Clinical Impact Statement: Countertransference (i.e., a therapist’s reactions that stem from the therapist’s own vulnerabilities and conflicts), particularly if not well managed, can impact psychotherapy treatment and affect its outcome. During the time of pandemics, a therapist might experience increased vulnerabilities, and/or might be exposed to increased triggers for countertransference (as potentially there is an increase amount of shared experiences with patients). Therefore, identifying countertransference, managing it, and using it in therapy could be useful to decrease the potential negative impact that countertransference can have in treatment.
During the past few months, the world has been experiencing unique challenges. We are all facing many environmental and social stressors (many of which are not new), which will impact us in various ways. We are not only experiencing the COVID-19 pandemic, but we are also experiencing the racism pandemic (Schullman, 2020). In the words of Fisher (2020):
The traumatic present is what we live in. The analogy that I keep thinking about is living in a war torn country, or living in a country where there is terrorism across social groups and all ethnicities. We have many war zones, we have the COVID war zone, we have the war zones of racism, the war zones of class and social economic inequality. For some of us, living in a war zone is very new. For others, this is the zone they’ve been living with, and now we have added COVID to it.
During therapy, patients share about their challenges related to the pandemics, such as physical distance and isolation, the pain and anger related to being discriminated against, health issues, confronting someone whose views regarding racism are different from theirs, decisions related to sending their kids back to school, and juggling work and home demands - some of which might also correspond to the therapist’s experience. Therapists and patients might also be experiencing similar emotional reactions. Additionally, the unique challenges of the COVID pandemic (i.e., physical distancing), and the changes that the pandemic has brought (e.g., no in-person meetings), have demanded important adjustments, all of which might also create a general state of stress or tiredness for therapists.
On the other hand, psychotherapists have shown resilience and adaptability in the face of challenges. We have quickly adopted telehealth services, adjusting procedures and documents accordingly. Additionally, we have been learning how to establish connection and conditions of safety for patients when the contact that we are having is virtual, and both therapists and patients might be facing a world that might feel threatening. However, in spite of such adaptations and responsiveness, there are several factors that could potentially interfere in establishing connection and conditions of safety for patients in treatment at a time when connection and safety feel crucial. One such factor is the therapist’s countertransference.
What is Countertransference?
There are many definitions and perspectives on countertransference. For the purpose of this work, countertransference is “…the therapist’s internal or external reactions that are shaped by the therapist’s past or present emotional conflicts and vulnerabilities” (Gelso & Hayes, 2007, p. 25). Countertransference can be chronic or acute (Gelso & Hayes, 2007) and can manifest as affect, cognition, and/or behavior (Gelso & Hayes, 2007). These reactions can affect treatment. Furthermore, Hayes et al. (2018) conducted a meta-analysis, and results showed that countertransference reactions are negatively related to treatment outcomes (although the effects of countertransference on treatment outcomes are small).
Additionally, even though countertransference refers to conflicts and vulnerabilities of the therapist, “countertransference always results from some mix of therapist and patient characteristics…” (Gelso & Hayes, 2007, p. 98). A therapist’s conflicts and vulnerabilities might not be triggered by each and every patient; thus, countertransference will be the result of therapist’s issues being activated by features of the patient that “push those buttons” or trigger such issues.
The current world context might introduce different sources of countertransference for therapists (e.g., therapists and patients might be sharing the same challenge of juggling work and home demands). Additionally, the uniqueness of videoconferencing might stir up and/or amplify a psychotherapist’s long-standing vulnerabilities. For example, a therapist with an anxious attachment style might experience heightened anxiety if he/she/they consider that teletherapy creates distance, and their overcompensation as a result of this might get in the way of connecting with a patient. Therefore, countertransference has the potential to affect the work negatively.
