Transference and Countertransference Explained Simply

Transference and countertransference are not specific to the therapist’s office. They occur in all relationships: a boss may take on traits of the father, while the partner becomes the mother. Conversely, not every intense reaction is colored in this way. Psychoanalyst Michael Ermann refers to this everyday occurrence as external transference, for example, in a relationship with a partner or with colleagues. If the same coloring is directed at me as the therapist, he calls it internal transference. In English-language literature, you will find both terms under “transference” and “countertransference.”

This becomes useful in therapy. The patient unconsciously perceives the therapist in familiar roles: old patterns resurface in the current therapeutic relationship. The therapist does not play along with these roles. The fact that she feels these roles within herself for a moment is something else entirely. What becomes visible here are traces of subjective experience, not faithful reflections of the patient’s life story.

A pattern keeps repeating itself for me across many treatments, and it is internal transference in its purest form: For some patients, I become the bad father. Then I’m seen as having an attitude and traits that aren’t mine. If I offer a friendly, cautious interpretation, they take it as scathing criticism.

Countertransference is my reaction to the patient’s transference. The term is used inconsistently: broadly defined, it encompasses everything a therapist experiences during a session; in its most common version, it refers only to the unconscious aspect of that experience. That aspect remains unconscious. I do not experience it directly; I infer it. If I become impatient, at a loss, or conspicuously caring, that is not the phenomenon itself, but its conscious aspect, and that is information: it reveals something about what is currently at work. This cannot be read off without checking it. My reaction is always shaped in part by my own material: my history and my preconceptions. There is a specific term for this personal component, self-transference, and it usually cannot be neatly separated. The dynamic flows in both directions: the patient reacts to me, while I react to him.

That was not always how this emotion was viewed. Around 1910, Sigmund Freud still regarded it as an obstacle that had to be overcome so as not to interfere with treatment. It was not until Paula Heimann came along in 1950 that it became a diagnostic tool.

Within these reactions, the professional literature distinguishes between two types, which can be traced back to the psychoanalyst Heinrich Racker. Concordant means: I sense what the patient is going through. Complementary means: I sense what he unconsciously attributes to someone from his history.

I have concordant reactions very often, especially when someone is suppressing certain feelings: Then I sense them, or that person triggers them in me. The bad father from the previous section is complementary, seen from my side: I slip into the role in which he once experienced someone else, and I feel, for example, the impulse to react in an overbearing and strict manner.

I can defend myself, too, not against my own feelings, but against the patient’s experience taking hold within me. It is called “concordant” when what arises within me mirrors the patient’s own experience: He is desperate, and that desperation surfaces within me. That is precisely what can be defended against, and specifically with a different feeling. If I become angry, that anger can serve as a shield against letting his depression in. This costs me my connection to him, because this resonance would have been the path to understanding him.

Just one word. Between TP and analytical psychotherapy, there is only this one difference on this issue, and it is stated verbatim in the Psychotherapy Guidelines, which lay down how both guideline-based approaches are defined in Germany. TP addresses unconscious psychodynamics “with consideration of transference, countertransference, and resistance.” Analytical psychotherapy sets the therapeutic process in motion “with the help of transference, countertransference, and resistance analysis, utilizing regressive processes.” Considering versus analyzing: That is the difference, quoted verbatim from the Guidelines.

In practice, this means: I consciously limit internal transference, that is, what is directed at me as the therapist. Positive internal transference usually goes unmentioned; it underpins the work. Only when it turns into withdrawal from everyday life is it brought up. I work on negative transference because otherwise resistances can easily arise from it. Negative transference is often triggered by hurt feelings, shame, or the feeling of not being understood.

This is very clearly evident in how I address transference when it comes up in the session. My job is to bring it into the contact between us, but in a non-threatening way: not by forcing it on the patient or hammering it into his head. It sounds something like this: “I notice that I feel annoyed. Can you relate to that? Do you have similar feelings? What might that be connected to?” Or something like: “I notice that what you’re saying makes me sad. Does that make sense to you?” Both are questions, not interpretations.

This requires a high degree of self-reflection. That is why it is a separate required component of today’s psychotherapy degree program, and in the subsequent specialist training, personal therapy in the chosen approach is added.

Four studies offer an answer to this question, and the answer is not clear-cut.

A meta-analysis by Hayes and colleagues from 2018 evaluated several studies on the relationship between countertransference and therapeutic success. It defines the term more narrowly than I did above: it refers to reactions influenced by the therapist’s unresolved conflicts. Across the studies, countertransference reactions are associated with slightly poorer treatment outcomes (r = -0.16). Where these reactions are successfully managed, the picture reverses: there, the association is clearly better (r = 0.39). One limitation is worth noting: For this second finding, only nine studies involving a total of 392 participants are available, and the results vary widely across the studies.

As for the other question, whether explicit transference interpretations improve the results, a systematic review from 2024 summarized the current state of research: 21 studies, 13 of which showed a benefit for at least one measurement. However, the studies differ so greatly in terms of approaches, patient groups, and measurement instruments that the authors explicitly refrain from drawing any general conclusions.

A randomized study by Høglend from 2011 involving 100 adult patients shows this more clearly. Among those with mature relationship experiences and an already good working relationship, targeted transference work was less effective than not using it at all. Among those with less mature relationship experiences and a weak working relationship, however, it was helpful.

Among adolescents, a more recent study by Ulberg from 2021 had mixed results. The main test of psychodynamic functioning did not reach statistical significance. The depression scores, on the other hand, were significantly better with transference work.

My own view on this is different: The more trust develops in the relationship, the easier it becomes to address even the most difficult transference feelings. It always comes down to the “how.” Høglend’s study measures whether interpretations were made. I’m interested in how.