Countertransference and Serious Illness Care

Students of counseling study themselves as part of the strategy to keep their personal issues out of the way of their clients. Countertransference is often unconscious and occurs when the clinician lets their own feelings shape the way they interact with or react to their client. Students of nursing or medicine or pharmacy do not usually learn this same principle or develop the ability to note how their own reactions are evoked by the client. Patients may hook the clinician’s life experiences. If the clinician is not aware of this countertransference, this can cause difficulty for both the patient and the clinician, and at minimum decrease clinical effectiveness.

For example, the “helper” may have cared for a parent with a brain injury. A patient with a brain injury can trigger the clinician’s personal experience so that the differences between the patient and the clinician’s family experiences become murky. The clinician may assume the patient’s experience is just like their own family member when those experiences are markedly different. When contrasts between personal history and the patient are missed, the clinician may project previous experiences on to the patient.

The concept of countertransference is largely discussed related to psychotherapy and an article in World Psychiatry also proposes that the meaning of countertransference has broadened since first suggested by Freud. Countertransference, when examined, can be useful information about the patient, because a clinician may react to the patient in the same way that others do. These perceptions may offer important information about how the client or patient relates to other people. Yet strong emotions towards the patient may also represent unresolved emotional issues or conflicts within the clinician.

The mirror side of countertransference is transference, the patient or client’s emotional reaction to the clinician. These reactions can be rich to explore, but only if acknowledged with awareness and a conscious effort to sort out the layers of feelings and beliefs.

Palliative care has strong ties to counseling due to issues of deep meaning, existential distress, and a care delivery model devoted to full person care. Therapeutic models have shifted away from strict adherence to analytical models toward an “authentic human relationship.”

“Transference phenomena is common in clinical care. It is not inherently pathologic, nor does it reflect failure on the part of the clinician or patient. Yet, if unrecognized, it can potentially lead to harmful consequences for patients and clinicians. For example, transference phenomena can contribute to implicit biases…” 

Palliative care offers one of the most intense human experiences, awareness of our own mortality. Yet, hospital culture and medical training “discourage engagement with mortality.”

How do feelings of countertransference show up in behaviors?

  • Avoidance
  • Impatience
  • Irritability
  • Fear of loss
  • Strong opinions
  • Numbness or deadening of emotions.
  • Feelings of depression, hopeless or helpless thoughts
  • Feelings of ineffectiveness
  • Decreased energy
  • Too much or too little sleep or food

What can a palliative care clinician do to minimize the risk from unconscious countertransference?

  • Examine and name emotions as they arise.
  • Build regular consultation into your practice, whether with peers or a consultant outside your team.
  • Foster a style of teamwork that acknowledges the role of countertransference and facilitates dialogue to move through personal triggers.
  • Know your own triggers, generally created by high intensity relationships and experiences in your life.
  • Recognize that being hungry, tired, or lonely may reduce your ability to moderate emotions.
  • Practice pausing when strong emotions are evoked and give yourself time to reflect and learn from your feelings without acting on the impulse.
  • Acknowledge and normalize feelings without over-catastrophizing emotions triggered during the clinical encounter. 
  • Recognize self-awareness as an ethical responsibility for anyone in a position to offer whole person care.




A Safe, Virtual Space to Debrief

Join CAPC’s, Breaking Point: Debriefing to Address the Challenges of Our Work Virtual Office Hours. These informal, confidential, facilitated discussions provide an opportunity to share common reactions to the demands of your work and coping strategies that may diminish the consequences of the stress.


The book previously studied in the WA Rural Palliative Care Initiative, When Professionals Weep: Emotional and Countertransference Responses in Palliative and End-of- Life Care, edited by Robert Niemeyer, Renee S. Katz, Therese G. Johnson, and Therese A. Johnson offers an in-depth examination of the topic of countertransference in serious illness care. The book includes a section by WA’s beloved Stu Farber, MD.

The Center for the Advancement of Palliative Care (CAPC) has an article on countertransference in palliative care entitled Countertransference in Palliative Care Practice: What’s a Clinician to Do? Updated February 9, 2022 | By Jill Farabelli

Pat Justis, Washington State Department of Health