Countertransference in Dementia Work: What Comes Up for Us as Therapists?

With thanks to our Accredited Registrant member, Jurgen Schwarz for this article.

Therapeutic work with people affected by dementia can be very meaningful, but it also brings quiet challenges that frequently go unnoticed. Beyond our clinical skills, dementia work touches us on a personal level. It asks us to face difficult themes like ageing, loss of independence, changes in identity, uncertainty and mortality, topics many of us would prefer to avoid.

Dementia reminds us that some losses are ongoing and cannot just be processed and set aside. The condition keeps changing, memory shifts, communication changes, and relationships evolve. Clients and carers often live in a state of uncertainty for years. As therapists, we walk alongside them through this uncertainty, bringing our own histories, fears, and assumptions into the relationship.

This is where countertransference deserves careful attention.

Countertransference is not something we can get rid of. It is a natural part of therapy. Our emotional reactions can give us useful information if we stay aware of them. In dementia work, these feelings can be especially subtle because they often connect to universal human realities rather than just our personal histories.

When dementia touches our own fears

Many therapists notice that dementia work evokes thoughts about their own future. We may wonder, consciously or unconsciously:

• What if this happened to me?
• What if I no longer recognised my partner or children?
• What would become of my identity if my memory changed?
• Would I still be myself?

or

• What if I had to care for someone I love every day?
• How would I cope with watching someone I know gradually change?
• Would I have the patience to manage the same questions and conversations over and over again?
• How would I balance caring with the rest of my life?
• What would happen to my own identity if I became a full-time carer?

These questions rarely appear explicitly during sessions, and they usually do not come up directly. Instead, they show up as emotional reactions. We might feel unusually sad, want to rescue the client, or feel uneasy when talking about future decline. They influence our therapeutic stance. We could become overly optimistic, minimise difficult conversations, avoid discussing progression, or focus exclusively on practical coping strategies because sitting around uncertainty feels too uncomfortable.

However, clients need us to sit with those uncertainties.

The pull to rescue

Many therapists enter the profession because they genuinely care about alleviating suffering. Dementia work can increase this caring impulse.

Watching someone gradually lose abilities, or noticing how tired a family carer is, naturally brings out our compassion. But sometimes, compassion can turn into a need to rescue. We search for solutions to problems that have no complete solution. We feel disappointed when interventions offer only modest improvements. We become frustrated with family members who seem unable to cope, forgetting that they are often functioning under enormous emotional strain themselves.

Wanting to rescue often reveals our own struggle with helplessness.

Noticing this does not mean we care less. Instead, it helps us return to our true role as therapists: not to take away suffering, but to help clients find ways to live with it.

Grief that accumulates

Unlike sudden bereavement, dementia frequently involves ongoing losses.

Partners describe losing conversations long before losing the person physically. Adult children grieve while still providing care. Individuals living with early-stage dementia may mourn changes in confidence, independence or forthcoming plans.

Therapists are repeatedly exposed to these cumulative losses.

Over time, these experiences can leave an emotional mark. We might feel unusually weighed down after sessions, bring clients' stories home with us, or notice a soft sadness that is hard to name.

This is not necessarily burnout.

Sometimes we need to acknowledge this ongoing grief rather than avoid it.

Regular supervision gives us a vital space to notice these emotional layers before they quietly affect our work with clients.

When personal experience enters the room

Many therapists have their own experiences of dementia within their families.

Perhaps a grandparent developed Alzheimer's disease. Perhaps a parent is currently living with dementia. Perhaps we have provided care ourselves.

These experiences do not disqualify us from working in this field. In fact, they may deepen our empathy considerably.

But personal experience can also make us miss things.

We may assume our client's experience resembles our own family's journey. We may become especially protective of certain clients. We may react strongly to family conflict because it resembles unsettled dynamics from our own lives.

The goal is not to get rid of these influences, but to notice them.

Reflecting helps us distinguish between what is our own and what is the client's.

The fear of "getting it wrong"

Another form of countertransference often appears as anxiety.

Therapists may worry about saying the wrong thing when memory difficulties become apparent. They may question whether a client has understood the session or whether therapeutic work remains meaningful as memories fade.

This worry can make us try too hard to make up for it.

We might become excessively structured, too careful, or focus more on thinking skills than on emotional experience.

Yet many people living with dementia retain emotional awareness long after memory has changed significantly.

Clients may not remember every conversation. They often remember how they felt in the therapeutic relationship. This shows us that therapy is not only about remembering insights. It is also about feeling safe, respected, accepted, and emotionally connected right now.

Our relationship with ageing

Working with dementia also makes us think about how we view ageing in general.

Society often tells us to resist, hide, or fear ageing. Therapists are just as affected by these messages as anyone else.

If we are not careful, we might unintentionally support the idea that getting older is mostly about decline and dependence. Clients living with dementia continue to experience humour, affection, creativity, frustration, love, inquisitiveness and moments of strong connection.

Being aware of our own assumptions helps us see the person, not just the diagnosis.

Staying reflective in practice

Reflection is not something we do just once. It is something we need to keep practising. Questions include:

• What emotions am I carrying after today's session?
• Am I feeling unusually responsible for this client's well-being?
• What aspects of this client's story relate to my own life?
• Am I avoiding particular topics because they make me uncomfortable?
• What belongs to my client, and what belongs to me?

Asking these questions does not mean we are weak.

They show professional maturity.

Supervision, personal therapy, reflective writing, and talking with trusted colleagues all help us stay aware of the emotions that run beneath our work.

The value of humility

Perhaps one of the greatest lessons dementia work teaches therapists is humility.

There are no words that remove all fear.

There are no techniques that stop progression.

What often matters most is our ability to stay present without feeling we have to fix everything.

Clients frequently remember being listened to with patience, being treated with dignity, and feeling understood during moments when life felt increasingly uncertain.

Being present like this takes emotional strength, but it also requires honesty with ourselves.

When we notice our own fears about ageing, helplessness, or loss, they are less likely to shape the therapy quietly.

Instead, they call to mind our common humanity.

Conclusion

Countertransference in dementia work is not simply a problem to solve, but a summons to deeper self-awareness. The feelings we feel are often completely understandable. They reflect the intensely human themes that dementia brings into therapy.

By staying reflective, seeking supervision, and being curious about our own reactions rather than judging them, we become better able to stay truly present with clients and carers. Perhaps this is one of the greatest gifts we can offer, not certainty or easy answers, but the ability to accompany another person during uncertainty without turning away ourselves.

You can read the rest of Jurgen's series on dementia here:
Why I Believe Therapists Belong in the World of Dementia Care | NCPS
The Power of Validation: Supporting Identity and Agency in… | NCPS
Walking Beside the Carer: How Therapists Can Alleviate the… | NCPS
Adjusting the Frame: How to Work Therapeutically When… | NCPS
The Therapeutic Hour as a Sanctuary: Creating Safety and… | NCPS