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 ( 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

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