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PSYCHOANALYTIC SOCIAL WORK
Clinical Crossroads: Countertransference, Ethics, and
Premature Termination
Dena Werner and Daniel Pollack
Wurzweiler School of Social Work, Yeshiva University, New York, New York, USA
ABSTRACT
The literature extensively examines the clinical constructs of
countertransference and premature termination through sev-
eral theoretical orientations. It explores how countertransfer-
ence is one of the most significant variables in successful
therapy outcomes, and how premature termination is often an
outcome of a poor therapeutic alliance stemming from the cli-
ent’s insecure attachment to primary caregivers (Berg & Lundh,
2022; Westerling et al., 2019). However, few studies explore the
interconnection of these two constructs and how clinicians
process their countertransference when it interferes with their
ability to provide effective treatment. Despite the gap in the
literature, clinicians are bound to experience countertransfer-
ence in their work with clients; thus, the literature must provide
language to describe these experiences to lessen the feelings
of guilt, shame, and uncertainty that tend to emerge through
these processes. This clinical note aims to provide a review of
these constructs through a case study to emphasize the clini-
cal, ethical, and legal dilemmas clinicians encounter when they
experience countertransference throughout the course of ther-
apy. While experiences of countertransference are intimate and
painful for the clinician, they are bound to happen; and it is
the responsibility of the clinician to address them in the best
interest of the client.
Introduction
Social work literature extensively examines the notions of countertrans-
ference and therapeutic impasses through various theoretical orientations.
The challenges of termination are also discussed (Prasko et al., 2022);
however, few studies explore the clinician’s countertransference and sub-
sequent decision to initiate an untimely termination. The ethical dilemma
of initiating termination becomes increasingly complex when considering
the client’s presenting problem, attachment style, and the nature of the
therapeutic relationship (Dalenberg, 2005). This dilemma may be exacer-
bated by the clinician’s conflicting feelings and concerns about
https://doi.org/10.1080/15228878.2024.2330356
© 2024 Taylor & Francis Group, LLC
CONTACT Dena Werner Dwerner1@mail.yu.edu Wurzweiler School of Social Work, Yeshiva University,
2495 Amsterdam Avenue, New York, NY 10033, USA.
KEYWORDS
Psychotherapy;
countertransference;
premature termination;
ethical dilemma
2 D. WERNER AND D. POLLACK
unintentionally hurting or abandoning their client (Prasko et al., 2022).
Weddington and Cavenar (1979) refer to this as the “countertransference
storm,” since many clinicians feel insecure and flooded with feelings of
guilt, shame, and self-doubt. Yet, when a client’s narrative triggers acute
discomfort in the clinician, it is simply a sign that the clinician needs to
be aware of the thoughts and feelings that are being elicited within them.
These countertransferential responses can then be used as a tool to deepen
the therapeutic process.
Everyone carries the weight of their past relationships and experiences.
Countertransference is not an indication of incompetence, rather it is a
subjective experience that informs clinicians of their individual and shared
experiences in the room (Dalenberg, 2005; Westerling et al., 2019). Just
like the signs on the highway are indicative of what the speed limit is
and intend to provide direction in consideration of fellow drivers and
safety laws, countertransference is a routine aspect of being a clinician
and is a primary tool of clinical work. Experiences of intense affect in
the room provide valuable insight for the clinician, oftentimes redirecting
the work into deeper territory where profound healing can take place.
Countertransference
As the field of psychotherapy evolves, so does the understanding of coun-
tertransference. Based on the work of Freud and other leading analysts,
countertransference was defined as a clinician’s response to their client’s
transference (Abargil & Tishby, 2021). Freud developed this term in 1910,
and from his classical vantage point, countertransference was to be avoided
at all costs lest it interfere with the work. Freud first alluded to this term
in a letter to Carl Jung in regard to a love relationship he had with a
patient (McGuire, 1979). Unlike Freud who believed this would be an
obstacle to Jung’s treatment with his patient, Jung viewed this emotional
reaction as the heart of his method and invited these countertransferential
feelings to guide his work (Jung, 1944; McGuire, 1979). Although they
did not openly discuss their opposing views, a year later Freud coined
the term countertransference and explained, “We have become aware of
the ‘countertransference’, which arises in him as a result of the patient’s
influence on his unconscious feelings, and we are almost inclined to insist
that he shall recognize this countertransference in himself and overcome
it” (Freud, 1910, pp. 144–145). While Melanie Klein and others concurred
with Freud’s interpretation of countertransference as being an obstacle to
the work, succeeding theorists began to conceptualize this construct from
a broader perspective (Stefana et al., 2021).
