What is Vicarious Traumatisation?


Vicarious trauma (VT) was a term coined by McCann and Pearlman that is used to describe how working with traumatised clients and the effect it has on trauma therapists.

Previously, the phenomenon was referred to as secondary traumatic stress coined by Dr. Charles Figley. The theory behind VT is that the therapist has a profound world change and is permanently altered by the interaction of empathetic bonding with a client. This change is thought to have three conditional requirements: empathic engagement and exposure to graphic and traumatising material, the therapist being exposed to human cruelty, and re-enactment of trauma within the therapy process. This change can produce changes in a therapist’s sense of spirituality, worldview, and self-identity.

VT is still a subject of debate by theorists, with some saying it is based on the concept of countertransference (refer to transference), burnout, and compassion fatigue. McCann and Pearlman argue, however, that there is probably a relationship between these constructs, but VT is unique and distinct.

As time has progressed, the term VT has expanded to more than just indirect trauma experienced by trauma therapists and has come to include many more populations, although the phenomenon is still evolving.

Signs and Symptoms

The symptoms of vicarious trauma align with the symptoms of primary, actual trauma. When helping professionals attempt to connect with their clients/victims emotionally, the symptoms of VT can create emotional disturbance such as feelings of sadness, grief, irritability and mood swings. The signs and symptoms of VT parallel those of direct trauma, although they tend to be less intense. Workers who have personal trauma histories may be more vulnerable to VT, although the research findings on this point are mixed.

Common signs and symptoms include, but are not limited to:

  • Social withdrawal;
  • Mood swings;
  • Aggression;
  • Greater sensitivity to violence;
  • Somatic symptoms;
  • Sleep difficulties;
  • Intrusive imagery;
  • Cynicism;
  • Sexual difficulties;
  • Difficulty managing boundaries with clients; and
  • Core beliefs and resulting difficulty in relationships reflecting problems with security, trust, esteem, intimacy, and control.

Contributing Factors

VT, conceptually based in constructivist self-development theory, arises from an interaction between individuals and their situations. This means that the individual helper’s personal history (including prior traumatic experiences), coping strategies, and support network, among other things, all interact with his or her situation (including work setting, the nature of the work s/he does, the specific clientele served, etc.), to give rise to individual expressions of vicarious trauma. This in turn implies the individual nature of responses or adaptations to VT as well as individual ways of coping with and transforming it. Some have postulated that this traumatisation occurs when one’s view of the world or a feeling of safety is shattered by hearing about the experiences of their clients. This exposure to trauma, however indirectly, can cause an interruption to the daily functioning of the clinician reducing their effectiveness.

Anything that interferes with the helper’s ability to fulfil their responsibility to assist traumatised clients can contribute to vicarious trauma. Many human service workers report that administrative and bureaucratic factors that impediment to their effectiveness influence work satisfaction. Negative aspects of the organisation as a whole, such as reorganisation, downsizing in the name of change management and a lack of resources in the name of lean management, contribute to burned-out workers.

Vicarious trauma has also been attributed to the stigmatisation of mental health care among service providers. Stigma leads to an inability to engage in self care and eventually the service provider may reach burnout, and become more likely to experience VT. The research has also begun to show that vicarious trauma is more prominent in those with a prior history of trauma and adversity. Research indicates that a mental health provider’s defence style might pose as a risk factor for VT. Mental health providers with self-sacrificing defence styles have been found to experience increased VT.

Research has demonstrated that females are more likely to develop secondary traumatic stress than males and counsellors not in private practice are more likely to develop secondary traumatic stress. Those with stronger counsellor professional identity (CPI) experience less secondary traumatic stress as well.

Specifically, in emergency medical service (EMS) personnel, previous veteran status increased likelihood of experiencing VT.

