Patient Transference

Sigmund Freud wrote:

“All these undesired happenings and painful affective situations are repeated by neurotics in the ‘transference‘ stage and re-animated with much ingenuity. They struggle to break off the unfinished treatment, they know how to recreate the feeling of being disdained, how to force the physician to adopt brusque speech and a chilling manner towards them, they find suitable objects for their jealousy, they substitute for the ardently desired child of early days the promise of some great gift which becomes as little real as that was” (Freud, 1990).

According to Freud, transference in the patient is an attempt to repeat past conditions. Oddly, this compulsion to repeat the past supersedes normal motivations of pleasure and pain. Freud attributes this to the repetition-compulsion. “In the case of a patient in analysis, on the other hand, it is plain that the compulsion to repeat in the transference the occurrences of his infantile life disregards in every way the pleasure-principle” (Freud, 1990).

Our patterns of interaction can be quite compelling. Patterns are predictable and establish a sense of comfort, even if they are destructive. Emotions relish repetition, flowing in recognizable patterns. Repetition-compulsion invites reoccurring themes into our lives that soothes anxiety through familiarity.

For example, certain patients “can be so contemptuous that everyone with whom they come in contact, including the therapist, may respond with negative or even hateful feelings.”

D.W. Winnicott suggests:

“This hateful reaction had much less to do with the therapist’s own personal past or intrapsychic conflicts. Rather, it reflected the patient’s behavioral strategies and the need to evoke specific reactions in others” (Gabbard, 2020).

Three Modes of Transference

Anna Freud suggests:

“The phenomena of transference come under three headings: transference of libidinal tendencies, transference of defensive attitudes, and acting in the transference” (Freud, 1937).

Basically, transferences occur at our most basic impulses and desires. However, we may substitute those initials desires by transferring the strong overriding defensive mechanisms concealing the desires.

In many ways transference and countertransference correlate well with the psychological concept of projective identification. In projective identification, Arthur C. Nielsen, Clinical Associate Professor of Psychiatry and Behavioral Sciences at Feinberg School of Medicine, Northwestern University explains that it is “an interpersonal defense mechanism by which individuals (inducers) recruit others (recipients) to help them tolerate painful intrapsychic states of mind” (Nielsen, 2019).

Therapist Countertransference

Markedly, countertransference can manifest in various ways, such as feeling overly sympathetic or empathetic towards a client, experiencing personal triggers or reactions to certain topics, or even developing romantic or platonic feelings towards the client. Therapists must take great caution to limit countertransference reactions, addressing them in a professional and appropriate manner.

Allan Schore warns:

“More insidious and often more damaging, are behaviors of the analyst that are the results of inner defense against his countertransference reactions, such as rigid silences, unbending attitudes, repression or isolation of troublesome impulses, fantasies, or memories. . . . The analyst . . . in his effort to stay sane and rational is often apt to repress the very transference-countertransference resonances and responses induced by the patient that would give him the deepest but also the most unsettling understanding of himself and the patient” (Schore, 2003, p. 283).

Depending on how the therapist reacts to the original transference, the interaction may strengthen resistance to change, validate the patient’s transference, and waste everybody’s time. Sometimes, the transference is sexual in nature and a therapist’s countertransference violates ethical standards, taking advantage of their role that places others in vulnerable situations, designed to create openness.

Real-World Examples of Countertransference in the Session

an example that illustrates how countertransference can impact a therapy session:

Dr. Smith, a seasoned therapist, had been working with a client named Emily for several months. Emily’s struggles with abandonment and rejection closely mirrored unresolved issues from Dr. Smith’s own past. During one particular session, Emily shared her feelings of being overlooked at work, which triggered Dr. Smith’s personal experiences of feeling undervalued by her peers.

Without realizing it, Dr. Smith began to over-identify with Emily’s stories, sharing too much about her own similar experiences. She found herself offering advice based on what she would have done in Emily’s situation, rather than listening to Emily’s unique perspective and feelings. This shift in focus from Emily’s needs to Dr. Smith’s personal narrative is a classic example of countertransference.

As the sessions continued, Dr. Smith’s countertransference became more evident. She pushed Emily to take actions that Emily didn’t feel ready for, projecting her own desire for resolution onto her client. This not only hindered the therapeutic process but also left Emily feeling unsupported and misunderstood.

It wasn’t until Dr. Smith’s supervisor pointed out the potential countertransference during a routine review that Dr. Smith recognized the impact her unresolved issues were having on the therapy. With this awareness, Dr. Smith took steps to manage her countertransference, such as engaging in her own therapy and reflective practice, which ultimately helped her to realign with Emily’s therapeutic goals and needs.