In the 1950s, the psychoanalytical interpretation of countertransference
reached a new dimension. Theodore Reik was one of the leading theorists
PSYCHOANALYTIC SOCIAL WORK 3
to suggest a different perspective with the publication of his book, Listening
with a Third Ear. In his work, he suggests clinicians must use their uncon-
scious to guide intervention. Several psychoanalytical theorists followed
in his footsteps and concurred with the belief that clinicians need to
sustain and work with their affect, not hide, or try to eradicate it. In an
article on countertransference, Paula Heimann (1949) writes, “My thesis
is that the analyst’s emotional response to his patient within the analytic
situation represents one of the most important tools for his work. The
analyst’s countertransference is an instrument of research into the patient’s
unconscious” (p. 81). Her work, along with other leading psychoanalytical
theorists, suggests that countertransference includes all emotional reactions
to a client and is an opening for deeper work. As Racker (1957) explained,
“Countertransference is the entirety of images, feelings, and impulses
towards the patient—an important tool for analytic practice” (p. 323). He
held that unprocessed countertransference could distort the clinician’s
interpretations and behaviors toward their client, and in turn influence
the client’s transference. This perspective lends insight into the work of
Winnicott (1949) who defined countertransference as a portion of the
client’s transference and labeled it as objective countertransference. To sum-
marize, this means that the therapist’s unprocessed pathology might inter-
fere with his ability to respond therapeutically, inadvertently eliciting a
transferential response within the client. Of course, the response elicited
will be specific to the client’s pathology and unconscious conflicts, and
thus Thomas Ogden (1979) built on this construct to develop the term
projective identification. He explains this as the clinician’s participation in
the emotional journey of the client but argues that it is stemming from
the client’s transference as opposed to the clinician’s countertransference
(Ogden, 1979; Weiss, 2014). Undoubtedly, these conceptualizations of coun-
tertransference greatly differ from Freud in the belief that it is not merely
an obstacle to treatment but can simultaneously be the most instrumental
tool and greatest danger to treatment (Stefana et al., 2021).
Researchers continued to study this construct and wondered whether
these unrecognized or unexplored emotional reactions could provide clues
about ruptures in the therapeutic alliance (Aleksandrowicz & Aleksandrowicz,
2016; Berg & Lundh, 2022; Hayes, 2004). With time, psychoanalytic the-
orists began to understand that countertransference is not merely a clini-
cian’s reaction to a patient, nor does the response belong solely to the
clinician; rather it is an outcome of a relational experience between the
clinician and client (Abargil & Tishby, 2021). In the late 1990s, Gelso and
Hayes aligned with this perspective by explaining that countertransference
is simply a tool to enhance the work of psychotherapy (Marin, 2019).
They further defined countertransference as “The therapist’s responsibility
in the intersubjective experience of psychotherapy” (Marin, 2019, p. 182).
4 D. WERNER AND D. POLLACK
This conceptualization strengthens the notion that countertransference is
not a sign of incompetence or an obstacle to the process but rather a
means by which clinicians can deepen their work with clients. This the-
oretical perspective differs greatly from Freud and other theorists who
suggest countertransference is an obstacle to the work. The assumption is
that when it is not used as a tool to guide treatment, countertransference
could lead to ruptures in the therapeutic alliance. In light of the differing
opinions, it is important to clarify that the authors hold the theoretical
perspective and carry the assumption that countertransference is the heart
of the method of treatment and one of the leading variables in successful
therapy outcomes (Westerling et al., 2019).
Countertransference exists on varying levels of consciousness within the
clinician. Whether spoken about or not, these experiences exert a powerful
influence on the therapeutic relationship and course of treatment (Foster,
1998). Clinicians will use different coping strategies and defense mecha-
nisms to manage their discomfort, and most often, clients will recognize
these reactions, even if only viscerally. Unmanaged countertransferential
reactions will often cause a clinician to become less attuned to their client’s
needs and consequently lead to ruptures in the therapeutic alliance (Penn,
1990; Tishby & Wiseman, 2022). This can be detrimental to the therapeutic
alliance and course of treatment; however, when processed and used skill-
fully, strong, and intense emotional reactions within the clinician can be
highly valuable to the work (Penn, 1990). It increases empathy, compassion,
and creates an opening for the clinician to connect more authentically
with their client.