While the term “vicarious trauma” has been used interchangeably with “compassion fatigue”, “secondary traumatic stress disorder,” “burnout,” “countertransference,” and “work-related stress,” there are important differences. These include the following:

  • Unlike compassion fatigue, VT is a theory-based construct. This means that observable symptoms can serve as the starting for a process of discovering contributing factors and related signs, symptoms, and adaptations. VT also specifies psychological domains that can be affected, rather than specific symptoms that may arise. This specificity may more accurately guide preventive measures and interventions, and allow for the accurate development of interventions for multiple domains (such as changes in the balance between psychotherapy and other work-related tasks and changes in self-care practices).
  • Countertransference is the psychotherapist’s response to a particular client. VT refers to responses across clients, across time.
  • Unlike burnout, countertransference, and work-related stress, VT is specific to trauma workers. This means that the helper will experience trauma-specific difficulties, such as intrusive imagery, that are not part of burnout or countertransference. The burnout and VT constructs overlap, specifically regarding emotional exhaustion. A worker may experience both VT and burnout, and each has its own remedies. VT and countertransference may also co-occur, intensifying each other.
  • Unlike VT, countertransference can be a very useful tool for psychotherapists, providing them with important information about their clients.
  • Work-related stress is a generic term without a theoretical basis, specific signs and symptoms or contributing factors, or remedies. Burnout and VT can co-exist. Countertransference responses may potentiate VT.
  • Vicarious post-traumatic growth, unlike VT, is not a theory-based construct but rather is based on self-reported signs.
  • Body-centred countertransference.


The posited mechanism for VT is empathy. Different forms of empathy may result in different effects on helpers. Batson and colleagues have conducted research that might inform trauma helpers about ways to manage empathic connection constructively. If helpers identify with their trauma survivor clients and immerse themselves in thinking about what it would be like if these events happened to them, they are likely to experience personal distress, feeling upset, worried, distressed. On the other hand, if helpers instead imagine what the client experienced, they may be more likely to feel compassion and moved to help.


Over the years, VT has been measured in a wide variety of ways. VT is a multifaceted construct requiring a multifaceted assessment. More specifically, the aspects of VT that would need to be measured for a complete assessment include self capacities, ego resources, frame of reference (identity, world view, and spirituality), psychological needs, and trauma symptoms. Measuring of some of these elements of VT exist, including the following:

  • Psychological needs, using the Trauma and Attachment Belief Scale.
  • Self capacities, using the Inner Experience Questionnaire and/or the Inventory of Altered Self-Capacities.
  • Trauma symptoms, using the PTSD Checklist, Impact of Events Scale, Impact of Events Scale-Revised, children’s revised Impact of Events Scale (Arabic Version), Trauma Symptom Inventory, Detailed Assessment of Posttraumatic Stress, and/or the World Assumptions Scale.
  • Secondary Traumatic Stress Scale is a 17 item, 5-point Likert scale that distinguishes between PTSD measures by framing the questions as stressors from exposure to clients.
  • The Professional Quality of Life (ProQol) version 5. This assessment has 30 questions on a 5-point Likert scale and measures compassion fatigue and secondary trauma.


VT is not the responsibility of clients or systems, although institutions that provide trauma-related services bear a responsibility to create policies and work settings that facilitate staff (and therefore client) well-being. Each trauma worker is responsible for self-care, working reflectively, and engaging in regular, frequent, trauma-informed professional confidential consultation.

There are many ways of addressing VT. All involve awareness, balance, and connection. One set of approaches can be grouped together as coping strategies. These include, for example, self-care, rest, escape, and play. A second set of approaches can be grouped as transforming strategies. Transforming strategies aim to help workers create community and find meaning through the work. Within each category, strategies may be applied in one’s personal life and professional life. Organisations that provide trauma services can also play a role in mitigating VT.

Research shows that many simple things increase happiness and this aids to lessen the impact of VT. People who are more socially connected tend to be happier. People who consciously practice gratitude are also shown happier. Creative endeavours that are completely detached with work also increase happiness. Self-care practices like yoga, qigong, and sitting meditation are found to be helpful for those who practice. The Harvard Business Review in a case study regarding to traumatisation stated that it is essential to create an organisational culture in which it is cool to be a social worker or a counsellor, where these professionals are empowered to influence the workplace issues, the strategy of human services in both corporate and care services. Additionally, research indicates clinicians who are exposed to VT are in need of targeted interventions that will boost their resilience. Findings have show interventions such as respite, increasing self efficacy, and having appropriate professional support buffer against the effects of vicarious trauma.

Individuals Found to Experience Vicarious Trauma


Children have been found to experience VT from the traumas experienced by their caregivers and peers. In children the following factors have been found to predict vicarious trauma symptoms:

  • Socioeconomic status.
  • Gender (girls more than boys).
  • Race.
  • Witnessing the trauma directly.
  • Caregiver warmth and hostility.