This example demonstrates how a therapist’s unconscious reactions and feelings towards a client, influenced by their own personal experiences, can affect the therapeutic relationship and the treatment process. It underscores the importance of therapists being aware of and managing countertransference to maintain objectivity and effectiveness in therapy.

Limiting Countertransference

By recognizing and managing countertransference, therapists can maintain a healthy therapeutic relationship with their clients, ensuring that their personal issues do not interfere with the client’s progress. This involves consistent self-reflection, supervision, and constant drawing on additional support from colleagues.

Managing countertransference is a critical aspect of effective therapy. Here are some practical strategies therapists can employ:

• Self-awareness and Reflection: Therapists should cultivate self-awareness to recognize their own emotional responses and biases that may arise during sessions.
• Education and Training: Continuous education on the dynamics of countertransference helps therapists understand its manifestations and impacts.
• Establishing Boundaries: Clear professional boundaries are essential to minimize the risk of countertransference affecting the therapeutic relationship.
• Supervision and Consultation: Regular supervision provides an opportunity for therapists to discuss and reflect on their feelings and reactions with a more experienced colleague.
• Mindfulness Practices: Engaging in mindfulness can help therapists remain present and attentive, reducing the likelihood of countertransference.
• Personal Psychotherapy: Therapists can benefit from their own psychotherapy to work through personal issues that might contribute to countertransference.
• Self-Care: Taking care of one’s own physical and emotional well-being is crucial for therapists to maintain a clear and focused mind during sessions.

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By implementing these strategies, therapists can better manage their countertransference reactions, ensuring they provide the most effective care for their clients.

Associated Concepts

• Ego State Theory: This theory posits that the human psyche is composed of distinct but interconnected ego states. Ego state therapy aims to help individuals identify and understand these ego states, resolve internal conflicts, and foster healthier communication between them.
• Projection: A defense mechanism where individuals attribute their own unacceptable thoughts, feelings, or motives to another person.
• Therapeutic Alliance: The collaborative relationship between therapist and client, which can be influenced by transference and countertransference dynamics.
• Self-awareness: The therapist’s understanding of their own internal processes, which is crucial for managing countertransference.
• Psychologist’s Fallacy: This refers to when an external observer assumes that their subjective interpretation of someone else’s experience is an objective conclusion.
• Empathy: The ability to understand and share the feelings of another, which can be complicated by countertransference if not properly managed.
• Boundary Setting: Establishing appropriate professional boundaries is essential for preventing and managing countertransference.

A Few Words by Psychology Fanatic

In the intricate dance of therapy, countertransference is the shadow that follows every therapist’s step, a silent partner in the therapeutic alliance. As we conclude our journey through the nuanced landscape of countertransference, we are reminded of its dual nature—a potential stumbling block or a stepping stone to deeper understanding.

From Freud’s initial warnings to modern-day embrace of its informative power, countertransference remains a testament to the therapist’s humanity. It is a mirror reflecting the therapist’s own inner world, a compass that, when navigated with skill, can guide the therapeutic process to uncharted territories of the human psyche.

Let us part with the acknowledgment that countertransference, when harnessed with self-awareness and professional acumen, can illuminate the path to healing. It is not the presence of these reflections that defines the therapist’s journey, but the wisdom to discern their origin and the courage to explore their meaning.

As therapists, may we continue to strive for clarity, to recognize our own reflections in the therapeutic mirror, and to use the insights gleaned to enrich the tapestry of our clients’ lives. For in the realm of the mind, where emotions intertwine with thoughts, countertransference is the silent dialogue between two souls in search of understanding.

Last Update: February 12, 2026

References:

Freud, Anna (1937). The Ego and Mechanisms of Defense. ​Routledge; 1st edition. ISBN-10: 1855750384; APA Record: 1947-01454-000
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Freud, Sigmund (1920/1990). Beyond the Pleasure Principle. W. W. Norton & Company; The Standard edition. DOI: 10.1037/11189-000
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Gabbard G. O. (2020). The role of countertransference in contemporary psychiatric treatment. World Psychiatry: Official Journal of the World Psychiatric Association (WPA), 19(2), 243–244. DOI: 10.1002/wps.20746
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Nielsen, Arthur (2019). Projective Identification in Couples. Journal of the American Psychoanalytic Association, 67(4), 593-624. DOI: 10.1177/0003065119869942.
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Schore, Allan N. (2003). Affect Regulation and the Repair of the Self (Norton Series on Interpersonal Neurobiology). W. W. Norton & Company; First Edition. ISBN: 0393704076; APA Record: 2003-02881-000
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