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20 July 2017

Cognitive Processing Therapy - Session 3

The written homework for session 3 was about making connections between events, feelings, thoughts, and resulting behavior. The tools for this session (and later sessions) were the list of stuck points I'd identified for myself, and A-B-C Worksheets that are divided into sections. You start with an Activating Event (where the thing happens), describe the Beliefs/Stuck point that goes along with the event (which is what you tell yourself), then describe the Consequence(s) (what you feel as a result). Once those are filled out, you ask yourself two additional questions: "Are my thoughts in B realistic?" and "What can you tell yourself on such occasions in the future?"

A disclaimer here, one you'll see often from me: I'm the patient. I'm the veteran with PTSD. I am not an expert on any of this. My writing is an accurate description of what I'm feeling and doing (I won't bullshit you) while I'm doing this therapy, but your experience will probably be different because whatever you went through was different. None of this is professional medical or mental health advice.

Another disclaimer: there are multiple versions of the CPT patient therapy workbook that come up in Google's results. For me, the "official" version is the paper one I got from the VA and that's the one I'm referring to. That's also why I'm not linking to any of the worksheets; they're "out there" on multiple non-VA websites and I don't have any way to tell what's the official current version.

That being said, a large part of what's going on here is Socratic questioning; this is mentioned in the CPT therapist manual, and once I looked up what Socratic questioning is things started making a lot of sense. In terms of CPT, it's an organized way of questioning me the patient (me) about what I'm saying-- challenging what I'm claiming is true about what happened and how I feel about it. As the patient, written as worksheets, it's an organized way to question my beliefs and more importantly the resulting consequences of those beliefs. In other words, a way to work past stuck points. (This is also quite closely related to critical thinking, which is a much broader topic.)

Another way of looking at what's going on with CPT is root cause analysis, aka the 5 whys, which also refers to Ishikwa diagrams. I mention these ideas because asking "why?" five times results in an answer that you don't get by just asking a question once, and Ishikawa diagrams are a more visual way to see the connections between an event, what you can tell yourself about the event, and the results or consequences. I've been able to use this while filling out these worksheets when I've been stuck.

Again, this is advice from a patient and not a mental health provider, but I think it's useful to do more than just fill in the blanks on the worksheet. Draw pictures, add arrows, underline, use different colors of ink. In response to the prompt "I feel something" I started with the "easy to pick from" emotions-- let's say, anxiety-- and then asked where being anxious leads to. I'm a little reluctant to just scan an A-B-C worksheet that I've filled out and post it, but here are slightly edited contents from one so you get some idea.

Activating event (something happens): I hear something; a PA system activating, a cell phone ringing, an alarm, a truck backing up and beeping, sudden and unexpected sounds.

Belief/stuck point (I tell myself something about it): There is something life threatening and dangerous about to happen.

Consequence (I feel something): here I go off script a little, and list what I feel instead of trying to write statements and sentences. Instead of just being "anxious" there's a path showing how things progress from initial response to actually feeling it.

  • Surprise
    • Startled, Excited
      • Terrified
      • Insecure
        • Worried
  • Fear
    • Anxious
      • Overwhelmed
      • Frightened
    • Worried
After that come the questions:
  • Are the thoughts in B realistic?
    • Not all noises alarms describe life threatening situations
  • What can you tell yourself on such occasions in the future?
    • Some such noises are beneficial and not all are dangerous
During the next actual session, I'll read these answers and explain why I mapped, rather than just listed the name of emotions-- I can explain that surprise led to being startled and excited, and that led to being terrified and feeling insecure led to being worried. At the same time, an initial reaction was also fear, which led me to feeling anxious, which made me overwhelmed and frightened (in addition to also leading to feeling worried). All of these emotions are exactly what happens when, for example, someone makes a loud or unexpected noise in a lecture hall.

A couple of things yet to add about the mechanics of all of this-- filling out the worksheets takes time. It's not an activity that you can just do for a few minutes during the commercials watching TV. The "activating event" is often the trauma that started all of this, or closely related things that happen/happened after, so it's not easy stuff to think about and write about. I lock myself in my bedroom in the middle of the night where I know I won't be interrupted. You might not need to go to that extreme, but have a time and a place to work on the worksheets. (This is why it's so important to have a regular schedule for the actual sessions, too.)

I'm also keeping a journal outside of the CPT workbook. One takeaway from the first time through CPT (nearly ten years ago) was that there was a lot happening besides just being diagnosed with PTSD, and I often have wished I'd written more down than was just on the worksheets. While CPT was going on then, I had a girlfriend (which was good) and a job where I'd been moved to a lesser position (which sucked) and these were at least inputs. 

More immediately, if in doubt write it down. The A-B-C worksheets feed into the Challenging Questions worksheets, which feed into more in later sessions. Don't half ass anything. Like a lot of things, what you get out is what you put in, so be honest with yourself. Write shit down. There's no rule saying you have to read or show everything you write in sessions.

Session 4 has already happened, but more on that soon.