Recent research focuses on the interconnection between countertrans-
ference and the attachment of the clinician and client (Barreto & Matos,
2022). The ways in which clinicians respond to their clients maintain
therapeutic and diagnostic value as these responses provide information
about both their internal working models (Westerling et al., 2019). The
concept of an internal working model was developed by John Bowlby (1988)
in his effort to theorize attachment and explain how humans develop
relational schemas. According to Bowlby, the internal working model is a
primary adaptive structure that provides children with the ability to develop
relationships with significant others. These relational schemas are reenacted
in the helping relationship, and thus therapeutic interactions will provide
insight into the clinician’s vulnerabilities and the client’s relational struggles
(Bowlby, 1988; Obegi & Berant, 2010). The research shows a clinician’s
countertransference will manifest itself in the room as “over-engaged” or
“disengaged” (Berg & Lundh, 2022). This is often seen in the clinician
who over-identifies with the client, resulting in over-engagement, or the
clinician who under-identifies with their client, resulting in higher levels
of disengagement (Berg & Lundh, 2022). These responses are based on
PSYCHOANALYTIC SOCIAL WORK 5
the attachment styles of both parties, and the one that is more likely to
emerge in the room based on the unique relational dynamic of the clini-
cian and client. For instance, clients with avoidant attachment tend to
engage with less reactivity while those with anxious attachment respond
with hyperactivation and a greater need for close proximity with the cli-
nician (Westerling et al., 2019). Clinicians will then respond to these
attachment needs based on their own primary attachment style, further
emphasizing their vulnerabilities and internal working models (Barreto &
Matos, 2022). Again, these countertransference responses serve as infor-
mation to enhance the therapy process and need to be acknowledged and
processed by the clinician.
Termination
Similar to the construct of countertransference, the concept of termination
was originally introduced by Freud as well. Although the term termination
seems to connotate a harsh indication of the ending of psychotherapy,
Freud chose this term with the intention of conveying that therapy is a
limited experience and clients will continue to endure adverse life events
and emotional challenges beyond the therapeutic encounter (Schachter
etal., 2018). As he stated, “Our aim will not be to demand that the person
who has been “thoroughly analyzed” shall feel no passions or develop no
internal conflicts” (Freud, 1937, p. 250). He further explains that clinicians
will not always fully meet their goals through their course of work with
a client. He supports this theoretical perspective based on his belief that
unless a conflict is present, it is unavailable for analytic interpretation or
interruption (Freud, 1937).
Termination remains a multi-faceted construct of therapy and theorists
continue to grapple with its complexity as they study it both from the
perspective of the clinician and client. The recent work of theorists explains
that the process of termination often triggers earlier attachment wounds,
histories of painful losses, and underlying pathologies (Barreto & Matos,
2022; Berg & Lundh, 2022; Schachter et al., 2018; Tishby & Wiseman,
2022). As seen in the literature, many of these are shared experiences of
the clinician and client. While clients might struggle with accessing these
experiences, clinicians cannot ignore or deny their emotional reactions
but need to affirm their humanity in the therapy room. By doing so, they
will strengthen the alliance, model healthy relational interactions, and
enrich the termination process for the client.
Clinicians tend to experience increased positive feelings of pride and
satisfaction when termination is timely, and display more intense reactions
of loss, shame, and incompetence when it is abrupt, untimely, and pre-
mature (Alfonsson et al., 2023; Fragkiadaki & Strauss, 2012; Lee et al.,
6 D. WERNER AND D. POLLACK
2023). Generally, there are four main types of termination: client-induced,
clinician-induced, mutual, and forced (Lee et al., 2023). While this man-
uscript briefly examines these different forms of termination, the focus of
this study is to shed light onto the intricacies of premature termination,
which is also referred to as “forced termination” by multiple authors.
Premature termination
There is minimal research on the termination phase of psychotherapy, let
alone the intricate process of premature termination (Kramer, 1986). While
clinicians lean on multiple theoretical constructs to navigate the ending
phase of treatment, these practices are often inept when it comes to pre-
mature terminations. The term premature termination is loosely defined
as the untimely completion of therapy that defies an opportunity for
resolution (Frayn, 1992). While there are several conditions that predict
premature termination, the research mainly focuses on therapeutic impasses,
alliance ruptures, and the client’s level of social, emotional, and intellectual
functioning (Frayn, 1992). The research further emphasizes that most
incidents of premature termination are a result of the client’s lack of
compliance, poor functioning, or inability to engage in treatment (Frayn,
1992; Kramer, 1986; Siebold, 1992). The studies show the majority of
clients who end therapy prematurely struggle with a low tolerance for
uncertainty, high levels of dysregulation, and insecure attachments with
primary caregivers (Piselli et al., 2011). This occurs because the process
of individuation and separation is enacted within the therapeutic relation-
ship as well (Siebold, 1992). When these reenactments are addressed
skillfully by the clinician, they create an opening for healing. However,
when they are overlooked or undermined, the rupture itself becomes the
reason for an untimely termination as the client is not able to integrate
their transferential reaction in a healthy way.
Most of the literature holds the client responsible for the premature
termination; however recently, researchers began to examine the clinician’s
role in unsuccessful treatment outcomes (Alfonsson et al., 2023; Levitt
et al., 2016). Alfonsson et al. (2023) conducted a qualitative study on the
mediating variables of premature termination from a client’s perspective.
Their study highlighted many critical components, including the impor-
tance of relational skills, theoretical and cultural competence, personality
traits, and levels of engagement. Of course, serious breaches of boundaries,
confidentiality, or lack of competence would necessitate termination on
behalf of the client, but such circumstances significantly differ from those
where ethics, values, and professionalism were practiced. Thus, these con-
clusions compel us to ask the question of, “If all is going well, what drives
a client to terminate prematurely?” Clinicians will rely on multiple
PSYCHOANALYTIC SOCIAL WORK 7
theoretical constructs to understand these processes, but from the client’s
point of view it is often a result of disengagement, lack of progress, dete-
rioration of symptoms, loss of confidence and hope in recovery, unresolved
therapeutic ruptures, financial, or interpersonal struggles (Barlow, 2010;
Bowie et al., 2016; Levitt et al., 2016). This question lends itself to yet
another one, “What could clinicians do differently to avoid negative treat-
ment outcomes and premature terminations?” While many clinicians rely
on attachment theory to understand these alliance ruptures and treatment
failures, this phenomenon also needs to be examined from the client’s
perspective to enhance practice procedures. This assumption is examined
more fully in the work of Judy Kantrowitz (2014) where she explains the
significance of listening to our patients for guidance in understanding their
relational needs.
Premature termination is often referred to as a painful process; however,
every so often it is a neutral agreement between the clinician and client
(Siebold, 1992). That is, both clinician and client agree termination is the
most plausible course of action and the surrounding affect is neither
intensely positive nor negative. While some clients abruptly terminate
treatment, others discuss their dissatisfaction and concerns with their
clinicians, allowing for a more positive outcome. Other times, the clinician’s
keen awareness guides them to end the relationship in a safe and holding
manner (Kramer, 1986). The latter, though engendered by the clinician in
a reflective way, could still result in clinical, ethical, or legal
consequences.
While clients play a role in their decision to terminate prematurely
from treatment, the countertransference of clinicians also influences the
ending of a therapeutic relationship. Clinicians experience countertrans-
ference at varying levels of consciousness which tend to be aroused in
response to family of origin, social, cultural, or earlier traumatic experi-
ences (Foster, 1998). These countertransferential reactions stimulate a flow
of information between the clinician and client and allow for the clinician
to tap into the client’s adverse childhood experiences that may have pre-
ceded verbal and linguistic development. Studies show that clinicians
working with trauma survivors have stronger somatic and emotional reac-
tions to their clients’ experiences, and therefore need to take intentional
steps to address these responses in supervision and personal therapy
(Cohen & Collens, 2013; Marin, 2019). This presents as being attuned to
one’s somatic and emotional responses in session, being open and curious
to explore these reactions in supervision and personal therapy, and taking
responsibility for how these issues might surface in the therapy room
(Marin, 2019). Oftentimes, clinicians dissociate certain painful experiences
to the extent in which they remain unconscious; however, the client might
still notice and respond to it. It is therefore also the clinician’s
8 D. WERNER AND D. POLLACK
responsibility to practice observing his/her emotional, somatic, and cog-
nitive experiences to increase self- awareness and their capacity for intro-
spection (Marin, 2019). The reality is ruptures in the therapeutic alliance
and premature terminations are more likely to occur when clinicians avoid,
deny, or minimize their countertransference; thus, it is imperative that
clinicians prioritize this element of the therapeutic journey and affirm
their humanity in the room (Cohen & Collens, 2013; Marin, 2019; Piselli
et al., 2011). Of course, this is best attained through the work of ongoing
supervision and personal therapy.
The scarcity of literature about the connection between countertrans-
ference and premature termination reveals its significance and of the
feelings of shame, ambivalence, and guilt it elicits within the clinician
(Siebold, 1992). Clinicians hold the position of healer, and thus it is
incredibly painful when termination occurs in response to their trauma
being triggered by the person who came to be healed (Marin, 2019). Piselli
et al. (2011) explain that the premature termination of a client is so sig-
nificant that it often impacts the clinician’s relationship with current and
future clients as well as their personal well-being. While self-reflection is
a core attribute of clinicians, it is important to outwardly speak of these
experiences to lessen the self-imposed shame and guilt that clinicians carry
in such incidents.
