A Countertransference Checklist for Therapists: A Preliminary Reflection Tool
Introduction
Therapy is an inherently relational process. Given that clinicians are human, it’s natural that clinicians may experience a range of emotional responses towards patients, potentially including warmth, attachment, protectiveness, or more “challenging” emotions like frustration or boredom.
The reflection prompts below are an attempt to think through how those emotional responses, along with burnout and other stressors in the clinician’s life, might gradually increase the risk of therapy harm if they go unrecognized. This is not an official metric, but rather a tentative tool that I hope may help clinicians:
1.) Identify patterns of emotions towards their patients
2.) Identify signs that their own professional capacity may be reduced (e.g. due to burnout)
3.) Identify early warning signs of boundary crossings or escalating flexibility that may lead to therapy harm (e.g. embarrassed to share one’s feelings or actions transparently with a supervisor or making increasing exceptions for a patient)
I don’t think that emotions themselves – even very strong emotions– are inherently bad. However, I believe that if emotions are not recognised or acknowledged (i.e. if the clinician hasn’t been self-reflective about their own countertransference), there can be a risk of harm to the patient and this risk is likely heightened for particularly strong or increasing emotions. Likewise, while I don’t believe that anyone should ever feel shame or guilt about burnout or extenuating circumstances in their own life, it is still valuable for clinicians to reflect on when changes related to these might “spill over” onto a patient.
Note on phrasing: the items below are written how I imagine a clinician experiencing the corresponding item might phrase it. For example, while I personally think the concept of “enough progress” in therapy is a tricky one, I imagine a clinician who is feeling frustration might reach for a term like “not enough progress”, and so have used that phrase.
Disclaimer- I am not a licensed clinician, and this checklist is not an official clinical tool or guideline, or meant to provide professional advice.
Self-reflection checklist about emotions towards patient:
(Suggestion- When evaluating this section, for each item that applies, consider:
Whether it is increasing in intensity over time
Whether it is specific to this patient, common for you, or reflective of a more general burnout
Whether you would feel comfortable transparently discussing it in supervision)
Feelings of “specialness” or positive regard:
I tend to have strong emotions (e.g. happiness, excitement) leading up to meeting with the patient or client
I feel energised when working with the patient or feel like there are frequent breakthroughs
I view the patient as especially insightful, unique, or special
I sometimes feel flattered or grateful for my patient’s positive transference or deep attachment towards me
Feelings of closeness or attraction to the patient:
I feel extremely trusting of the patient
I feel attracted or drawn to the patient in some way (physically, emotionally, mentally)
At times, I have wished that I had instead met the patient as a friend or date (or in another role)
Sometimes the patient is so easy to talk to that I end up disclosing more than I planned (or sometimes it is hard not to feel friendly towards the patient)
Feelings of frustration, indifference, or “negative” regard:
I sometimes dread or feel less enthusiastic about meetings with the patient
I sometimes feel relief when the patient cancels (or would feel relief if they cancelled)
I feel especially guarded around this patient
I sometimes feel (or feel guilt over feeling) “negative” emotions like irritation, frustration, or boredom when working with the patient
I find myself thinking about the patient much less often than usual outside of sessions
I sometimes feel “stuck” when working with the patient, or as though I wish there had been more progress
I view the patient as especially difficult, selfish, or manipulative
I think I would feel relief if the patient wanted to switch clinicians
I sometimes feel frustrated or tired of my patient’s negative transference or criticism towards me
“Intensity” towards the patient:
I worry about the patient quite a bit
I find myself thinking about the patient or client more often than usual outside of sessions
I have had dreams or nightmares about the patient
I have daydreamed about the patient at times
Sometimes things (books, events, songs, etc.) remind me of the patient
I feel especially emotionally invested in this patient
I sometimes miss the patient or feel unusually disappointed if a session is cancelled
I often wonder what the patient thinks of me as a person
I think I would have a hard time adjusting if the patient wanted to switch clinicians
Insecurity related to working with the patient:
I sometimes feel more insecure or hesitant when working with the patient
I often feel nervous before sessions
Sometimes I feel like an imposter or wonder what I am doing “wrong” that the patient is not making more progress
I feel like the patient and I have very different communication styles, and misunderstandings are frequent
Other (connecting the patient to other aspects of my life)
The patient reminds me of myself in some ways
The patient reminds me of someone else in my life in some ways
Some of the patient’s traumas overlap in some way with my own
Feelings related to the capacity of the patient:
Sometimes the patient seems so wise, insightful, or mature that it is easier to forget the power dynamics of therapy (or it feels more reasonable to take some liberties with the boundaries)
Sometimes the patient seems so helpless or vulnerable that it is easy to forget they have areas of strengths or resilience
I feel a need to save or rescue the patient at times
Burnout and Professional Capacity:
Burnout:
Sometimes I dread going to work (in general)
I sometimes miss the version of me that used to look forward to seeing patients
I feel pressure (due to finances, pressure from my employer, etc.) to see more patients than ideally I would want to
There just isn’t enough time to prepare for each session as much as I would like to
Sometimes I am so tired or burnt out that it feels like a relief when sessions are more positive or “easy”
Conversely, sometimes I am so tired or burnt out that it is hard to respond as well to more intense or complex sessions
Personal trauma or extenuating circumstances:
I’m going through so much in my own life that it feels hard when patients seem to want even more from me
I have had major traumas or stressors in my own life recently or have had external circumstances impact the way I provide therapy
I have had to frequently cancel or reschedule sessions due to everything going on in my own life
My life feels very unpredictable right now
I feel like I don’t really have the time or energy to seek ongoing training, education, or consultation right now (even if in theory I think it might be beneficial)
Skillset:
The patient has a condition that I am not very familiar with or is part of a marginalized group that I am not part of
There have been some misunderstandings related to aspects of the patient’s experience or identities in therapy so far
I sometimes think or wonder if the patient needs a higher level of care than what I can provide
I feel like the patient is “at the edge” of my scope of practice
Some potential “warning signs” of therapy harm:
I would feel embarrassed to tell my supervisor (or a hypothetical supervisor) the full extent of my feelings or interactions with the patient
I have delayed seeking consultation about this case despite recognising the potential need for it
My feelings towards the patient (whether of closeness, frustration, “specialness”) have been growing with time
Difficulty “managing” feelings:
I think I can “manage” my emotions (i.e. not show frustration or inappropriate attachment in sessions), but it is very challenging or takes a lot of energy
I think I can mostly manage my emotions, but I worry there have been times where they have shown through in small ways
I don’t think I have been able to manage my emotions
Over time, it has become more challenging to manage my countertransference
I have made some exceptions for the patient (particularly if the amount of exceptions are growing with time)
There have been repeated ruptures that remain only partially repaired or unresolved
The patient seems to be giving me more and more intense feedback recently (e.g. that they are struggling in therapy or feeling very conflicted about therapy)
