present and responsive. A therapist who acts on those reactions without awareness, by cutting sessions short, becoming overly reassuring, or subtly punishing the client with emotional distance, can derail the work. The research suggests that the damage is not from having the reactions; it is from failing to notice and manage them.

Countertransference Outside Psychodynamic Therapy

For years, countertransference was treated as psychoanalytic territory. Cognitive behavioral therapists tended to ignore the concept or dismiss it as belonging to a different framework. That has changed. Researchers and clinicians have argued that countertransference appears in CBT as well, framing it through the lens of therapist schemas: the deep-seated beliefs and assumptions the therapist carries, which can be activated by certain clients and lead to complementary emotional reactions.¹⁰

In CBT and its offshoots, the language differs but the phenomenon is the same. A therapist with an unexamined belief that they must always be competent may become defensive when a client challenges the treatment plan. A therapist with a strong caregiving schema may over-accommodate a dependent client rather than pushing for independence. In cognitive behavioral supervision, techniques such as guided discovery, imagery work, and role-playing are used to help therapists and supervisors map these reactions and understand the beliefs driving them.¹¹

Schema therapy, a more integrative approach, goes further. Therapists trained in schema therapy have reported that recognizing how their own early maladaptive schemas get activated in sessions can actually be used to the client’s benefit, helping the therapist better conceptualize the case and even supporting the therapist’s personal growth.¹² This dovetails with the broader shift across the field: countertransference is not something only Freudians worry about, and it is not something to be eliminated. It is built into the structure of any helping relationship.

What Mirror Neurons May Have to Do With It

One of the more intriguing lines of research connects countertransference to neuroscience. The mirror neuron system, discovered in the 1990s, shows that the brain circuits activated when a person performs an action, expresses an emotion, or has a sensation are also activated, automatically and unconsciously, in someone observing that person. Researchers have proposed that this mechanism, which they call “embodied simulation,” may provide a fundamental biological basis for understanding another person’s mind.¹³

This is relevant to countertransference because it suggests that a therapist’s body is literally mirroring some of what the client is experiencing at a neural level, before any conscious interpretation takes place. The heaviness a therapist feels after a client describes grief, the anxiety that creeps in when a client discusses a threatening situation: these may not be purely psychological projections. They may be the therapist’s nervous system doing exactly what it evolved to do. This does not mean every countertransference reaction is an accurate readout of the client’s state, since the therapist’s own history and schemas inevitably color the signal. But it provides a biological grounding for the clinical observation that therapists can sometimes “feel” what clients have difficulty putting into words.

Countertransference Outside the Therapy Room

The concept is not limited to formal psychotherapy. Nurses working closely with patients experience countertransference too, expressed through physical symptoms, through shifts in how involved they become with a particular patient, and through the positive and negative descriptions they use when talking about patients to colleagues.¹⁴ A nurse who finds herself dreading entering a certain patient’s room, or another who goes to extraordinary lengths for a patient while neglecting her other assignments, is experiencing countertransference dynamics even if she has never heard the term.

In general hospital settings, the consequences can be concrete and serious. One documented case involved a psychotic patient with multiple complex medical problems whose refusal of care and chaotic clinical course provoked strong countertransference reactions from both the primary care team and the consultation-liaison psychiatry team. Those reactions adversely affected the patient’s treatment, illustrating how unrecognized countertransference in a medical setting can lead to care breakdowns that go well beyond the emotional.¹⁵

Any professional relationship that involves caring for or helping vulnerable people creates conditions for countertransference: social work, teaching, pastoral counseling, even certain forms of legal advocacy. The label may belong to psychotherapy, but the phenomenon belongs to human interaction.