Foster Parents

Foster parents have been found to experience VT related to the trauma of those they care for. Several studies have found that foster parents experience vicarious trauma, burnout, and compassion fatigue and report that emotional disengagement (a common symptom of VT) is a coping strategy.

Counsellors and Other Mental Health Providers

Counsellors and other mental health professional have been found to experience vicarious trauma when working with veterans and others that have experienced trauma. Some of the factors that predict vicarious trauma severity include:

  • Professional trauma.
  • Level of peer supervision.
  • Social support availability.
  • Emotional coping strategies.
  • Long hours and high caseloads.
  • Population served by the clinician.
  • Defensc mechanisms of the therapist.

American Muslims

After the terrorist attack on the World Trade Centre in the United States, many Muslims were relegated with terrorists and attacks of violence were perpetrated against them. This caused many individuals in this community to experience VT and added to a feeling of worry and being unsafe. Those feeling a stronger sense of religious identity were more likely to experience VT.

What is Transference?


Transference (German: Übertragung) is a phenomenon within psychotherapy in which the feelings a person had about their parents, as one example, are unconsciously redirected or transferred to the present situation.

It usually concerns feelings from a primary relationship during childhood. At times, this transference can be considered inappropriate. Transference was first described by Sigmund Freud, the founder of psychoanalysis, who considered it an important part of psychoanalytic treatment.


It is common for people to transfer feelings about their parents to their partners or children (that is, cross-generational entanglements). Another example of transference would be a person mistrusting somebody who resembles an ex-spouse in manners, voice, or external appearance, or being overly compliant to someone who resembles a childhood friend.

In The Psychology of the Transference, Carl Jung states that within the transference dyad both participants typically experience a variety of opposites, that in love and in psychological growth, the key to success is the ability to endure the tension of the opposites without abandoning the process, and that this tension allows one to grow and to transform.

Only in a personally or socially harmful context can transference be described as a pathological issue. A modern, social-cognitive perspective on transference explains how it can occur in everyday life. When people meet a new person who reminds them of someone else, they unconsciously infer that the new person has traits similar to the person previously known. This perspective has generated a wealth of research that illuminated how people tend to repeat relationship patterns from the past in the present.

High-profile serial killers often transfer unresolved rage toward previous love or hate-objects onto “surrogates”, or individuals resembling or otherwise calling to mind the original object of that hate. It is believed in the instance of Ted Bundy, he repeatedly killed brunette women who reminded him of a previous girlfriend with whom he had become infatuated, but who had ended the relationship, leaving Bundy rejected and pathologically rageful (Bundy, however, denied this as a motivating factor in his crimes). This notwithstanding, Bundy’s behaviour could be considered pathological insofar as he may have had narcissistic or antisocial personality disorder. If so, normal transference mechanisms cannot be held causative of his homicidal behaviour.

Sigmund Freud held that transference plays a large role in male homosexuality. In The Ego and the Id, he claimed that eroticism between males can be an outcome of a “[psychically] non-economic” hostility, which is unconsciously subverted into love and sexual attraction.

Transference and Counter-Transference during Psychotherapy

In a therapy context, transference refers to redirection of a patient’s feelings for a significant person to the therapist. Transference is often manifested as an erotic attraction towards a therapist, but can be seen in many other forms such as rage, hatred, mistrust, parentification, extreme dependence, or even placing the therapist in a god-like or guru status. When Freud initially encountered transference in his therapy with patients, he thought he was encountering patient resistance, as he recognised the phenomenon when a patient refused to participate in a session of free association. But what he learned was that the analysis of the transference was actually the work that needed to be done: “the transference, which, whether affectionate or hostile, seemed in every case to constitute the greatest threat to the treatment, becomes its best tool”. The focus in psychodynamic psychotherapy is, in large part, the therapist and patient recognising the transference relationship and exploring the relationship’s meaning. Since the transference between patient and therapist happens on an unconscious level, psychodynamic therapists who are largely concerned with a patient’s unconscious material use the transference to reveal unresolved conflicts patients have with childhood figures.

Countertransference is defined as redirection of a therapist’s feelings toward a patient, or more generally, as a therapist’s emotional entanglement with a patient. A therapist’s attunement to their own countertransference is nearly as critical as understanding the transference. Not only does this help therapists regulate their emotions in the therapeutic relationship, but it also gives therapists valuable insight into what patients are attempting to elicit in them. For example, a therapist who is sexually attracted to a patient must understand the countertransference aspect (if any) of the attraction, and look at how the patient might be eliciting this attraction. Once any countertransference aspect has been identified, the therapist can ask the patient what his or her feelings are toward the therapist, and can explore how those feelings relate to unconscious motivations, desires, or fears.

Another contrasting perspective on transference and countertransference is offered in classical Adlerian psychotherapy. Rather than using the patient’s transference strategically in therapy, the positive or negative transference is diplomatically pointed out and explained as an obstacle to cooperation and improvement. For the therapist, any signs of countertransference would suggest that his or her own personal training analysis needs to be continued to overcome these tendencies. Andrea Celenza noted in 2010 that “the use of the analyst’s countertransference remains a point of controversy”.

What is Role Suction?


Role suction is a term introduced in the United States by Fritz Redl in the mid-20th century to describe the power of a social group to allocate roles to its members.

W.R. Bion’s group dynamics further explored the ways whereby the group (unconsciously) allocates particular functions to particular individuals in order to have its covert emotional needs met; and the process has recently been highlighted anew within the systems-centred therapy of Yvonne Agazarian.

Among regularly occurring group roles are those of the scapegoat for the group’s troubles; the joker; the peacemaker; the critic/spokesperson for group standards; the idol, or upholder of the group ideal; and the identified patient. In mixed gender groups, women may be disproportionately pressured by role suction into playing a nurturing/peacemaker role.

Refer to Karpman Drama Triangle.

Driving Forces

The ease whereby people pick out those who play complementary games, and the psychological splitting of good and bad help fuel such role differentiation.

Behind role suction, such forces as projective identification and countertransference have been singled out as operating at an unconscious level in the group.

Role lock – confirming mutual suction into complementary roles, such as victim and abuser – is ensured by the intermeshing of projective identifications.

Wider Systems

The British anti-psychiatrists explored the theme of group suction in connection with role attribution in the family nexus, as well as with the allocations of roles in the wider social system, David Cooper suggesting that ‘there are always good or bad, loved or hated ‘mothers’ and ‘fathers’, older or younger ‘brothers’ and ‘sisters’…in any institutional structure”.

A wider variety of roles can however be found in organisational life, the person-in-role acting as a container for the (unconscious) group forces.

Role of the Therapist

Bion has described his experience as a group therapist when he “feels he is being manipulated so as to be playing a part, no matter how difficult to recognise, in somebody else’s phantasy…a temporary loss of insight, a sense of experiencing strong feelings, and at the same time a belief that their existence is quite adequately justified by the objective situation”. Bion’s work has also been used to illustrate the part played by role suction in the selection of group leaders – dependent groups favouring narcissistic leaders, the fight/flight group paranoids.

R.D. Laing considered that a central part of the therapist’s job was “not to allow himself to collude with the patients in adopting a position in their phantasy-system: and, alternatively, not to use the patients to embody any phantasy of their own” – to resist role suction. Later therapists however have explored how a measure of adaptation to patients’ role suction – a degree of role responsiveness – can be a useful element in the therapeutic use of the countertransference.


From the point of view of systems-centred therapy, the debate relates to the interface between a personal system and the psycho-dynamics of social systems themselves.

Debate has arisen about how far the group imposes roles, and how far the individual’s own personality goes to meet the group halfway. Earl Hopper has used the term personification to challenge Redl’s concept, suggesting instead that group roles reflect the underlying personality of the individual involved. However, Kibel objects that in many cases the roles imposed are in fact ego-dystonic; with others pointing to how personal tendencies combine with group expectations with varying degrees of fit.

What is Parallel Process?


Parallel process is a phenomenon noted between therapist and supervisor, whereby the therapist recreates, or parallels, the client’s problems by way of relating to the supervisor.

The individual’s transference and the therapist’s countertransference thus re-appear in the mirror of the therapist/supervisor relationship.


Attention to parallel process first emerged in the nineteen-fifties (1950s). The process was termed reflection by Harold Searles in 1955, and two years later T. Hora (1957) first used the actual term parallel process – emphasising that it was rooted in an unconscious identification with the client/patient which could extend to tone of voice and behaviour. The supervisee thus enacts the central problem of the therapy in the supervision, potentially opening up a process of containment and solution, first by the supervisor and then by the therapist.

Alternatively, the supervisor’s own countertransference may be activated in the parallel process, to be reflected in turn between supervisor and consultant, or back into the original patient/helper dyad. Even then, however, careful examination of the material may still illuminate the original therapeutic difficulty, as reflected in the parallel situation.

What is Acting Out?


In the psychology of defence mechanisms and self-control, acting out is the performance of an action considered bad or anti-social. In general usage, the action performed is destructive to self or to others.

The term is used in this way in sexual addiction treatment, psychotherapy, criminology and parenting. In contrast, the opposite attitude or behaviour of bearing and managing the impulse to perform one’s impulse is called acting in.

The performed action may follow impulses of an addiction (e.g. drinking, drug taking or shoplifting). It may also be a means designed (often unconsciously or semi-consciously) to garner attention (e.g. throwing a tantrum or behaving promiscuously). Acting out may inhibit the development of more constructive responses to the feelings in question.

In Analysis

Sigmund Freud considered that patients in analysis tended to act out their conflicts in preference to remembering them – repetition compulsion. The analytic task was then to help “the patient who does not remember anything of what he has forgotten and repressed, but acts it out” to replace present activity by past memory.

Otto Fenichel added that acting out in an analytic setting potentially offered valuable insights to the therapist; but was nonetheless a psychological resistance in as much as it deals only with the present at the expense of concealing the underlying influence of the past. Lacan also spoke of “the corrective value of acting out”, though others qualified this with the proviso that such acting out must be limited in the extent of its destructive/self-destructiveness.

Annie Reich pointed out that the analyst may use the patient by acting out in an indirect countertransference, for example to win the approval of a supervisor.


The interpretation of a person’s acting out and an observer’s response varies considerably, with context and subject usually setting audience expectations.

In Parenting

Early years, temper tantrums can be understood as episodes of acting out. As young children will not have developed the means to communicate their feelings of distress, tantrums prove an effective and achievable method of alerting parents to their needs and requesting attention.

As children develop they often learn to replace these attention-gathering strategies with more socially acceptable and constructive communications. In adolescent years, acting out in the form of rebellious behaviours such as smoking, shoplifting and drug use can be understood as “a cry for help.” Such pre-delinquent behaviour may be a search for containment from parents or other parental figures. The young person may seem to be disruptive – and may well be disruptive – but this behaviour is often underpinned by an inability to regulate emotions in some other way.

In Addiction

In behavioural or substance addiction, acting out can give the addict the illusion of being in control. Many people who suffer with addiction, either refuse to admit they struggle with it, or some do not even realise they have an addiction. For most people, when their addiction is addressed, they become defensive and act out. This can be a result of multiple emotions including shame, fear of judgement, or anger. It is important to be patient and understanding towards those who suffer with addiction, and to realise that most people want to break free from the symptoms and baggage that come with addiction, but do not know how or where to start. Thankfully, there are many preventative measures and programs than can help those who personally struggle with addiction, or for those who have a friend or family member that suffers with addiction.

In Criminology

Criminologists debate whether juvenile delinquency is a form of acting out, or rather reflects wider conflicts involved in the process of socialisation. Deviant behaviour is commonly associated with crime and social deviance. Many of those who are involved in crime, usually grew up in broken homes, or had no authority figure in their life. For some, a life of crime is all they have ever known. This could be a reason as to why there is a debate over whether or not juvenile delinquency is a form of acting out.


Acting out painful feelings may be contrasted with expressing them in ways more helpful to the sufferer, e.g. by talking out, expressive therapy, psychodrama or mindful awareness of the feelings. Developing the ability to express one’s conflicts safely and constructively is an important part of impulse control, personal development and self-care.

What is Acting In?


“Acting in” is a psychological term which has been given various meanings over the years, but which is most generally used in opposition to acting out to cover conflicts which are brought to life inside therapy, as opposed to outside.

One commentator, noting the variety of usages, points out that it is often “unclear whether ‘in’ refers to the internalisation into the personality, to the growth in insight, or to the acting within the session”.


With respect to patients, the term ‘acting in’ has been used to refer to the process of a client/patient bringing an issue from outside the therapy into the analytic situation, and acting upon it there.