Unresolved countertransference experiences could lead to incidents of
premature termination, yet oftentimes clinicians choose to terminate
treatment in response to working through their countertransference in
supervision or personal therapy. This might be because of earlier or
current experiences that hinder their ability to treat this particular client,
including but not limited to cultural differences, adverse childhood
events, intrapersonal conflicts, or personal or professional limitations.
For example, a clinician might be unable to treat an eating disorder
because they lack training in that area or because they previously or
currently struggle with a similar issue and are aware of their limitations.
Despite the judgment often imposed on clinicians who initiate termina-
tion, the reality is that these clinicians are displaying high levels of
competency as they are aware of their own histories, attachment styles,
needs, and limitations. Too often clinicians hold back from initiating
termination in fear of appearing incompetent, unskilled, unempathetic,
or lacking in ethics, morals, and values. While continuing to work with
their clients might seem virtuous, if their struggles are ongoing or remain
unresolved, then it will only result in a therapeutic impasse where the
client will be forced to initiate the premature termination after being
stuck in this position for an excruciatingly long period of time (McClure
& Hodge, 1987; Perlstein, 1998). Needless to say, it is imperative that
the clinician keeps the client’s best interest in mind while holding the
PSYCHOANALYTIC SOCIAL WORK 9
knowledge that premature termination is sometimes the most clinically
and ethically appropriate call of action.
Ethics
The NASW Code of Ethics intends to provide a practice framework for
clinicians for professional development and guidance in resolving and
preventing ethical dilemmas. The six core principles of the Code include
service, social justice, dignity and worth of the person, importance of
human relationships, integrity, and competence (NASW, 2021). These core
principles incorporate multiple ethical standards that are relevant to pro-
fessional practice, including the termination of services. Under this section,
the Code states that social workers should terminate services when they
are no longer needed or beneficial to the client (NASW, 2021). It further
explains specific conditions that might lead to premature termination, like
financial difficulties or changes in employment, as well as those that should
not determine the termination of services, like the desire to pursue social,
financial, or sexual relationships (NASW, 2021). Of necessity, these stan-
dards remain somewhat ambiguous as they intend to provide a structure
for care. Since they are not precise directions for care, clinicians are often
conflicted when considering untimely terminations.
The Code describes ethical dilemmas as a “circumstance in which two
or more ethical principles of social work conflict” (NASW, 2021, p. 1).
Abramson (1985) explains that these dilemmas arise when “social workers
are not sure about what is right or what is good or when there is a con-
flict between opposing moral systems or obligations” (p. 387). It is under
these circumstances where clinicians need to consider their prima facie
duties to ascertain how to resolve their ethical dilemmas. This includes
careful reflection on the moral principles of autonomy, beneficence,
non-maleficence, and justice. The struggle, as described by Reamer (1982),
is that clinicians need to consider between two “independently acceptable”
resolutions (p. 580). In this case, the question centers on whether the
client will benefit more from termination or the continuation of care.
Exploring countertransference in the therapy room
The authors present a case study to emphasize the clinical dilemmas cli-
nicians might confront when a client’s emotional struggles bump into
those of the clinician’s personal life. The case study brings attention to
the parallel process that is bound to occur between the clinician and
client; and the countertransference that emerges in response to relational
patterns, adverse childhood events, traumatic experiences, and insecure
attachments with caregivers. It explores the influence of this clinician’s
10 D. WERNER AND D. POLLACK
negative core beliefs in response to her client’s experiences, the intraper-
sonal and interpersonal conflicts, and the ethical and legal ramifications
of initiating a premature termination.
Case study
Linda is a 35-year-old female pursuing treatment to manage her symptoms
of anxiety which manifest in her inability to develop intimate relationships.
Linda practices as a lawyer in a renowned law firm and despite acknowl-
edging her skill, talent, and success, she reports feeling irritable, restless,
and unfulfilled in her personal life. She refers to loneliness as her com-
panion but is also not ready to commit to a relationship in fear that it
will interfere with her productivity at work. While she has a strong rela-
tionship with her father, she displays much anger and disgust toward her
mother. She constantly thinks about her mother’s opinions and reactions
to her decisions, worrying that she will disapprove, criticize, or judge her.
This fear carries over to her interactions with men, as she constantly
worries that they too will disapprove, criticize, or judge her. Evidently,
she avoids engaging in meaningful interactions with men and will end a
relationship as soon as someone displays romantic interest in her. Her
resistance in the therapeutic relationship mirrors this core belief, as she
has adopted the role of victim to rationalize and protect herself from
exploring her adverse childhood experiences that dictate her current
struggles.