12 July 2017

Cognitive Processing Therapy - Week^HSession 2

It's actually been two weeks since session 1; what would have been week two was an off week. Social Worker had another commitment at my normal scheduled time last week, which happened to be noon the Friday before a four day weekend for Independence Day.

Anyway. 

I've not been able to find it written anywhere that CPT has to be done in twelve consecutive weeks, including the VA's therapist manual, but having two weeks between sessions feels too long. One thing that I find helpful about this kind of therapy is that I can't avoid it-- there's going to be another session in seven days, and so I have to read the stuff and write the stuff. If I have two full weeks without a session, as happened here, that tension (or motivation) is gone and it's a lot easier to just avoid thinking about what I'm doing in therapy. Which feels counterproductive to therapy that's supposed to cause me to confront and counteract avoidance.

Anyway.

Several days before this session, SW called to see if I wanted to move my appointment time from 1200 to 1300. I managed to not call back; more on this in a bit, but I don't have a sense of time passing. If someone calls me it's very likely that I won't realize that several days have passed since the call came in. So it was already the day before the session this past Friday, and I figured I'd just go to the session at the (initially) scheduled time. I'd also received a postcard reminder in the mail with the initially scheduled time.

When I arrived at the clinic and tried to check in, the kiosk said I was too early. My appointment was at 1300, not 1200. So I went at talked to Front Desk, who said the same thing. After making it clear that I believed this was incorrect, I asked Front Desk when the appointment had been changed and by whom. After I looked at the call log on my phone, it turns out SW had called me, left a voicemail, and then changed the appointment time to 1300 the very next day.  Front Desk messages Social Worker, who doesn't respond. Looks at this point like I have an hour to kill.

At about 1200, SW appears at The Door; another patient is scheduled at 1200, but if that person doesn't show then I can still have my session at 1200. A few minutes pass, and SW appears at The Door again to let me know to come hither and proceed to The Back for The Session. If the 1200 patient shows up, we might need to rearrange things. (1200, unsurprisingly, never does show up that I'm made aware of.)

We discuss scheduling, including this SNAFU. I mention that I'd be much better off having the rest of the sessions actually scheduled, because my life runs on my calendar. I mention that I have no sense of time passing, that days and weeks and months can go by without my noticing. The best word I have to describe it is dissociation, but I'm not sure that this is accurate. "Zoned out" is perhaps another term to use, and short term memory (and/or loss thereof) may be involved too. I'm not sure. We discuss this a bit, and he doesn't seem to think it's PTSD related. There aren't any other factors like TBI or alcohol/drug use. I repeat, as I have before, that I've been tested for adult ADHD and the day long test was negative.

The result of the scheduling discussion was that I won't get the remaining sessions scheduled, but I will have them scheduled for the rest of July. There may be at least one more week where "due to other commitments" SW won't be able to keep the weekly schedule. When I let him know that a) we're already looking at mid-September for finishing the therapy and b) I'm planning to head back north at the end of September, I'm assured that we'll still finish and even if we don't it's okay to skip the last session. (No, it isn't okay, but I'll fight that battle later.)

I'm looking at MyHealtheVet as I'm writing this (7/11/17) and I have no future mental health appointments scheduled, including this week's session. Hrm.

It's crossed my mind not to include all of the details of scheduling and the waiting area and parking and all of that in these posts-- is is really relevant?-- but I've decided to include this stuff because it's part of being in the therapy. I feel as though it's often sugar coated, "oh you just do this 12-session therapy and you're better" and my experience says it's not really that simple.

-----

The bulk of the actual therapy part of the session is taken up with me reading my statement on why I think the trauma (having missiles lobbed at my unit and the very real fear of chemical weapons being attached to them) happened. I actually wrote this out twice, and read the second version out loud because it was a bit more coherent. A short summary is that these things happened because I was in a unit whose job it was to be there, and because Iraq had invaded Kuwait (and, it was suspected, was considering going after Saudi Arabia as well), we were shooting at them-- therefore it was logical that Iraq was shooting at us.

I never actually got to read what I'd written on the other part of the assignment, writing about what effect the event(s) had on my life concerning safety, trust, power/control, esteem and intimacy with regard to myself, others, and the world; but since I did take the time to write it all out on my own, I still got some benefit from doing so.

Discussion from there centered on how I'm interpreting why the bad stuff happened, rather than on the specifics of the events that caused it-- how am I seeing the world? An example that came up was carrying a firearm. While there have been a number of cases where yayhoos with guns have showed up at public places and started shooting, the likelihood of needing a weapon that you're carrying in day to day life is rather low. The threat landscape for an individual carrying a firearm changes internally, because when you're packing heat you are also in different mindset than when you're not.