The therapist is advised to respond to the issue immediately to prevent further and more disruptive acting in.

Hanna Segal distinguished positive acting in from destructive acting in – both being aimed however at affecting the analyst’s state of mind, whether to communicate or to confuse.


The term was used in 1957 by Meyer A. Zeligs to refer specifically to the postures taken by analysts in a psychoanalytic session.


Psychoanalysis also describes as ‘acting in’ the process whereby the analyst brings his or her personal countertransference into the analytic situation – as opposed to the converse, the acting out of the patient’s transference.

The result is generally agreed to produce a chaotic analytic situation which hampers therapeutic progress.

The term was used rather differently however by Carl Whitaker in the 60’s, so as to refer to the technique whereby therapists increase their involvement in a session in such a way as to ramp up the patient’s anxiety for therapeutic ends.

What is Body-Centred Countertransference?


Body-centred countertransference involves a psychotherapist‘s experiencing the physical state of the patient in a clinical context.

Also known as somatic countertransference, it can incorporate the therapist’s gut feelings, as well as changes to breathing, to heart rate and to tension in muscles.

Refer to Countertransference.

Various Approaches

Dance therapy has understandably given much weight to the concept of somatic countertransference. Jungian James Hillman also emphasised the importance of the therapist using the body as a sounding-board in the clinical context.

Post-Reichian therapies like bioenergetic analysis have also stressed the role of the body-centred countertransference.

There is some evidence that narcissistic patients and those suffering from borderline personality disorder create more intense embodied countertransferences in their therapists, their personalities favouring such non-verbal communication by impact over more verbalised, less somatic interactions.


Susie Orbach has written emotively of what she described as “wildcat sensations in my own body…a wildcat countertransference” in the context of body countertransference. She details her role responsiveness to one patient who evoked in her what she called “an unfamiliar body experience…this purring, reliable and solid body” to counterbalance the fragmented body image of the patient herself.

The Irish Experience

In Female Trauma Therapists

Irish psychologists at NUI Galway and University College Dublin have recently begun to measure body-centred countertransference in female trauma therapists using their recently developed ‘Egan and Carr Body-Centred Countertransference Scale’ (2005), a sixteen symptom measure.

Their research was influenced by developments in the psychotherapy world which was beginning to see a therapist’s role in a therapeutic dyad as reflexive; that a therapist uses their bodies and ‘self’ as a tuning fork to understand their client’s internal experience and to use this attunement as another way of being empathic with a client’s internal world. Pearlman and Saakvitne’s seminal book on vicarious traumatisation and the effect of trauma work on therapists has also been an important directional model for all researchers studying the physical effects of trauma work on a therapist.

High levels of body-centred countertransference have since been found in both Irish female trauma therapists and clinical psychologists.[16] This phenomenon is also known as ‘somatic countertransference’ or ’embodied countertransference’ and it links to how mirror neurons might lead to ‘unconscious automatic somatic countertransference’ as a result of postural mirroring by the therapist. Hamilton et al (2020) revisited BCT in a larger sample of 175 therapists (122 females) and that the a similar pattern of body-centred countertransference was reported as in the previous two studies. The most common being:

  • Muscle Tension: 81%;
  • Tearfulness: 78%;
  • Sleepiness: 72%;
  • Yawning: 69%;
  • Throat constriction: 46%;
  • Headache: 43%;
  • Stomach disturbance: 43%;
  • Unexpectedly shifting in body: 29%;
  • Sexual arousal: 29%;
  • Raised voice: 28%;
  • Aches in joints: 26%;
  • Nausea: 24%;
  • Dizziness: 20%; and
  • Genital pain: 7.5%.

The authors reported how previous researchers did not find BCT because surveys have previously failed to ask specifically about it, and have focused on emotional and cognitive and relational CT. The authors finally called for larger longitudinal studies and also larger sample sizes to allow a comparison of gender and orientation effects as well as whether higher levels affect levels of burnout and therapeutic engagement and treatment outcomes 26. Hamilton, L., Hannigan, B., Egan, J., Trimble, T., Donaghey, C., & Osborn, K. (2020). An exploration of body-centred countertransference in Irish Therapists. Clinical Psychology Today, 4(2), 26-38.

