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Causes of Countertransference
Why does countertransference occur? You and your patients may be similar or dif-
ferent in any number of ways such as your values, behaviors, attitudes, language,
physical appearance, age, gender, etc. These similarities and differences affect the
ways in which you identify with the patient. Countertransference can occur when
you have extreme over-identification with a patient (you perceive the patient as “just
like me”). When you over-identify, you become wrapped up in your patient’s situa-
tion and have difficulty distinguishing where the patient’s feelings stop and yours
begin. For example, you may find yourself thinking about and feeling very involved
with a patient whose child is affected with muscular dystrophy and is the same age
as your son. The more you perceive yourself as similar to a patient, the greater the
chance of over-identification.
Countertransference can also occur when you experience extreme disidentifica-
tion (you perceive the patient as “nothing like me”) (Watkins 1985 ). When you dis-
identify, you feel disconnected, disengaged, and possibly even become hostile and
rejecting toward the patient. For instance, a patient declines testing for colon cancer,
despite a very suggestive family history. You may consider his decision to be irre-
sponsible and find yourself pulling away from him. The more you perceive yourself
as dissimilar to a patient, the greater the chance of dis-identification.
Counselor countertransference is sometimes a reaction to patient transference.
For example, some patients may expect you to be a nurturer, and their demands
prompt you to engage in rejecting countertransference. In addition, countertransfer-
ence may be prompted by a particular type of patient (e.g., terminally ill or cogni-
tively impaired) and/or by certain genetic counseling situations that “push your
buttons” (e.g., sex selection, presymptomatic testing of minors), or it may be a more
habitual type of reaction you have toward all or most of your patients (e.g., distanc-
ing from patients’ strong emotions, being overly protective, etc.).
A growing literature in genetic counseling suggests many potential triggers of
genetic counselor countertransference. These include the patient characteristics
such as behavior or appearance (Reeder et al. 2017 ; Weil 2010 ); general similarity
to the patient as well as medical/genetic similarity (Reeder et al. 2017 ); patient emo-
tional responses (Weil 2010 ) such as anger (Reeder et al. 2017 ; Schema et al. 2015 );
patient’s use of defenses (Weil 2010 ); discomfort with disease, disability, and loss
(Geller et al. 2010 ; Reeder et al. 2017 ; Weil 2010 ; Wells et al. 2016 ); patient behaves
differently from genetic counselor expectations (Reeder et al. 2017 ); giving bad
news (Mathiesen 2012 ; Reeder et al. 2017 ; Weil 2010 ); discomfort asking patients
about certain topics such as psychiatric conditions (Monaco et al. 2010 ); personal
life events that are similar to patients’ situations, such as pregnancy (Menezes 2012 ;
Menezes et al. 2010 ; Sahhar 2010 ); pregnancy termination (e.g., Anonymous 2008 );
birth of a child with a disability (e.g., Bellcross 2012 ); personal health issues (e.g.,
Glessner 2012 ); and health issues in a loved one (e.g., Matloff 2006 ).
Cultural issues may also lead to countertransference reactions. “Working with
patients who differ from the genetic counselor with respect to ethnicity, culture,
12 Genetic Counseling Dynamics: Transference, Countertransference