In a different vein, countertransference also has the potential of being useful and informative if the therapist can manage it (Gelso & Hayes, 2007). In addition, a meta-analysis found a positive relation between countertransference management and psychotherapy outcomes (Hayes et al., 2018). Thus, identifying, understanding, managing, and addressing our countertransference is central for psychotherapy work.
What Might Help Therapists Identify, Manage, and Use Their Countertransference in the Time of Pandemics?
Different factors have been related to countertransference management, some of which are inherent to the therapist (e.g., therapist characteristics), and others that are more about creating conditions that might aid in managing countertransference (e.g., supervision and consultation).
- It has been proposed that there are five therapist’s characteristics that affect countertransference management (Van Wagoner et al., 1991):
- Self-Insight (knowing and understanding oneself, including sensations, feelings, thoughts, behaviors, and motives)
- Conceptualizing Ability (using theory to understand the dynamics of the patient and of the therapy relationship)
- Empathy (putting oneself into another’s shoes, including feeling what the other person is feeling, and intellectually understanding such experience)
- Self-Integration (“…having a relatively stable identity, being able to differentiate from others, and generally possessing sound psychological health,” Gelso & Hayes, 2007, p.99)
- Anxiety Management (allowing oneself to feel anxiety, control it, and understand it)
- These characteristics are interrelated and can be considered “constituents of the countertransference management process” (Gelso & Hayes, 2007, p. 101). These factors have been mostly assessed by the Countertransference Factors Inventory (CFI; Van Wagoner et al., 1991), and its variations (e.g., CFI-R; Hayes et al., 1991).
- Pérez-Rojas et al. (2017) developed a scale to assess countertransference management in the therapy hour (Countertransference Management Scale; CMS). It encompassed the previously mentioned five factors; however, factor analysis showed that two factors emerged:
- Understanding Self and Client - which comprised therapists’ self-awareness; understanding (including conceptual understanding- of the self, the client, and the dynamics between the therapist and client); and empathic understanding of the client.
- Self-Integration and Regulation - which included items related to manifesting self-integration and adequate anxiety management during the therapeutic hour.
- According to Hayes et al. (2018), these factors “…appear to be useful for understanding and controlling countertransference manifestations” (p. 504).
- Several authors emphasize the importance of self-care to manage countertransference (Baehr, 2004; Hayes et al., 2018; Pérez-Rojas et al., 2017). This includes healthy eating, getting adequate sleep, regular exercising, engaging in hobbies or activities one enjoys, socializing, and so forth. Self-care might help us increase resilience and wellbeing, and “having a good baseline” helps with not only experiencing less countertransference but also containing countertransference reactions.
- Considering that we are in a time of pandemics, self-care can include awareness of time spent watching the news (and restricting such viewing if needed), being mindful of not spending too much time videoconferencing (e.g., to avoid “Zoom fatigue”). Additionally, due to physical distancing, it might be relevant to be aware of and to address our need for connection (e.g., engaging in videoconference calls with friends and/or family).
- Mindfulness is “… paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally” (Kabat-Zinn, 2005, p. 4). The practice of mindfulness can take many forms, one of which is meditation.
- Both quantitative (Fatter & Hayes, 2013) and qualitative research (Millon & Halewood, 2015) have found that meditation is positively related to countertransference management, and several authors (e.g., Baehr, 2004; Hayes et al. , 2018) highlight the benefits of engaging in meditation practice for therapists.
- Importantly, when looking at the relation between the different therapist’s factors and amount (i.e., hours per week) and frequency of meditation per week, the amount and frequency of meditation was only related to self-insight (Fatter & Hayes, 2013). Additionally, in Millon and Halewood’s study (2015), therapists did not report a reduction in amount or intensity of countertransference reactions due to mindfulness meditation, yet they identified that such practice allowed for a different way of relating with their countertransference experiences (i.e., with openness and acceptance).
- Meditation practice comprises the capacity to increase one’s observing and containment of one’s own reaction, and as such, it can be considered a skill. Because of meditation’s relevance in the reviewed literature, and that this skill can also relate to other factors (e.g., increase self-insight), it is presented separately from self-care.