After two years of treatment, Linda discloses that she has a rare medical
condition that affects her daily functioning in a significant way. Mary, the
clinician, is taken aback by this disclosure because, (1) Linda denied having
any medical conditions in the intake process and (2) she has never alluded
to this condition in any of their previous sessions or interactions. While
Mary responds with compassion and curiosity in session, she is over-
whelmed by this information and notices her anxiety in the room. Mary’s
response is personal as she was recently diagnosed with a rare medical
condition. As Mary acknowledges the intensity of her emotions and begins
to recognize her countertransference in the room, she grapples with ques-
tion of, “Can I competently provide treatment to a client experiencing a
parallel struggle or do I terminate the relationship in the best interest of
the client?”
Although Mary’s countertransference is rearing its head now, she has
been struggling with complex emotions throughout the course of their
work. Unclear to her at the time, Mary struggled to like Linda during
their early months of treatment and often spoke about it in supervision.
With time, Mary became aware that these struggles were rooted in her
countertransferential feelings around Linda’s dedication to remaining a
PSYCHOANALYTIC SOCIAL WORK 11
victim. Her successful attempt at working through these earlier feelings
of countertransference confuses her more now as she wonders if it is
possible under these circumstances as well.
The Clinician’s countertransference
Following the client’s disclosure, Mary shares her experience in supervision.
She describes the similarities and differences between their coping mech-
anisms and the intensity of the pain she feels as she sits in the therapy
room. Her problem, she tells her supervisor, is, “The pain I feel in session
is more about my own losses than my client’s, and therefore it interferes
with my ability to be present with her.” She further describes the anxiety
she feels before their sessions, sharing that it is rooted in her fear of
evoking her own biases and viewpoints onto her client. Mary also shares
her concern about her personal pain surfacing in the room since it might
impede her ability to properly support her client in the here-and-now of
the therapy experience.
To complicate matters further, Linda’s relationship with her mother
mirrors Mary’s relationship with her father. While Mary is married with
two children and maintains a successful clinical practice, she notices that
her body often contracts when Linda speaks of her ruptured relationship
with her mother. Like Linda, Mary has a difficult relationship with her
father who struggles with depression and is therefore often critical, cynical,
and disconnected from the family. Mary deeply resonates with Linda’s
pain, but at the same time, she struggles to be a holding force in session
because of her past relationships and recent medical trauma.
For many months, Mary processes her countertransferential experiences
with her clinical supervisor. She considers terminating the therapeutic
relationship because (1) she struggles to remain present in session because
of her countertransference and (2) her medical condition is ongoing and
the constant reminders in session are too painful. When discussing this
conflict, Mary’s supervisor repeatedly reassures her that she will support
her decision either way; and whenever she doubts her ability to support
Linda, she gently reminds her, “Your ability to model survival is everything
for her right now.”
A large part of Mary’s work is distinguishing between her personal
experiences and those of her client. It is often challenging to separate her
own emotional experiences from those of her client. Through supervision
and personal therapy, Mary learns that many of these experiences belonged
to both of them. Yet, as part of her work, Mary needs to recognize the
differences between their experiences so she can remain present in the
relationship and therapy room. Exploring the different responses people
have to illness and adversity based on adverse life events, attachment
12 D. WERNER AND D. POLLACK
styles, protective and risk factors, resources, and resilient outcomes are all
imperative to her work. Most importantly, Mary needs to better understand
her needs and to identify the benefits and consequences of continuing or
terminating treatment. This conversation is ongoing and includes an explo-
ration of the clinical, ethical, and legal ramifications of her decision. The
main pointers of her supervision sessions are outlined below to emphasize
the complexity of the process and the importance of working through
countertransference to safeguard the needs of our clients.
Working through countertransference
Clinical implications
There are several factors playing a role in Mary’s decision-making process.
First, Mary needs to identify the commonalities and differences in their
stories to distinguish between the client’s self and her experience in the
room. This is an important step in properly addressing her countertrans-
ference and clinical concerns. This work translates into recognizing the
similarities and differences between their relationships with parental figures,
coping styles, resources, personality traits, and response to their diagnoses.