There's a subplot here, because I did a remote tour just before I joined the unit I went to the Desert with. A fair amount of my time during that 15 months was spent on exercises and training (which is normal and expected), all of which was directly applicable to my time in the Desert. I didn't do any training before shipping out for Desert Shield, because I really didn't have to-- I'd done all of the wartime training, with the exception of the mobile unit specific stuff, at the unit I'd just come from. So mindset matters a lot, and being in a place and a time where the USSR was not that far away wasn't all that different from going to Saudi Arabia where Iraq wasn't that far away.

One of my wartime duties during said remote tour was "runner", meaning I got to go outside and take stuff from my squadron to a command post and back. This of course involved a lot of wearing chem gear out in the elements. Driving a pickup truck in a gas mask with glasses insert, for the record, isn't either easy or fun. Doing so, including being outside during Alarm Black, also meant that I got a fair amount of practice at least pretending that whatever was outside my chem gear (which I was walking and driving through) would kill me in seconds. I had to demonstrate, that I could do that and my regular job in Mission Oriented Protective Posture (MOPP) 4, meaning the mask and hood and the whole getup. So it was in that mindset, that at some point I'd have to spend multiple 12-hour shifts doing my job in MOPP 4 after an attack involving chemical weapons, that I arrived in the Desert.

At one point, the powers that be came up with MOPP Alpha, which was "take cover, don mask hood and gloves, keep all skin covered". If you were caught outside, it was recommended that you wear your rain poncho. If chemical agents were detected, then go to MOPP 4.  To me it didn't make sense-- a few months before that I'd spent 12 hours at a time in MOPP 4 Alarm Black during an exercise, and now in real world you're telling me to basically just fake it? Aside from which-- imagine that you have a bucket over your head and you're wearing gloves like you'd wear snowmobiling. Now, wearing those, pull on an extra pair of pants, an extra jacket, and a pair of boots that you have to tie and keep in mind that you're doing all this knowing that chemical agents have actually been detected.

I am also reminded of a guy in my unit who was about 6' 5" tall; the pants legs of his chem gear weren't long enough, and the official recommendation was that he use duct tape to cover the several inches between the bottom of the protective suit and his boots. Imagine doing all of the above and then having to wrap your ankles several times around with duct tape.

So what we were really talking about in the session was (as I'm reading my notes) levels of safety and what could have happened vs what actually did happen. One of the reasons some officer in the Desert came up with MOPP Alpha was the likelihood of chemical agents actually showing up, the other was that chem gear was a finite resource-- the suit can be "used up" and for whatever reason there was a question about how many we had available. He/she/they looked at the situation and came up with MOPP Alpha.

As it turned out, there were officially no chemical agents dropped on us. There could have been, though, and that's the thing that's been stuck in my head all these years. When someone came running through the hallways of the bunker I was sitting in that one night like Paul Revere, telling us all to make sure we had our masks on, that's the moment I knew that shit was real. Whatever it was that prompted that person to do that, I don't know, but the only thing that makes sense in that context was that someone had detected something, or thought they had. History says otherwise. I'll never know.

The other difficult thing that came up was that I didn't have anywhere to run to for at least half of every 24 hours. "On duty" meant that there was an underground bunker to run to when the alerts went out. "Off duty" meant that I was in a house that was away from the city and the main site. I'm from the Midwest, where the first thing you learn as a kid after you learn to walk is that when the sirens go off for a tornado you find a basement or cellar or some similar place. This was the Desert, and there were no basements underneath what passed for barracks (they were actually houses, and I'm not complaining about comfort level-- they just weren't what you'd think of when hearing the word "barracks"). You could choose which bedroom to be in, or the living room or kitchen or bathroom, but no one room offered any more protection than the other. I can't find the exact document where I read this, but the idea was that if one or more SCUD missiles made it past the Patriot batteries, and there were chemical agents along for the ride, hopefully one site or the other would remain a safe zone.

Heads or tails? Live or die? Call it in the air.
As Saudi and U.S. military ambulances took away the wounded, U.S. servicemen and women stood stunned, as if unable to believe that a Scud -- an unguided ballistic missile known for its inaccuracy -- could be launched against such a sprawling city as Dhahran and hit a building housing American soldiers.  --Washington Post, Tuesday, February 26, 1991; full story here.
-----

One other thing about what I did and where I was; I worked in radio communications, which is one of the tools used in command and control of armed forces. The thing about working in radio communications is that, if things are working right, you are transmitting a signal that someone else can hear several hundred miles away. If in doubt, triangulate the signal and aim something big and explosive in that direction. There's nothing stealth about radio.

I got to see a lot of briefings. We (meaning us airmen) were both allowed and encouraged to attend the daily staff briefings on what was going on and I did whenever I could. There was a lot of stuff I didn't care about-- the weather briefing didn't change much one day to the next-- but especially once Desert Shield became Desert Storm, there were a lot of photos and a lot of videos of shit in Iraq blowing up. (When you're a young airman in your first war, that shit's pretty cool.)