Couples and Family Therapy Add Layers of Complexity

Individual therapy involves one therapist and one client, producing one set of countertransference dynamics. In couples or family therapy, the complexity multiplies. The therapist is simultaneously relating to two or more people who have their own transferences toward each other and toward the therapist. The therapist may unconsciously side with one partner, feel pulled into a parental role with both, or re-enact dynamics from their own family of origin. Researchers studying this area have noted that these reciprocal phenomena are even more complex to identify and handle in couple and family treatment than in individual therapy.¹⁶

A couples therapist who had a parent with narcissistic tendencies may find themselves siding with the partner who reminds them of their other parent, without realizing it. Or a family therapist may feel a surge of anger toward a teenager whose defiance echoes something from the therapist’s own adolescence. The challenge is not only recognizing these pulls but managing them in real time, because in relational therapy the therapist’s alliance with each person in the room is always being watched and tested by the others.

How Teletherapy Changed the Picture

The mass shift to online therapy during the COVID-19 pandemic created a natural experiment in countertransference. Researchers who studied psychologists transitioning from face-to-face to teletherapy with existing clients found that the type of countertransference reactions remained consistent across both formats, but the felt intensity of those reactions was reduced during online sessions.¹⁷

That dampening effect is a double-edged sword. On one hand, less intense countertransference might sound like a benefit, fewer emotional storms in the therapist’s chair. On the other hand, those reactions serve as clinical information. If the signal is weaker, the therapist has less to work with. The same study found that therapists reported increased hesitance to work with intense emotions during teletherapy and felt they had to work harder to stay engaged. Meanwhile, seeing into clients’ homes during video sessions introduced novel reactions that therapists had never encountered in an office setting, such as curiosity or judgment about a client’s living situation, or distraction from background activity in the client’s environment.¹⁸

As hybrid models of therapy become the norm, clinicians are still working out how to recalibrate their countertransference antennae for a screen-mediated relationship. The physical co-presence that supports embodied simulation is partially lost in a video call. What replaces it, and how therapists should adjust, remains an open question.

Measuring Something That Resists Measurement

One of the persistent challenges in countertransference research is that you are trying to quantify something that is, by definition, partly unconscious. Researchers have developed several self-report instruments, but each runs into the same paradox: if a therapist is unaware of a reaction, they cannot report it on a questionnaire. The Therapist Response Questionnaire, tested on Swedish psychotherapists, showed promising validity for capturing the complexity of countertransference but did not fully replicate its expected factor structure in confirmatory analysis, suggesting that the dimensions of countertransference do not carve nature at perfectly clean joints.¹⁹

The eight-factor Countertransference Questionnaire mentioned earlier was developed empirically and has been widely used in research linking countertransference patterns to specific types of personality pathology in clients.²⁰ But even its creators would acknowledge that a questionnaire filled out after a session captures only what the therapist was able to notice. The most clinically important reactions, the ones that are acted out rather than reflected on, may be the hardest to measure.

This is one reason supervision remains central to the profession. A good supervisor can sometimes spot countertransference in a trainee’s case presentation that the trainee cannot see: the patient they never bring up, the one they describe with unusual warmth, the one whose missed appointments they do not seem to mind. These observations are informal and not easily quantified, but they may catch what questionnaires miss.

What Clients Should Know

If you are in therapy, countertransference is happening. That is not a scandal. It is an inherent feature of a relationship between two human beings, one of whom is sharing their most vulnerable material. What matters is not whether your therapist has emotional reactions to you but whether they are aware of those reactions and managing them responsibly.

Signs that countertransference might be going unmanaged include a therapist who seems unusually invested in one particular outcome for you, who gets visibly frustrated when you do not follow their advice, who shares personal information that seems to serve their needs more than yours, or who avoids certain topics you bring up. On the positive side, a therapist who occasionally names their own reaction, something like “I notice I feel protective of you when you describe that situation, and I want to make sure that is not getting in the way of what you need here,” is likely doing healthy countertransference work.

Therapists do not stop being people when they sit in the clinician’s chair. The best ones use that fact deliberately, turning their humanity into a therapeutic tool while staying honest with themselves about where their reactions are coming from. The concept of countertransference, once a whispered clinical embarrassment, has become one of the more useful ideas in modern mental health care.