Curiosity and Compassion
- According to Fisher (2020), curiosity is diminished in times of crisis; thus, as an antidote to the current pandemics, she proposes to increase curiosity, as it “uses the mind to be interested rather than reactive.” Increasing curiosity could help therapists increase some of the therapist factors previously mentioned (e.g., empathy), and decrease reactivity, which is frequently associated with countertransference.
- Fisher (2020) also states that compassion is a “mind and body experience that elicits feelings of warmth, relaxation, support” and recommends being compassionate with ourselves and others as a way to address the fact that “currently the world is traumatic” (Fisher, 2020).
- Therefore, curiosity and compassion could allow us to learn about and relate to ourselves and others in a different way than the one that stems from countertransference reactions in a time of pandemics.
Knowledge and Practice
- To better understand and address countertransference, it is beneficial to increase our knowledge about countertransference and countertransference management. Such knowledge could include learning about countertransference (e.g., the difference between concordant and complementary countertransference, the difference between countertransference and projective identification), therapist’s self-disclosure, processing the therapeutic relationship, addressing ruptures and repairs in treatment, racial identity models; attachment styles, among others. However, knowledge by itself is not enough, as we need to be able to translate such knowledge into practice for it to become useful.
- Practicing ways to address countertransference in treatment might help us feel more prepared to do so when it occurs, as it could provide a template to relate to ourselves and our patients. Such practice has the potential to be very beneficial as we are providing telehealth services.
- Several authors have recognized the relevance of practice to increase therapists’ effectiveness, promoting Deliberate Practice, which “…is arguably the most evidence-based method we know of to improve performance in an effective and reliable manner” (Deliberate Practice Institute, 2020). Deliberate Practice involves much more than engaging in practice, and as such, intersects with other factors presented in this list (e.g., supervision). However, it is addressed in this section as the team from the Deliberate Practice Institute (2020) created a series of videos presenting clinical challenges that can arise while providing teletherapy in the time of COVID-19. Such practice opportunities could allow a therapist to identify his/her/their countertransference reactions to different types of clients and issues during the time of pandemics, and to practice ways of responding. Additionally, it could also increase self-insight (e.g., it could help someone identify, from their responses to the practice videos, who triggers what and when).
Supervision and Consultation
- Supervision and consultation could help therapists identify their countertransference, practice how to manage it, address it if it has been acted out, and use it to inform the work (Hayes et al., 2018; Pérez et al., 2017).
- Additionally, it could potentially provide some normalization in relation to what it is to have reactions due to one’s own conflict and vulnerabilities, and it can help identify when added aid (e.g., psychotherapy) might be needed.
- The therapist’s personal therapy can become essential to address conflicts and vulnerabilities, particularly when dealing with chronic countertransference issues (Gelso & Hayes, 2007; Hayes et al., 2018).
- In a time of pandemics, personal therapy can also provide space to process the different aspects that are affecting our overall wellbeing.
Countertransference can affect treatment. During times of internal or external turmoil, therapists must be able to manage their conflicts and vulnerabilities that might arise during a session. The previous list of factors can help therapists to identify, address, and use countertransference in the time of pandemics, but this list is by no means exhaustive. Further research is needed to determine the role of these factors in managing countertransference in the time of crises, and their relation to treatment outcome.
Cite This Article
Palma, B. (2020). Identifying, addressing, and using therapists’ countertransference in the time of pandemics. Psychotherapy Bulletin, 55(3), 14-19.
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Fisher, J. (2020). Tigers running wild: Living in a time of threat [Webinar]. Academy of Therapy Wisdom. https://therapywisdom.pages.ontraport.net/tigers-replay
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Shullman, S. L. (2020, May 29). APA. ‘We are living in a racism pandemic’ says APA president. https://www.apa.org/news/press/releases/2020/05/racism-pandemic
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