It wasn't until I was a civilian sitting at home after being out for a number of years, that I started seeing the same kinds of photos and videos on CNN (among other places) during the wars in Iraq and Afghanistan. The talk was always of targeting command and control elements of the enemy, and blowing that shit up. The realization I had was that the shit being blown up then, and the shit being blown up when I was in the Desert-- command and control-- was exactly where I worked, just on the other side of the lines. That there was command and control on the other side meant that there were also radio guys who'd dropped out of college to join the military. Enlisted people with wives and girlfriends and families, lists of what they'd do when they got back home, the same bitches and moans and gripes and complaints I had but in a different language.

I had a unique view of Desert Shield and Desert Storm, compared to a lot of people-- I'd come from the pointy end of the spear back to the hand holding it. I'd also spent high school and some college as a hacker exploring the world of cyberspace, where borders and distance-- in fact, a lot of rules-- are very different. I'm a sponge when it comes to information, and being where I was with the background I had meant that what my senses picked up went straight into my brain.

A lot of it stuck.

-----

One notable change I made this week: I play a lot of Urban Terror. It's a game, a first person shooter that's a mod of Quake III. As a game, it has nothing to do with the Desert or PTSD, other than for me it's a diversion. When I was in Wisconsin, I'd often play for a couple of hours between getting off of work and going to get breakfast before going home. Here, I play sometimes for several hours a day, especially if I'm feeling like shit and want to disappear into a different world for a while. Within the game, I'm skilled enough that it's immersive.

I decided to stop playing while I'm doing CPT; the hours (and hours) I spend playing are better spent making sure I'm getting my stuff done for the therapy, and for thinking about and doing due diligence on what I'm planning for after the therapy is done. I can't afford to just "not be here" for several hours a day; I have enough trouble with that already.

Putting away the crutches and walking on sore limbs, even when it's mental and not physical, is a bitch.

-----

I promised I'd post a list of the stuck points I've identified. Here is that list, with the disclaimer that it's an initial list. Some of these will get crossed off, others will get modified, I will find others as I work through the rest of the therapy. They are not cast in stone. Yours will be different. (As I'm copying, pasting, and formatting these I see several I need to tweak.)

  • I don't deserve to live when other people lost their lives
  • If we'd have been in the right environment we'd have been much safer
  • I cannot trust others to understand (any of this)
  • I need to be on guard all the time because something terrible will happen
  • I need to be able to protect others
  • I must control my life/what happens to me
  • No civilian can understand any of this, no one will ever see me as being a good person
  • I must always stand my ground against threats
  • No one can ever really be trusted
  • Doing my job meant that a lot of people died and I feel responsible for what happened to them
  • I don't have a future because I can't manage this
  • The country made my service irrelevant after 9/11
  • If people find out I have all these thoughts they will never accept me as a person
  • I cannot ever rely on people/the military/government who say they will help, they will always fail (you're safe in this bunker-- no wait, you're not)
  • If there is a noise/alarm then it is something I need to worry about-- a threat
  • If something happens to alter my plans I cannot adjust because doing so will compromise safety
  • I didn't see as much/the same level of action as others so how I am feeling isn't as important 




05 July 2017

Cognitive Processing Therapy - Week 1

I've heard it said that the hardest part of therapy, or of getting help, is getting started-- and I agree. Once things get started, once you start working on something with some structure, at least now you're working within a schedule and set of rules. Once you start actually doing something, even on the worst of days you can look in the mirror and know you're being honest telling yourself that you're actually taking a step forward. Getting started this time has been especially difficult. The problem is not that I am against getting help-- it's that once I decided I needed help the road to actually getting help has been far too long.

Documentaries and articles always seem to start with "here's a veteran who is struggling" and end with "but she's got a complete life now", and the description of what the vet actually did in the middle ends up (to me) sounding like they pulled up to the drive thru window and ordered a happy meal and that's it. Okay, you got some pills. Okay, you went to individual therapy. Okay, you went to group therapy. You got a complete meal. Burger, fries, soda. The message of the documentary or the article is always that if you just go get help everything will get better. With all due respect to McDonalds the assumption, or the promise, is that you'll be lovin' it.

"Help" for me right now is sessions with a social worker at a VA community based outpatient clinic (CBOC) in Lawerenceville GA. Cognitive processing therapy is a 12-week session program. At the risk of repeating myself, it took going to a Vet Center, primary care, the emergency room, trauma recovery, and a letter to a U. S. Senator to get into CPT.

Getting to the clinic is optimally (according to Google Maps) about a 40 minute drive; in reality, I have to allow at least an hour to get there and more if I stop for soda and/or gas. The drive is usually pretty routine, if you consider passing through green lights doing 70 m.p.h on a divided highway normal. If traffic is bad, which seems to be another common occurrence, or if I'm going either direction during peak times, it can be a two hour trip. This session was scheduled at noon, so at least rush hour wasn't an issue.

I have almost no sense of time and have almost no circadian rhythm lately. I can't fall asleep unless I'm exhausted, and my brain and central nervous system don't seem to give a shit that I have appointments to go to. So the night before the session, I don't sleep at all. This is partly because I'm very anxious and the PTSD is trying to fuck me up, and partly because I'm afraid if I do go to sleep there won't be a snowball's chance in hell that I'll be able to wake up in time. Lately, I've been crashing at around sunrise.

