Are We Treating Veterans or Managing Our Own Reactions?

In military mental health settings, countertransference is an inevitable part of relational work. Yet it remains one of the least openly discussed factors influencing the quality of care veterans and service members receive.

As a readjustment counselor, I often speak with social workers at local VA Medical Centers and Community-Based Outpatient Clinics who comment on the perceived ease of Vet Center caseloads, often in comparison to medical centers. However, in my 1.5 years at the Vet Center, I have experienced significant and ongoing changes, most recently, a shift that will substantially increase my caseload. This change has forced me to grapple with a difficult question of whether I can continue to provide high-quality, ethical care to my current clients while responsibly taking on new veterans and service members, or whether I risk embodying the very negative perceptions sometimes associated with veteran care.

I have raised these concerns with my supervisor, who has offered reassurance and encouraged a “one day at a time” approach. While supportive, I also recognize the limitations of her role within a hierarchical VA system, one shaped by expectations, metrics, and accountability pressures that extend beyond any one individual. In this context, I find myself questioning not only my capacity but the value and sustainability of my work.

How High Caseloads Intensify Countertransference

When clinicians move rapidly from one trauma narrative to the next, countertransference is often managed through emotional distancing, rigid structure, or a focus on efficiency over exploration. Veterans’ anger, grief, or mistrust may feel difficult to sit with when time is limited, and outcomes are measured. The pressure to “keep things moving” can subtly shift therapy away from attunement and toward containment.

These adaptations are understandable but when left unexamined, they can quietly shape clinical judgment. Justified mistrust may be labeled as resistance. Emotional expression may be rushed to meet timelines. The therapist’s need for resolution or emotional safety can begin to guide the work more than the veteran’s readiness or needs.

Institutional Context Matters

Countertransference in VA settings does not occur in isolation. It unfolds within a system shaped by hierarchy, bureaucracy, and narratives about resilience, compliance, and recovery. Clinicians may feel moral discomfort when veterans express anger toward the military or the VA itself. Care becomes shaped not by clinical attunement, but by the therapist’s need for resolution, certainty, or emotional safety when witnessing systemic failures they cannot fix.

Marginalized veterans are often most affected by these dynamics. Veterans who are women, LGBTQ+, people of color, or those whose trauma includes discrimination or institutional betrayal may evoke discomfort or defensiveness, especially in high-volume settings where complexity feels costly. Without reflection, clinicians may minimize or redirect what feels emotionally or politically difficult, unintentionally replicating the very invalidation veterans seek therapy to heal from.

The Cost of Silence

One of the greatest challenges in addressing countertransference within the VA is the lack of protected reflective space. Supervision frequently prioritizes documentation, risk management, and policy adherence over emotional processing. Many clinicians fear that acknowledging strong reactions will be interpreted as unprofessional rather than responsible.

Over time, this silence contributes to burnout, emotional numbing, and rigidity. Veterans experience this as reduced empathy, less individualized care, and a sense that therapy mirrors the impersonal systems they already distrust.

The Practical Ways I Plan to Manage My Countertransference 

Addressing countertransference does not require unlimited time or ideal conditions; it requires intention within real-world constraints. So far, I have found three practices particularly helpful, as I grow in the field and my professional and personal obligations shift.

1. Get the Therapist. Whether weekly, biweekly, or monthly—whatever your finances can realistically support—having your own therapist is an investment in ethical care. As someone who struggles with vulnerability, I value having a confidential space that belongs solely to me, where my reactions are not discussed in hallways or consultation rooms. Working with my therapist has become a consistent reflective practice, helping me reduce unconscious reactivity and clearly name what belongs to the veteran, what belongs to the system, and what belongs to me.

2. Take the PTO. Stepping away from systemic obligations, client worries, and the constant pressures of the VA has allowed me to fully inhabit the present moment. Being disconnected gives me the space to reflect, ponder, and even go on tangents without the constraints of a one-hour lunch break or a fifteen-minute bathroom break. This uninterrupted time has become essential for processing my reactions and maintaining perspective.

3. Supervision. While I have weekly supervision with my supervisor and peer consultation with other local Vet Centers, I’ve noticed an internal hesitation during these sessions that makes it difficult to be fully vulnerable. This hesitation has made me interested in attending an external supervision group with other clinicians of similar training and experience. A colleague recently invited me to join her weekly external group, which feels like a space where I might be able to reflect more openly without the worry that sharing could put my job at risk. I’m considering joining on weeks when I don’t have my regular supervision as a way to expand reflective support in a setting that feels safer for deeper processing.

Moving Toward More Ethical and Humane Care

Veterans do not need perfect therapists, because I surely ain't one! They need clinicians who are self-aware, supported, and willing to examine how personal reactions and institutional pressures enter the therapy room. Countertransference will always be present in VA and military mental health settings. The question is whether it remains unspoken and unmanaged, or whether it becomes a source of insight that strengthens ethical, trauma-informed care.

Improving quality of care within the VA requires more than policy reform. It requires a cultural shift that treats therapist self-reflection as foundational to healing work with veterans and service members.