Cognitive Behavior Therapy (CBT) helps patients change their realities by taking charge of overt and covert self-statements. For many years, I used CBT and other similar approaches in therapy. Even though these approaches do not address unconscious processes, they seemed useful for many patients, including a 30- something man I’ll call Sam.
Sam talked a lot about being the designated “black sheep” in his family yet he was always very responsible, taking care of his parents and siblings. At work and in his marriage he over-functioned and protected those under him. We made progress until Sam experienced several serious stressors one after another. He was not able to use skills learned in therapy to bounce back as had previously been the case. He became more overtly suicidal than I’d ever seen him.
As always, Sam was remarkably compliant with every treatment suggestion. In a conversation with Sam’s psychiatrist regarding hospitalization options, the psychiatrist commented that Sam was the most treatment compliant patient he’d ever had. This psychiatrist’s offhand comment illuminated a four-year-long transference process.
Sam’s suicidality included an angry hopelessness and the decision to embrace being the “black sheep.” As I thought about this and the psychiatrist’s comment, I realized Sam had been unconsciously showing me his lifelong efforts to win approval and be a “good boy” in his enduring treatment compliance. When I told Sam that maybe part of the problem was that he had spent his whole life trying to be a “good boy” and that he even played that out with the psychiatrist and with me, he suddenly burst into tears. From that point on, Sam began to get better and I realized the power of interpreting to patients how their lifelong patterns of behavior are unconsciously enacted in the treatment setting.