For instance, when Mary received the diagnosis, she sought the best prac-
titioners in the country for treatment. She researched, networked, and
tried several treatments to alleviate the pain and minimize the short-and-
long-term effects of the disease. She continues to meet with her medical
team and is constantly engaged in further research to expand her under-
standing of the condition. By contrast, Linda has not seen a medical
practitioner since she received the diagnosis during adolescence. She does
not have a treatment plan, nor does she visit her primary care physician
on an annual basis. Her avoidance is triggering Mary for many reasons:
she chose to be an active participant in her treatment, she is aware of
the ramifications of her client’s neglect and avoidance, and her behavioral
patterns are a reminder of her elderly father who does not seek the
appropriate care for his diabetes. As mentioned earlier, Mary also expe-
rienced a countertransferential response to Linda’s dedication to a life of
victimhood since the beginning of their relationship and it continues to
resurface throughout the course of their work. A part of Mary’s work is
to recognize that here too, her anxiety is being elicited in response to her
client’s denial and avoidance. She needs to work with the projective iden-
tification that continues to exist and to process her anger and frustration
in response to being misled about Linda’s medical history.
To deepen her ability to stay with Linda, Mary also needs to process
her feelings of helplessness in face of Linda’s avoidance. Through explo-
ration, Mary’s supervisor is able to help her recognize the dual process
PSYCHOANALYTIC SOCIAL WORK 13
that is occurring in the room. The sense of helplessness she feels isn’t her
own, it is Linda’s feeling of helplessness that is being projected and evoked
within her. The projective identification that is transpiring is disrupting
her ability to stay present and grounded in session, making her want to
run away from the case just as Linda wants to run away from her prob-
lems that brought her to the therapy room in the first place. Understanding
this process allows her to consciously exit the battlefield so she can prop-
erly align with her client’s needs.
In addition, Mary needs to consider the therapeutic relationship and
the potential damage she might cause by continuing treatment or by ini-
tiating a premature termination with Linda. The client’s background, attach-
ment style, symptomatology, support system, and resources need to be
carefully assessed (Dalenberg, 2005). Based on the case conceptualization,
it is clear that Linda presents with an anxious-ambivalent attachment style.
This is seen in her ambivalence to connect with her clinician as well as
with significant others outside of the therapeutic relationship. As attach-
ment theory explains, people develop an internal working model based
on earlier attachment with caregivers and when there is a disruption of
safety, an insecure attachment might present as anxious ambivalence
(Bowlby, 1988). This complicates an individual’s ability to connect securely
with others as well as to regulate distressing emotions. As noted, Linda
presents as highly dysregulated and is often unable to access her resources
to manage her anxious symptoms. Although Linda lives with supportive
friends, she struggles to seek their support in fear of being a burden but
then imposes on their space when she feels uncertain and overwhelmed.
Linda engages with men until they display romantic interest in her and
then self-sabotages by abruptly ending the relationship because of her fear
of intimacy. She often seeks support from her father, but the absence of
a relationship with her mother severely impacts her ability to authentically
connect with others. Evidently, this shows up in the therapy room in the
way she cancels sessions at the last minute, demands special attention,
and engages in the constant push and pull where she alternates between
seeking and avoiding connection. This is mentioned because it plays a
role in the therapeutic relationship and Mary’s decision-making process.
For a successful therapeutic outcome, Mary needs to recognize and own
her attitude toward Linda’s behaviors, and work through her impatience,
exhaustion, and frustration in supervision.
Lastly, and most importantly, Mary needs to evaluate whether she has
the emotional bandwidth to support Linda through a seemingly parallel
journey. Poorvu (2015) discusses this idea in depth, particularly in regard
to clinicians living with physical illnesses. He explains clinicians need to
consider whether they will disclose their illness to their patients and how
the changes in their use of self might impact the therapeutic relationship.
14 D. WERNER AND D. POLLACK
While Mary believes it is unhelpful to disclose her condition at this point
in time, it is something for her to consider as she continues to work with
Linda. That is, when choosing to disclose aspects of illness, the clinician
needs to carefully consider what would be helpful for the client and when
it would be helpful for the client. The decision to self-disclose, including
the timing and choice of words, are very important elements of the process
(Marin, 2019). The disclosure needs to be made with the intention to
provide relief to the client, not the clinician, and at this time it would be
to free Mary from the projective identification taking place in the thera-
peutic space as opposed to deepening the connection and experience for
the client.
