Judith S. Beck, PhD, President

In CBT, countertransference refers to therapists’ unhelpful emotional or cognitive reactions to clients that may interfere with treatment if left unexamined.

As CBT therapist, what is the most important question to ask yourself to assess whether you’re having an unhelpful negative reaction to a client?

At the beginning of each workday, therapists should examine the list of clients they are due to see that day and ask themselves, “Which client (or clients) do I wish would not come in today?” Then they need to take steps, which are outlined later in this article, to ensure they will be able to establish a good working alliance in the upcoming session with that client.

What Is Countertransference in Cognitive Behavior Therapy?

Some therapists, even CBT clinicians, label unhelpful reactions to clients as “countertransference.” But that term has a specific psychoanalytic definition: a therapist’s unconscious responses based on their own unresolved conflicts. In CBT, though, we don’t necessarily view all our negative reactions as psychopathological or requiring remediation. It’s just human nature, for example, to be mildly annoyed when a client attends to a relatively unimportant text during a therapy session. Or to be anxious when a client expresses suicidal ideation or has a problem that the therapist feels ill-equipped to deal with. Therapists must be especially careful when clients display therapy-interfering behaviors, such as being manipulative, unmotivated, or resistant.

What Leads to Unhelpful Therapist Reactions?

Clients may fail to make progress. They may make unreasonable demands on their therapist or try to violate the boundaries the therapist has established. A client may remind the therapist of a difficult person in their own life, perhaps a parent, a boss, or a bully. Or maybe it’s the client’s attitude or behavior toward the therapist, especially if the client is disrespectful, unappreciative, aggressive, or rude.  It’s especially important for therapists to recognize their own reactions when they perceive that clients have violated one of the therapist’s key values, such as revealing neglectful, harsh, or abusive behavior toward young children.

A female therapist in session with a female client.

None of these behaviors necessarily lead to a therapist’s negative reaction. Some (usually highly experienced and competent) therapists may be able to handle these kinds of situations with equanimity, because they hold realistic expectations for themselves and their clients, for example, “Even though I’m a competent therapist, I can’t sufficiently help every client. No one can. If I have difficulty with a client, it doesn’t reflect on my overall competence” and “Given clients’ genetics and epigenetics interacting with the meanings they have derived from their life experiences, it makes sense that they behave exactly as they do.” 

However, it’s important for therapists to intervene when their reactions could negatively affect the relationship, potentially leading to a rupture. The following are a few examples of therapists’ behavior that are quite unhelpful: criticizing clients, speaking in an annoyed tone of voice, being overly controlling, or insisting that the client’s point of view is invalid.  It’s essential for therapists to acknowledge that clients are supposed to pose challenges in treatment—their challenges are why they need our help.

How Can CBT Therapists Manage Countertransference?

Fortunately, there are a number of steps you can take when you have an unhelpful reaction to a client.

  1. Monitor your reactions to clients during sessions and between sessions.
  2. Use CBT strategies to evaluate and respond to your unhelpful cognitions about the client, including self-compassionate techniques when relevant.
  3. Modify unhelpful expectations you hold for your client and yourself.
  4. Specify the client’s problematic behavior. Refrain from using a general description (“The client was being difficult.” “The client was resistant.” “The client was unmotivated.”) Instead, ask yourself, “What did the client say or do (or not say or not do) in the session—or between sessions—that was a problem?”
  5. Remain non-defensive; instead, become curious about the client’s behavior.
  6. Conceptualize the client’s underlying assumption that was associated with their behavior: For example, “If I lie to my therapist, she won’t criticize me.” “If I tell my therapist he’s wrong, he won’t try to make me change.” “If I exaggerate a crisis, my therapist will take my phone calls between sessions.”
  7. Ask yourself, “Is the client feeling safe enough with me?” Clients’ therapy-interfering behaviors are often associated with their attempts to protect themselves from the activation of their very painful beliefs about themselves and others (including you).
  8. Reflect (by yourself or with a supervisor or colleague) on how you might solve the problem.
  9. Make sure to set appropriate limits with the client.
  10. Work on accepting your own emotional discomfort.
  11. Do good self-care throughout the day.

Can Therapist’s Reactions Be Overly Positive?

While this article has focused on therapists’ unhelpful negative reactions to clients, it’s also important to monitor unhelpful reactions to clients that are overly positive. Therapists may, for example, empathize too strongly with clients or feel overly responsible for them. They may try to protect them from emotional pain by avoiding needed exploration of sensitive issues. They may idealize the client or become overly supportive. In these kinds of cases, therapists need to identify their own assumptions about the nature of therapy, the therapeutic relationship, and the best way to promote healing and progress for their clients.

It’s essential to have a good working relationship with clients. Predicting problems that could lead therapists to engage in unhelpful behavior during or between sessions is the first step in preventing these unhelpful reactions. Conceptualizing unhelpful beliefs of both the therapist and the client will help therapists figure out how to prevent or solve problems in therapy.  

Read more about the therapeutic relationship in CBT: