Countertransference: Ethical Implications

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Countertransferences represent “projections by therapists that distort the way they perceive and react to a client.”  (Corey, Schneider-Corey, & Callanan, 2007, p. 57)  Conversely, the Oxford Dictionary of Psychopathology further refines that basic definition of countertransference as follows:

Counter-transference (noun) In psychoanalysis, the analyst’s emotional reactions to the patient and to the patient’s transference, influenced by the analyst’s unconscious needs and conflicts.  It should be carefully distinguished from the analyst’s conscious reactions to the patient.  It was first mentioned by Sigmund Freud (1859-1939) in 1910 in an article on ‘The Future Prospects of Psycho-Analytic Therapy.’  Since the 1970s there has been an increasing tendency in psychoanalysis to exploit the counter-transference in a controlled manner as part of the technique of psychoanalysis, support for this approach being drawn from Freud’s comment in 1913 in an article on ‘The Disposition to Obsessional Neurosis’ that ‘everyone possesses in his own unconscious an instrument with which he can interpret the utterances of the unconscious in other people.’ (Colman, 2009, p. 177)

Using the latter definition, countertransference isn’t necessarily something we clinicians should avoid.  If instead we recognize, monitor, and manage our “output,” we can elicit genuine responses from our clients.

Consider the following example of psychotherapy of a military service member.

Just as a therapist avoids zealously demonizing the abuser in the therapy of a sexually traumatized borderline patient, the therapist avoids relishing in bloodlust or on the other extreme, exhibiting strong outward repugnance to combat while in the service of the patient’s therapy.  To do the former or latter could result in the patient closing off a valued aspect of themselves to the therapist, leaving the conflict maintained and the maladaptive behavior perpetuated.  (Kim & Gray, 2009, discussion para. 1)

As I reflect on the wide range of possible voluntary and involuntary reactions to the blood-spattered details of combat, I have to confess that I am probably prone to exhibiting disgust, and subsequently rejecting the client.  Generally speaking, the thought of hostility repulses me, yet it remains a constant concern (and source of post-traumatic stress) for our military service members who have served in combat.  Imagine the result if I were to share this aversion with a combat veteran without properly positioning the context.  It would inexorably poison the professional relationship, and it could potentially obstruct any attempt to proceed with psychotherapy in a productive manner.  There are a number of possible solutions to this dilemma.

Perhaps the solution to the predicament is to demonstrate some measure of therapeutic neutrality.  Neutrality has the therapeutic value of encouraging the patient to think for him or herself, and the ethical value of helping to avoid undue influence of the patient on the basis of the therapist’s values.  (Bishop, Josephson, Thielman, & Peteet, 2007, para. 2)  It could be argued that we could bottle up those concerns and allow for the therapy to continue.  Without a doubt, this is the “safe route.”  However, I believe in this situation it might be appropriate to push the boundaries of neutrality.

There is an alternative.  Individual psychotherapy with adults, if it is to foster such maturity, will accordingly adopt a flexible approach to the rules of therapeutic neutrality, balancing respect for the patient’s right to make his or her own choices with an acknowledgment that certain of the therapist’s values and beliefs will implicitly, and sometimes should explicitly, find expression in the therapeutic process.  (Bishop, Josephson, Thielman, & Peteet, 2007)  What I am suggesting is my reaction may be the reaction that he expects, and perhaps has even experienced when he has shared details of war with his support system of trusted friends and family members.  It is not out of the realm of possibility that the repulsive reaction itself is one that military people fear, and that subsequently contributes to one aspect of his post-traumatic stress.

So, instead of repressing that reaction and advocating therapeutic neutrality, I would suggest that we wield it to the benefit of the client.  I am implying that we could impress a line of questioning that addresses his support system, his friends, family, and trusted associates.  We could ask them if they have shared that experience with them, and subsequently ask the client what their reactions were.  We could continue that line of questioning to inquire about concerns regarding the sharing details of combat with his support system for fear of their reaction.  Inevitably the outcome of the discussion is indeterminable until it actually happens, but the end result is that our internal conflict as clinicians has been sufficiently leveraged to induce a positive line of questioning.

I would suggest this strategy has benefits for the client, the clinician, and the interplay of the clinical relationship.  Personally, not addressing the issue would cause me stress, which could inhibit my ability to perform my clinical duties.  Properly employed, a situation that was initially conceived negatively could be twisted to the benefit of the clinical relationship.  Ideally, the discourse would succeed in uncovering stressors that would have remained unaddressed otherwise, benefiting the client.  If, instead, we had remained neutral… we easily could have missed an opportunity to add value to the clinical relationship.

In closing, we should prepare ourselves for the inevitable event of conflicting feelings and values with our clients.  I believe this can be achieved through self-assessment and a rigorous commitment to accessing our emotional inventories. As our clinical experience grows, and our confidence grows with it, we should not only aspire to avoid the conflicts of countertransference, but aspire to wield it to the benefit of our clients.

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Bishop, L., Josephson, A., Thielman, S., & Peteet, J. (2007, Spring). Neutrality, autonomy and mental health: A closer look. Bulletin of the Menninger Clinic, 71(2), 164-179. Retrieved from

Colman, A. M. (2009). Oxford dictionary of psychology (3rd ed.). Oxford, NY: Oxford University Press.

Corey, G., Schneider-Corey, M., & Callanan, P. (2007). Issues and ethics in the helping professions (8th  ed.). Belmont, CA: Brooks/Cole.

Kim, E. H., & Gray, S. H. (2009, Fall). Challenges presenting in transference and countertransference in the psychodynamic psychotherapy of a military service member. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 37(3), 421-438. Retrieved from

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