Photo by Alex Green on Pexels
My office at the VA was the smallest in the department. It was at the end of the hall, next to the exit and the bathroom. I decided I’d capitalize on its size by making it a cozy cave. I substituted yellow-hued, dim lights for the overhead fluorescents, and covered the industrial carpet with a deep purple and blue rug. The vets I worked with had to sit right next to my desk, in the room’s only spare chair. If I had moved even slightly forward during a session, our knees would have touched.
This kind of physical proximity doesn’t feel good to trauma survivors, who prefer a nice spatial bubble around them, and room enough to survey the environment for threats. But there was something about that office’s limitations that made it so each of us could tolerate the closeness.
The VA offers two treatments for combat trauma and military sexual trauma (MST), Cognitive Processing Therapy (CPT), or Exposure Therapy, each of which is evidence-based. I’d always been uneasy about CBT-based treatments, but couldn’t put my finger on why. I had a hunch that the constraints of quantitative research, where so much rests on one or two chosen variables, were key to its success—so much was left out of the frame of inquiry. I decided I’d train in CPT to see if I could change my mind, or at least identify what was driving my instinctive distrust of the protocol.
To become certified in CPT, I’d need three clients to successfully complete the protocol. The dropout rate is high. Each week, the worksheets assigned as homework become more complex, diving deeper into the veteran’s chosen “index trauma.” The index trauma is the traumatic event with which he or she is most preoccupied, or which invades their consciousness against their will, or is the “worst” event they’ve endured.
The logic behind CPT is complex, and I don’t have the room to go through it here, but one of its core tenets is that when a person works through his index trauma, the resulting reduction in affect and PTSD symptoms will create a cascade-effect, lessening the intensity of the other traumas as well.
The door to my office opened, and my new client* came in and sat down. He was the fourth or fifth veteran to sign up for CPT with me. One veteran had successfully completed the protocol, but illness and other problems had derailed others, who had either stopped showing up or dropped out because they couldn’t keep up with the work. My client sat down and, cocking his head to see how I’d react, immediately cracked an off-color joke about me. I laughed, and his shoulders dropped. He then told me an equally crude joke about himself.
I pulled out my enormous three-ring binder, full of worksheets and instruction handouts. The protocol is complex and intense, and managing to process the worksheets from the prior week, and then shift to go over the instructions for the next, all in an hour, felt almost impossible. It got progressively worse for us, because as we got to know each other, topics outside the zone of the index trauma kept creeping in. He’d tell me about his childhood, his siblings, his children’s achievements. I’d listen and refrain from opening things up, prodding us to return to the work at hand.
A few weeks in, he came in and put his worksheets on my desk. He told me that he wasn’t a quitter and he was going to finish the protocol. But he thought I should know in advance that it wouldn’t work. He told me he’d already been to groups, to treatment, had been dosed up with medications, and then when that didn’t help, decided to wean himself off them, trying exercise and massage instead. Nothing had worked. His PTSD was still overwhelming. He regularly blew up at strangers and family members. He had contempt for most people, and felt lonely and isolated. His sleep was garbage; he couldn’t relax, couldn’t focus, couldn’t figure out what to do with himself each day. He confessed to me he couldn’t be fixed, and this was likely a waste of our time.
The CPT protocol uses as its measure of effectiveness an assessment tool which the client fills out each week before session. The assessment lists all the symptoms outlined in the Diagnostic and Statistical Manual’s diagnostic category for PTSD. From week to week, the assessment tracks the level of symptom severity the client is experiencing, and their level of daily function.
The goal of CPT is to break the adaptive patterns the client has made to the symptoms of PTSD. The worksheets hone in on the thoughts and feelings that the client has about his index trauma, along with his behavioral adaptations to his symptoms. Does he go grocery shopping at 4 a.m., to avoid people? When was the last time he was able to eat in a restaurant, or go to a movie or a party, being immersed in a crowd without panic? How many nightmares did he have last week, and did they wake him up? Can he make it through an appointment at the DMV without storming out of the building? Can he tolerate a loved one’s questions about how he feels? Can he get through a Friday night without baiting someone at a bar, trying to get the other to throw the first punch?
Each week, the symptoms are noted, and the level of function is assessed. If the client’s symptom score goes down by a certain percentage by the protocol’s close, the treatment is considered a success.
One day, we were going over my client’s homework, working through one of his core beliefs: that his home was likely to be invaded at night. His behavioral adaptations were time consuming and costly. He had cameras throughout his property, posted at his entryway and back door. He checked the camera feed multiple times a day.