Even so, I have the appointment entered in the calendar on my phone with reminders at time to leave, and an hour before that.

If my truck is running, I drive myself; my truck isn't right now, so my sister drove me to this session. I'm not really in the mood to talk, and she respects that. I'm riding shotgun so I keep an eye on Google Maps and traffic, which gives me something to do. If I were driving myself, I'd still keep an eye on Google Maps for traffic, and I'd have the radio up as far as my shitty speakers can handle. I'm not, so the radio is off.

The clinic itself is in yet another professional office space strip on yet another curved blacktop road in the middle of urban sprawl. There's often nowhere to park, and no alternate places, so if all the spaces are full I have to wait for someone to come out and leave.

Inside the clinic: several rows of chairs, only one of which offers back to the wall seating. That row is next to a TV that no one ever seems to be watching, turned up far louder than it needs to be. There are check-in kiosks along one wall, and reception desks along another. Getting to either requires walking or standing behind directly the rows of chairs where other people are waiting for appointments, which can be uncomfortable for people who are afraid of being snuck up on.

I go to a kiosk, check in. One screen shows my upcoming appointments, and two that are supposed to appear do, but I don't have another session scheduled for CPT. Odd. I try to print a list of my upcoming appointments, but either the printer is broken or it's out of paper.

I sit down next to the TV. It's the only available place where I can have my back to a wall (which is actually a window) and not have people walking behind me. I pull a set of Decibullz molded earplugs (https://www.decibullz.com/earplugs/) from my pocket, wiggle them into place. (I don't do/accept product endorsements, I'm not an affiliate or anything-- but they really help with noise. I found out about them from a DJ who's in clubs several nights a week.) I can still hear the TV, but not nearly as much, and the noise of the room is now blocked.

The thing about noise-- I'm from the Walkman generation, I'm used to having noise in my ears, but when the PTSD is acting up the hyperawareness and hypersensitivity are acting up too. More noise, especially random and uncontrollable noise, just ratchets up my anxiety level. TV is an especially bad trigger because it's random noise often punctuated by things like a clip of the latest terrible thing that happened on the news. Two other common sources of triggers are cell phones, which might as well be missile alerts, and loud constant mechanical noise (leaf blowers, mowers, vacuum cleaners, etc) that remind me of the constant sound of generators and air conditioners in the Desert. So for now, if I'm out in public and feeling at all anxious, and if it's safe to do so, I wear earplugs.

People don't get earplugs (or ear buds). I had someone standing in front of me talking for full two minutes before I finally took an earplug out and asked him what the fuck he wanted. He was asking if the hog outside was mine-- which is nunya anyway, but just as a general rule the waiting room at a VA clinic isn't a bar. Leave people alone. Especially if people are wearing ear plugs (mine are bright red).

The clinic has two major sections, the Front where the waiting room is, and the Back. A Door separates these two worlds. When your provider is ready for you, they appear at the Door and call for you. When you go through the Door, they have to hold it open for you. (The Door has an electronic keypad/card lock. Although there is no sign indicating so, the border between Front and Back made by the Door is of some official concern.) Since I am there for a mental health appointment, SW leads me to a far back corner office that is just down the hall from another office that belongs to a SW. Again, no sign indicating so, but this feels like the mental health area.

The session has a somewhat predefined script; there is a therapist's manual that outlines nearly everything that's included in the VA's CPT, defines what happens at what session, etc. I have a copy of the manual, which is a little like having a copy of the teacher's edition of a math textbook. I've also been through this therapy before, so I kinda know what's coming. When I first did CPT, I didn't know that there was a standard manual for the therapy (and didn't know to ask). I tend to think of this kind of therapy as training, because it's teaching your brain to respond differently, and that seems to help.

I spend more time than is probably normal talking about the trauma I experienced. I'm supposed to be talking for five minutes, but I've already written down what I want to say before the session. I don't read it verbatim, just wing it from memory, but writing it down ahead of time helped a lot towards having it organized in my brain. This SW has met me once, and even reading my medical records doesn't do much for figuring me out. I'm not sure about SW's age, but it's been my experience (especially in Atlanta) that I have to specify that I was not in Iraq. Most people I encounter don't remember that there was a Persian Gulf War before that.

We also started talking about stuck points for next time, and I got a staple bound copy of the patient CPT workbook. First time around, each session I got just the handouts and worksheets for each session. Maybe this matters, maybe not? I've since got rid of the staples and put the whole thing into a three ring binder. I also have a blank Livescribe notebook for writing down assignments; I didn't this session, but next session I'm going to use my Livescribe pen to scribble some notes and record everything.

A word about organization: I am a hacker, which by definition means I'm something of a packrat when it comes to information. One never knows when something might be handy later. I'm also really trying to make the most of this, so I'm also looking at materials outside the official CPT patient workbook.  I've written about doing this before; the idea is that the CPT manual is narrow in focus, which is fine within sessions, but I have a lot of bigger questions to answer (and stuck points to challenge). "The binder" for this twelve sessions will be the CPT workbook, interleaved with Livescribe pages that go with the stuff specific to sessions. The Livescribe pen doesn't care where the physical pages are or how they're physically ordered. So when it's all done, I'll have a detailed and annotated manual rather than just one where I filled in some blanks every week.

Next week session is session 2; my assignment for that session is to start listing some potential stuck points. I've started doing that already. People seem to find my blog when looking for stuck points (or information about them), so I'll post a list of some of mine with my session 2 notes.

Speaking of session 2: my second session will be two weeks after the first. That's why there wasn't a second appointment listed when I checked in-- it hadn't been scheduled yet. Session two is scheduled for the first week of July. Assuming there are no other delays, this puts me finishing CPT in late September. As to the reason why session 2 was delayed, the social worker explained that he wasn't available this week (June 30).

Because who wants to sit at work in a VA clinic talking to a veteran until 1300 on the Friday before the Fourth of July?

Think about that, let it sink in for a minute.

-----

As mentioned above, I'm looking at some other sources of information about cognitive psychology, PTSD, and generally trying to make sense of life. Two specific books I've found helpful recently:

Psychology of Intelligence Analysis by Richards J. Heuer, Jr. 


Tribe by Sebastian Junger

I also constantly refer to Patience Mason's Post-Traumatic Gazette; Patience has recently updated and made all of the issues available. They are an invaluable resource. The quote "Everything after the word should is bullshit."  --Patience Mason is from http://www.patiencepress.com/documents/FSPTG1(Rev).pdf.



23 June 2017

Cognitive Processing Therapy - Week 0

The last time I talked to anyone from the Department of Veterans Affairs (the VA) was at my last appointment with a social worker at the Lawrenceville GA clinic on April 28. I have specifically been trying to get into cognitive processing therapy (CPT) which is a 12-week therapy program that I've done before, but for different reasons. This time I want to focus on the Persian Gulf War and my experiences there.

I don't want to rewrite the whole story here, but before that I'd been to a Vet Center five times, primary care three times, trauma recovery once. and the Atlanta VAMC emergency room once. I've been trying to get help with the elevated level of PTSD symptoms I've been experiencing since around Christmas 2016 and have been unsuccessful. It's just been one referral, one consult, after another.

So let's call this part one:

At that last appointment, the social worker initially had nothing to offer. I repeated several times that I was feeling much worse, and that I felt very strongly about wanting to do cognitive processing therapy. Now. Today. Let's get started and do this so I can get better. After a while of this, it occurred to her that the person from trauma recovery who does CPT happened to be in the Lawrenceville clinic that day-- would Social Worker like me to ask him about CPT?

Yes, I wanted you to do something to get me into that therapy a month ago, and a month before that when I was in the emergency room.

So she goes and talks to trauma recovery guy, and the best he can do is put "me in the queue".

Now, trauma recovery guy knew who I was because my name had come up in Trauma Recovery, who instead of offering me CPT offered me the Intensive Outpatient Recovery Program (IORP). When I'd gone to talk to Trauma Recovery in April, I'd also indicated that I wanted to do CPT.  So anyone in TR who heard my name should have also heard "cognitive processing therapy" along with it, meaning either the psychologist I talked to in TR didn't mention it or TR just ignored me. But the trauma recovery guy who's down the hall in Lawrenceville swears I'm on the list.

I didn't make another appointment with the social worker from primary care because I saw no point in doing so; there was no additional data entry to be done, meaning there was no where else to send a consult to. So I was "in the queue".

Weeks pass, I handle family visiting very badly. I try writing a letter to my U. S. Senator to ask for help. After a number of attempts to write something coherent, I just spell it all out and send it. A request for a records release form comes from the Senator's office, I send that back, and then a week ago today I get a call from someone from the VA in Atlanta. This person is someone who is in charge of things and can get things fixed. After several days of telephone tag (which was partially due to me not sleeping on any kind of schedule), we have a long conversation in which I explain all of what's happened over the past nearly six months.

He contacts the trauma recovery guy who does cognitive processing therapy in Lawrenceville, the same one who "put me in the queue" back in April. Because of the phone tag delay, I wasn't able to get into the appointment slot that the trauma recovery guy had open last week; but would I like to get an appointment this Friday at 1400? Yes, yes I would. 

When I was talking to guy in charge the other day, he mentioned a couple of other things. 

First, there's a telehealth option where the VA gives me a tablet with internet access (I'm guessing an iPad that does cellular) so that I can do therapy from home. In almost six months, no one else even mentioned that this was an option.

Second, trauma recovery guy who does cognitive processing therapy had two open time slots in Lawrenceville in June. The first was last Friday, the second is today. Remember that I was "in the queue", according to the social worker I saw the last week of April, who said she'd talked to trauma
recovery guy. I was most definitely "in the queue".