Loughran (2002) found that 38 therapists out of 40 who had responded to a questionnaire (which was distributed to a sample of 124 therapists) on a therapist’s use of body as a medium for transference and countertransference communication reported that they had experienced bodily sensations (nausea or churning stomach, sleepiness, shakiness, heart palpitations, sexual excitement, etc.) while in session with patients.

Frequency of Symptom Occurrence

A list of the frequency of occurrence of body-centred countertransference symptoms reported by trauma therapists (Sample A: 35 Female Irish Trauma therapists[20]) and Irish clinical psychologists (Sample B: 87 Irish Clinical Psychologists[21]) in the previous six months ‘when in-session with a client’ is given below in order of frequency:

  • Sleepiness (A; 92%, B; 76%).
  • Muscle Tension (A; 83%, B; 79%).
  • Yawning (A; 65%, B; 77%).
  • Unexpected shift in body (A; 77%, B; 57%).
  • Tearfulness (A; 71%, B; 61%).
  • Headache (A; 54%, B; 53%).
  • Stomach Disturbance (A; 41%, B; 46%).
  • Throat Constriction (A; 34%, B; 36%).
  • Raised Voice (A; 29%, B; 33%).
  • Dizziness (A; 26%, B; 19%).
  • Loss of voice (A; 32%, B; 18%).
  • Aches in joints (A; 37%, B; 18%).
  • Nausea (A; 23%, B; 18%).
  • Numbness (A; 29%, B; 15%).
  • Sexual Arousal (A; 26%, B; 11%).
  • Genital pain (A; 6%, B; 2%).


A small but significant relationship was found between female trauma therapists’ level of body-centred countertransference and number of sick leave days taken, suggesting a possible relationship between uncensored body-centred countertransference and somatization. This relationship was not however found in clinical psychologists who were working mainly with a non-trauma population. Therapists have noted the connection between a tendency for some clients to express emotional discomfort by focusing on bodily symptoms rather than being able to put their emotional distress into words. It is thought that such processes are more common in people who have experienced childhood abuse and trauma.

Recent research which measured female genital arousal in response to rape cues found that women when listening to rape, consent or violence developed genital arousal more frequently than men. It also might explain the relatively frequent reported experience of sexual arousal amongst Irish female trauma therapists. Further validation of body-centred countertransference in psychologists and therapists is on-going in both NUI Galway and Trinity College Dublin.


Therapists have been warned against assuming too automatically that their body-feelings always involve somatic resonance to the client, as opposed to being produced from their own feelings/experiences – the same problem appearing with countertransference generally.

What is Countertransference?


Countertransference is defined as redirection of a psychotherapist‘s feelings toward a client – or, more generally, as a therapist’s emotional entanglement with a client.

Refer to Transference and Body-Centred Countertransference.

Early Formulations

The phenomenon of countertransference (German: Gegenübertragung) was first defined publicly by Sigmund Freud in 1910 (The Future Prospects of Psycho-Analytic Therapy) as being “a result of the patient’s influence on [the physician’s] unconscious feelings”; although Freud had been aware of it privately for some time, writing to Carl Jung for example in 1909 of the need “to dominate ‘counter-transference’, which is after all a permanent problem for us”. Freud stated that since an analyst is a human himself he can easily let his emotions into the client. Because Freud saw the countertransference as a purely personal problem for the analyst, he rarely referred to it publicly, and did so almost invariably in terms of a “warning against any countertransference lying in wait” for the analyst, who “must recognize this countertransference in himself and master it”. However, analysis of Freud’s letters shows that he was intrigued by countertransference and did not see it as purely a problem.

The potential danger of the analyst’s countertransference – “In such cases, the patient represents for the analyst an object of the past on to whom past feelings and wishes are projected” – became widely accepted in psychodynamic circles, both within and without the psychoanalytic mainstream. Thus, for example, Jung warned against “cases of counter-transference when the analyst really cannot let go of the patient…both fall into the same dark hole of unconsciousness”. Similarly Eric Berne stressed that “Countertransference means that not only does the analyst play a role in the patient’s script, but she plays a part in his…the result is the ‘chaotic situation’ which analysts speak of”. Lacan acknowledged of the analyst’s “countertransference…if he is re-animated the game will proceed without anyone knowing who is leading”.