Ethical implications
Continuing treatment when a clinician is unable to competently provide
services creates an ethical dilemma. Indeed, a core aspect of ethical prac-
tice revolves around countertransference experiences as clinicians juggle
responsibility, judgment, and truth (Wilson, 2013). Consequently, Mary is
conflicted about whether to continue working with Linda or to terminate
services prematurely. Continuing to provide services honors the ethical
principle of service, but it could also potentially lead to a misuse of ser-
vice. According to the Code, social workers have an obligation to act in
alignment with the client’s best interest. The Code also states that clinicians
need to act with integrity and competence (NASW, 2021). However, ter-
minating services prematurely seems to minimize the importance of human
relationships and honoring the dignity and worth of Linda. The dilemma
between the continuation or termination of services often surfaces when
a clinician and client are experiencing similar phenomena. This is better
understood in the context of the aftermath of Hurricane Sandy, COVID-
19, and the current war in the Middle East. In light of such events, pre-
vious experiences of countertransference collide with universally shared
experiences, and clinicians need to hold their personal experiences and
those of their clients. While Mary’s experience appears more intimate as
it relates to a more personal and private challenge, she is ultimately strug-
gling to discern between the principles of beneficence and non-maleficence
as she is unsure whether to act paternalistically or to err on the side of
caution to assure no harm. The weight of ethical burdens is heavy; and
yet, they are unavoidable in this line of work.
Legal implications
When resolving this ethical dilemma, Mary needs to consider the legal
implications as well. A premature termination or the continuation of
PSYCHOANALYTIC SOCIAL WORK 15
treatment could lead to litigation. That is, if continuing treatment causes
Mary to behave unethically, Linda might report Mary to the licensing
board. However, Mary could also choose to report the untimely termina-
tion of their therapeutic relationship. In a worst-case scenario, premature
termination, or an unsuitable course of therapy, could lead to an increase
in symptomatology or suicidality. This outcome could most certainly result
in a lawsuit or disciplinary procedures before a licensing board.
Reaching A decision
Despite Mary’s intense emotional and somatic responses to her client’s
disclosure, she chose to continue working with her. As mentioned previ-
ously, Mary felt that it was imperative for her to consider the clinical,
ethical, and legal implications when choosing to either continue treatment
or initiate a premature termination. Once Mary began to process these
aspects of the work in supervision, she was able to address her own grief,
pain, and anxiety that was emerging in response to her client’s medical
diagnosis in her personal therapy. Although this has been an ongoing
process for her, this experience added a new dimension of depth to their
work as Mary needed to explore and process what it was like for her to
support someone else through a strikingly similar experience. Making the
decision to continue treatment was difficult and complex; however, it is
important to note that she was only able to come to this place of clarity
from working through her struggles in clinical supervision and personal
therapy. With time, Mary noticed her anxiety diminish prior to, during,
and in-between her sessions with Linda. Like she shared with her super-
visor, “It’s not gone completely, I still check-in with myself every session,
but it feels less overwhelming because I am okay with it. Now I know it’s
the human part of me in the room and that I don’t need to get rid of it.
I only need to learn how to make space for it.” As mentioned previously,
a significant part of addressing countertransference is honoring the clini-
cian’s humanity in the room and using it as a means to deepen the work.
Moreover, as Freud (1910) stated, it is advisable for clinicians to seek
therapeutic counsel to expand self-awareness and reduce the blind spots
in their work.
Conclusion
The relationship between the clinician and client is a critical component
of psychotherapy. The exchanges between the clinician and client are often
used as a tool to resolve the issues that bring the client into therapy
(Dalenberg, 2005). Due to the significance of the relationship, issues of
countertransference are an important source of information for the
16 D. WERNER AND D. POLLACK
clinician and need to be addressed so as not to hinder the therapeutic
process (Barreto & Matos, 2022; Frayn, 1992; Westerling et al., 2019). As
stated previously, countertransference is not an indication of incompetence
but is merely information to be processed to deepen the work. Yet when
these experiences are denied or avoided, it becomes increasingly complex
to manage the upheaval they might cause and are more likely to result
in an impasse or untimely termination.
When clinicians engage with clients, they are bound to experience issues
of countertransference and therapeutic impasses. It is therefore essential
that the literature provides the language to describe these experiences to
lessen the feelings of guilt, shame, and uncertainty that tend to emerge
through these processes. This clinical note aims to provide a review of
these constructs through a case study to emphasize the clinical, ethical,
and legal dilemmas clinicians encounter when they experience counter-
transference in the course of therapy. While experiences of countertrans-
ference are intimate and painful for the clinician, they are bound to
happen; and it is the clinician’s duty to address these issues while simul-
taneously prioritizing the clinical, ethical, and legal standards of the Code.
Ultimately working through these feelings and ethical considerations will
lend itself to greater clarity and more successful therapeutic outcomes
beyond the clinician’s work with a given client.
Disclosure statement
No potential conict of interest was reported by the author(s).
ORCID
Dena Werner http://orcid.org/0000-0001-7990-6195
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