Look, I wasn't fucking born yesterday. I'm a hacker, and I'm quite familiar with how a queue works because I've written code that uses them. I'm also a veteran, and have had enough hurry up and wait to last an entire lifetime. Finally, after all I'd been through already I knew it was bullshit-- even when I managed to get scheduled appointments, they never resulted in me being in therapy anyway. 



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Part two

Last week, after finally talking to the guy in charge, the social worker who does cognitive processing therapy called and left a vociemail with a date and time. I called back and confirmed. A week ago Friday, I finally had an appointment to go to that wasn't an intake. SW and I had a frank discussion about everything that happened, including the part about "the queue". We also started discussing the actual therapy and how to get that started.

This week, today, is week one of cognitive processing therapy.

In trying to do some preliminary thinking about stuck points and trauma and all of that, I've realized that in all of the different kinds of therapy I've done, the only one that directly addressed the Desert was prolonged exposure therapy. All of the others-- mindfulness, acceptance and commitment, behavioral activation, wellness recovery action plan, transitions clinic (aka intensive outpatient recovery), even the stuff I did at the Vet Center, none of them included me directly thinking about what had happened during the Persian Gulf War.  

Now, all of that therapy talked about a lot of other things, ways to be calm and to cope in a positive way. They offered checklists, guides, explanations, to do lists. After going through all of it, and ending up being homeless for two years and failing out of college twice, then ending up on disability and wondering if ending my life would help matters, I can't help but wonder what the fuck any of the therapy (or the medication) was really supposed to accomplish.

Looking back lately, I'll be damned if it wasn't like trying to treat a broken leg by learning to use crutches more efficiently instead of setting the broken bone properly and putting it all in a cast or a boot first. I've had first aid classes at various times in my life, and one of the most important rules is always to try to stop the bleeding-- but you have to identify where the blood is coming from and why before you can make the bleeding stop.

In all but prolonged exposure therapy, it was usually against the rules to talk about specific traumatic events or triggers. More than once I wanted to raise my hand and ask "so what the fuck are we here to talk about then?" In prolonged exposure therapy, it was a just about the event (which in my case was being ass out of luck in a bunker), and not about reactions to it and feelings about it. I've honestly had very few times in my life since coming back in 1991 where I was able to actually sit down and talk about the really good shit, how I feel about it, how it relates or doesn't relate to the world I'm in now.

Nobody seems to want to hear about the morally ambiguous parts, where you realize that all of the videos you've seen of precision munitions blowing apart a bunker in Iraq are blowing up a command and control facility that is probably quite similar to yours. No one wants to hear that since 2003, the war that defined your life is now just a footnote to another generation's war. Certainly no one wants to hear that you're having trouble managing your life because you have all of this shit in your head, and it's crowding out the simple things that everyone takes for granted as easy.

I don't expect this round of cognitive processing therapy to answer all of these questions, or even any of them. What I do hope for, is that I can change the thought patterns that I've had going on over the past six months (and really, three plus years) into something that I can actually move forward from and maybe even build on. I have a lot of things I need to try to make peace with. Where I am now, both in terms of location and in terms of mental health, isn't allowing me to do that.

It took writing a far too emotional letter to my U. S. Senator to get into this therapy. I do have a lot more to say about that, but for right now I have to set that part of the story aside and focus on the therapy I've fought to get into.

It is a 12-week program, which means I'm going to be working on this all summer-- assuming no delays, done in mid-September. So I'm where I am until then. Once the therapy is done, I expect that my outlook on things will have changed, that I will feel differently than I do now, and that life is going to need to change. It's possible I'll stay here, if I find work that I can do. It's possible I'll just go back to Wisconsin for a while and try to figure things out from there again.

I'm going to try to post something every week through the 12 weeks. Depending on a lot of things, posts might not appear exactly every seven days.

So it begins.

08 June 2017

Trippin' on pills

I've been spending a lot of time reading my own writing. I never had any concrete goals when I decided to start writing this blog, it's just that I'd looked for information on how to handle college as a person with PTSD and hadn't found much. Maybe I could, by recording my experiences, add something to what little discussion there was. As time went on, this blog became a place to vent and a diary, and often both. It still is those things. Most of my posts here aren't prepared ahead of time, I get an idea (or two or three) for some period of time, which is often pretty short, and then I start typing.

My first entry here was on 7 December 2008. I was still a part time student at Madison Area Technical College, juggling classes with a full time job I hated and a part time job on the same university campus (UW-Madison) that I hoped to someday graduate from. PTSD has me in pretty rough shape lately, but it had me in pretty rough shape back in 2008 too. When I sit here and chronologically follow my posts from then until now, I realize just how much and for how long I've been fighting to keep my head above water.

PTSD and I go back much farther than 2008, for the record, but that's when it was actually diagnosed and that's when I started writing blog posts about my problems with it.