At night, before going to bed, he’d check the windows and doors, circling the house three times, to make sure they were secure. He’d check the placement of the furniture, too, making sure it was in exactly the same position as the day before. That way, when he came down at night to confront the intruder, he’d be able to move seamlessly through the darkness, using the couch and chairs as screens, behind which he could fire or spring out for a surprise attack.
The worksheet asked him to write the belief down, and then assign it a probability score. My job was to ask him to read the belief aloud to me, and then tell me his score and why he picked it. How likely was it that his home would be attacked? 40%? 70%? How probable was it that the furniture was going to save him, if the intruder had a gun? 80%? 20%? How much safer did he feel, checking the windows three times, instead of one? 5%? 90%? What feelings arose, as he looked at the core belief, and then at the probability of its occurrence? Was there anything we could do to bring that probability percentage down?
I understood the protocol’s logic. Here was a man who had survived combat, and who was charged with keeping his subordinates safe. He had a terrible temper, honed and salted with threats, to keep people in line. Now his family relationships were fraying because of his rigidity and dominance. He was impatient, suspicious, perpetually on the verge of rage. He was so tense that the prospect of a justified conflict—poor service at the hardware store, a sideways look from a driver in a passing car—brought him the sweet relief of letting it rip, humiliating and chastising strangers, even sometimes getting into a physical fight. Here was a classic case of “bringing the war home” and if he kept it up, this man could die, or suffer from suicidal thinking, or addiction, or utter alienation from civilian life.
But here’s the thing. The protocol asked only about the index trauma. Because it stressed functionality and symptom reduction, there was no space for me to ask my client about the larger meaning of that trauma, and how it was linked to the meaning systems that gave purpose to his life. There was no room to enlarge the box, ask about his spirituality, or his politics, or about how he’d been coached by family and friends to respond to traumas in his childhood. There was no question on the worksheet about why he’d joined the military in the first place, and what he thought he’d gain from serving his country.
The next week, as we were working our way through the probability questions, I asked him to tell me how frequently he and his friends and family had their homes invaded when he was a kid. I asked him how many cars were stolen. I asked how many times a week he’d been blindsided by emotional or physical violence, and how long it took him to learn to defend himself. We’d said enough to one another before, around the edges of the protocol, for me to be pretty sure I knew the answers.
My client was a man of color who lived in a neighborhood where violence and theft were usual. By the time he was 9, he was adept at physical conflict and had already learned to ward people off with an anticipatory verbal attack. By the time he was a teenager, he’d left his family home. The trauma of white supremacy and intergenerational violence long predated the trauma of combat. And even labeling these forms of trauma as distinct entities, as if they were antiseptic categories, able to be parsed and analyzed in a medical framework, didn’t begin to capture the complexity of this series of braided experiences, which shaped in part this funny, intelligent, sardonic, cruel, and loving man.
It wasn’t just “70% probable” that his childhood home would be invaded—it was expected. Anyone foolish enough not to engage in those protective behaviors would be an inevitable target. It was in that session that I asked myself what group of people had drafted and staffed these worksheets, and what their childhood homes and neighborhoods looked like. Maybe they lived in a world where a break-in was a less than 5% probable occurrence. Maybe their sunny expectations that people would greet them with kindness and curiosity, that there was no need to monitor their environment for safety, were rooted in race and class as much as their particular lived experiences. Maybe the dominant culture reflected back to them a benevolence and a certainty about their future success that they believed was an experience everyone shared.
How much of what counts as “probable” in CBT is rooted in a false generalizing of a certain kind of situated experience? And what forms of stigma, and pathologizing diagnoses, can greet those who come from a different situated context? What is the unacknowledged ground upon which the definition of what “mental health” looks like stands? Whose experiences, class positions, and racialized world views are embedded in these definitions, which are then put forth in evidence-based practices like CPT as universal traits?
We finished the protocol, and I handed him his certificate. By the end, I had a strong sense of how his trauma histories—some incident-based, some chronic and structural—had helped him become a strong father, a compassionate leader, and a person who was terrified of closeness and vulnerability. I told him I thought he’d benefit from excavating the meanings he’d made of his experiences, and the ways structural violence had contributed to behaviors for which he blamed himself. He told me that sounded interesting, and wondered if it might help. He closed the door on his way out, leaving me at my small desk, wondering if I’d see him again.
*Please note that the client I describe in this post is a composite of many veterans with whom I have worked throughout my time as a trauma therapist.
CBT's Achilles' Heel