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.

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