If I were required to write the closing chapter of this story right now, the chapter would be a narrative of how I had done my best to overcome trauma, a disability, failure, and a bunch of other things while in the end failing to do so. The last sentences would not end with a glowing description of my graduation ceremony, there would be no final page consisting of a picture of me in cap and gown holding my degree (which is what I'd ultimately planned for my final blog entry). The final page, if I had to write it today, would simply be blank. The book would end, without a moral to the story or even a punchline.

I washed out of UW-Madison in spring 2011; yes, I returned to UW-Madison for one semester in spring 2014, but the time between, during, and after that actual last semester was entirely dependent on spring 2011. It would not have been an outrageous thing for me to have tried to kill myself after I lost my appeal, and was told that I'd have to take at least one semester off. I have met students at UW-Madison who had done exactly that, in some cases making more than one attempt, because the grades they were getting didn't meet what other people expected. I decided, instead, to stay and fight my way back. No way was I going to let this PTSD shit beat me. No way was I going to take "the easy way out".

In fall 2010, I was in my second semester at UW-Madison. The first, that spring, had been a train wreck. I spent most of the summer working, but I also spent a large amount of time looking at what had gone wrong and trying to come up with answers. I made some pretty major changes; I moved into an apartment that was nearly on campus, eliminating a nerve wracking hour long bus commute back and forth every day. I talked to the campus disability resource center and got set up with a Livescribe smartpen to take better notes in class. I did a lot towards planning to study more effectively. I retook two of the classes that I'd failed in spring.

Even with all of that, I was still struggling; so in mid-October 2010 I called and made a mental health appointment at the VA. From https://stillinthedesert.blogspot.com/2010/10/choosing-medication-as-treatment-option.html:
And right now, the writing in journals and making flash cards and working through cognitive therapy worksheets isn't getting it done.  So on Tuesday when I'm at the VA hospital, my doc and I are going to discuss medication as a part of my treatment plan.
I believed then that I was pretty close to figuring it all out, that all of the therapy so far and all of the research I'd done on how to be a better student added up to something that was close to a solution that would see me through the rest of college. Maybe, I thought, if I could just get over this last bit of trouble I'm having, then everything would be cool. If I could concentrate a little better, that would be enough. My own research suggested either sertraline (Zoloft) or paroxetine (Paxil) as options for medication; the choice turned out to be sertraline.

I passed all of classes except one (and that was a pass/no credit class so it doesn't count), putting up a 2.6 GPA. Not stellar by any means, but a long way away from failing everything.

By January the amount of sertraline I was taking had been increased, and both trazodone (Oleptro) and bupropion (Wellbutrin) were added to my prescription list.

By February and the first set of midterm exams, I was already in trouble, already behind in my classes. I was able to get help with testing accommodations, but I never did get caught up. That semester, spring 2011, was another train wreck. After that semester is when I'd officially washed out, and UW-Madison required me to take a year off.

In fall 2009, I was working the same two jobs and taking essentially the same class load and did all right. In fall 2010, I was also working the same two jobs and taking essentially the same class load and did all right. Neither of those semesters were at all easy, but I didn't fail my classes.

If I told you that I'd failed out of school because I was drinking too much, or smoking pot too much, or using too many illegal drugs, you might be inclined to say that these were likely reasons to wash out. Bad results are almost expected from people who do these things. How many people go to UW-Madison for one or two semesters, get into the binge drinking and party atmosphere, zorch their classes, and then end up having to transfer somewhere else? You never see these students, but there's a whole office of academic deans and support staff that work full time to handle processing them out.

From https://stillinthedesert.blogspot.com/2010/12/finding-track-of-time.html, in early December 2010:
I am having a great deal of trouble with time and sleep management since starting on the meds.  The past few days, I've had so much of an issue that I've been questioning the increased dosage-- was this really a good idea?  I'm having more trouble now, not less.  WTF?  
Correlation does not equal causation. I know. I don't have any science to show you that says that the psych meds I was on are the direct cause of my problems in classes in spring 2011. There were other forces at work in my life in the first few months of 2011. I had a new girlfriend who I'd break up with a few months later. I was still working two jobs. My classes, mostly math, weren't easy classes. 2011 was also the 20th anniversary of Desert Storm. Could there be unaccounted for factors? Of course. Maybe I was eating too much pizza, or drinking too much coffee, or listening to the wrong kind of music.

I will say that based on what I wrote, which is a pretty unfiltered recording of what I was thinking at feeling at the time, my life started taking a serious turn for the worse at the same time as my medication doses were being increased and the number of different medications I was on was being increased. That I was able to get at least something accomplished-- passing all of my classes in fall 2010-- may well have been due in part to positive effects from the initial dose of (only) sertraline that I was taking.

It's strange now to read my own blog entries where I'd say that yes I was feeling ok about this or that, and read how brave and noble I felt in staying in Madison and vowing to return to UW-Madison. I look at my MyHealtheVet records from the mental health appointments I had then, and I was often recorded as saying that yeah, things weren't always going well but I was optimistic. Of course I was optimistic, I couldn't feel anything else.