In this sense, the term includes unconscious reactions to a patient that are determined by the psychoanalyst’s own life history and unconscious content; it was later expanded to include unconscious hostile and/or erotic feelings toward a patient that interfere with objectivity and limit the therapist’s effectiveness. For example, a therapist might have a strong desire for a client to get good grades in university because the client reminds her of her children at that stage in life, and the anxieties that the therapist experienced during that time. Even in its most benign form, such an attitude could lead at best to “a ‘countertransference cure’…achieved through compliance and a ‘false self’ suppression of the patient’s more difficult feelings”.

Another example would be a therapist who did not receive enough attention from her father perceiving her client as being too distant and resenting him for it. In essence, this describes the transference of the treater to the patient, which is referred to as the “narrow perspective”.

Middle Years

As the 20th century progressed, however, other, more positive views of countertransference began to emerge, approaching a definition of countertransference as the entire body of feelings that the therapist has toward the patient. Jung explored the importance of the therapist’s reaction to the patient through the image of the wounded physician: “it is his own hurt that gives the measure of his power to heal”. Heinrich Racker emphasised the threat that “the repression of countertransference…is prolonged in the mythology of the analytic situation”. Paula Heimann highlighted how the “analyst’s countertransference is not only part and parcel of the analytic relationship, but it is the patient’s creation, it is part of the patient’s personality”. As a result, “counter-transference was thus reversed from being an interference to becoming a potential source of vital confirmation”. The change of fortune “was highly controversial. Melanie Klein disapproved on the grounds that poorly analysed psycho-analysts could excuse their own emotional difficulties” thereby; but among her younger followers “the trend within the Kleinian group was to take seriously the new view of counter-transference” – Hanna Segal warning in typically pragmatic fashion however that “Countertransference can be the best of servants but is the most awful of masters”.

Late Twentieth-Century Paradigm

By the last third of the century, a growing consensus appeared on the importance of “a distinction between ‘personal countertransference’ (which has to do with the therapist) and ‘diagnostic response’ – that indicates something about the patient…diagnostic countertransference”. A new belief had come into being that “countertransference can be of such enormous clinical usefulness….You have to distinguish between what your reactions to the patient are telling you about his psychology and what they are merely expressing about your own”. A distinction between “neurotic countertransference” (or “illusory countertransference”) and “countertransference proper” had come (despite a wide range of terminological variation) to transcend individual schools. The main exception is that for “most psychoanalysts who follow Lacan’s teaching…counter-transference is not simply one form of resistance, it is the ultimate resistance of the analyst”.

The contemporary understanding of countertransference is thus generally to regard countertransference as a “jointly created” phenomenon between the treater and the patient. The patient pressures the treater through transference into playing a role congruent with the patient’s internal world. However, the specific dimensions of that role are coloured by treater’s own personality. Countertransference can be a therapeutic tool when examined by the treater to sort out who is doing what, and the meaning behind those interpersonal roles (The differentiation of the object’s interpersonal world between self and other). Nothing in the new understanding alters of course the need for continuing awareness of the dangers in the narrow perspective – of “serious risks of unresolved countertransference difficulties being acted out within what is meant to be a therapeutic relationship”; but “from that point on, transference and counter-transference were looked upon as an inseparable couple…’total situation'”.

Twenty-First-Century Developments

Further developments in the current century might be said to be the increased recognition that “Most countertransference reactions are a blend of the two aspects”, personal and diagnostic, which require careful disentanglement in their interaction; and the possibility that nowadays psychodynamic counsellors use countertransference much more than transference – “another interesting shift in perspective over the years”. One explanation of the latter point might be that because “in object relations therapy…the relationship is so central, ‘countertransference’ reactions are considered key in helping the therapist to understand the transference”, something appearing in “the post-Kleinian perspective…[as] Indivisible transferencecountertransference”.

Body-Centred Countertransference

Psychologists at NUI Galway and University College Dublin have recently begun to measure body-centred countertransference in female trauma therapists using their recently developed “Egan and Carr Body Centred Countertransference Scale”, a sixteen symptom measure. High levels of body-centred countertransference have since been found in both Irish female trauma therapists and clinical psychologists. This phenomenon is also known as “somatic countertransference” or “embodied countertransference” and links to mirror neurons and automatic somatic empathy for others due to the actions of these neurons have been hypothesised.