PTSDDaddy – Cognitive Behavior Treatment (CBT) Introduction
Cognitive Behavior Treatment, what is CBT?
“The approach consists of highly specific learning experiences designed to teach the patient the following operations: ( 1 ) to monitor his negative, automatic thoughts (cognitions) ; ( 2 ) to recognize the connections between cognitions, affect, and behavior ; ( 3 ) to examine the evidence for and against his distorted automatic thoughts; ( 4 ) to substitute more reality- oriented interpretations for these biased cognitions; and ( 5 ) to learn to identify and alter the dysfunctional beliefs which predispose him to distort experiences.” (Beck, et al., 1979, p 4)
Now, let me put this into English for all of us non-psyches. Cognitive Behavior Treatment CBT is designed to take daily events in our life that trigger us (whether it pisses us off, makes us paranoid because it’s a security concern, or puts us in a situation where there’s too many people) and work to reprogram our brain’s automatic response to these events.
You see we vets have been put into some rather unique situations in life that require a completely different way of thinking and reacting. Not only have we experienced unique situations, but we have had to experience these over and over and over. We have conditioned ourselves to react in certain ways that’s required to maintain security for us and for our brothers in arms. It only makes sense that we react this way in these situations and much of the reason we arrive home safe is because of our automatic reactions.
Why is this an issue to begin with?
Ok so if we lived in Afghanistan then yes the way we re-programmed our brains would be accurate and useful. We are not in Afghanistan though we are at home. Now these reactions are extreme and not completely necessary, at least not for survival. Our reactions may even become obnoxious to our loved ones.
CBT Step 1: realizing the trigger
Step one in this process was really difficult step for me. Recognizing these triggers was challenging because I refused to admit they are triggers to begin with. Hearing a noise outside that must be investigated is “common sense” to me. As far as I was concerned everyone else was an idiot for NOT investigating the noise to make sure there’s no threat. That’s how you get killed. That’s complacency! NO… No it isn’t. Not in America.
I made the argument to my counselor later in life. What if my reactions are not unreasonable? What if I have PTSD and these reactions because I have an understanding of the “real” threat and everyone else is ignorantly bliss? ISIS is a real threat who is showing up in more locations. If I am to let my guard down and become complacent, what happens the day that that gets my family killed?
I expected her to argue against my questions but she did not. She brought up that it was a good point and a legitimate concern. How do I react to something like that? First, I finally admit that perhaps checking the window to see what the noise was outside was a trigger and I was overreacting. Then, to agree with me that if something bad were to happen to cause that noise my reaction is justified and legitimate. This is confusing to me at the time. Still a bit confusing but I think we need to understand that the threat levels here are extremely low compared to those we faced in Afghanistan. And you can “what if” everything until it’s justifiable. Nobody can stop bad things from happening so I might as well work at making life more enjoyable rather than jumping at every noise I hear. Right?
CBT Step 2: recognizing a connection between event, how I see this event, and how I react to it
Along with step 1, step two just goes further into our triggers. Now that we know the trigger (a noise outside) we decide how it makes us feel (I feel threatened until I know what it is) and our reaction to this (I have to go investigate what that was to see if it’s a threat or not). So In this step we are really assessing the trigger and our brain/body/emotional reaction to this event. Many times I could not see any of these during the event itself. Later in the day or week, like a lightbulb turning on, I would realize “oh shit, that was a trigger” and then I would go over how I felt, what I did, what the noise was, basically investigating the facts afterwards.
CBT is a lot of self-analysis. In order to change ourselves we must first understand ourselves. The environment changed us for a reason, but unless we can look at ourselves from the outside we will not be able to change those reactions. These (what I lovingly term) “PTSD moments” happen without thought. Much like the muscle memory we train ourselves in shooting we just react that way. On the other hand, UNLESS we react that way we remain anxious and overly alert to that situation and the fact that we have NOT completed the task we feel necessary. Ultimately UNLESS I go check to see what the noise was myself, I will not stop obsessing with investigation of what made the noise. My way of “turning it off” is seeing for myself what made the noise. Without seeing myself I cannot “turn it off”.
CBT Step 3: Good-Bad-Ugly
Everyone is used to running an After Actions Review (AAR) wherein after an operation or exercise you list everything that went right, everything that went wrong, what to continue doing right, and what to fix. This is similar in the sense of you list more details you can remember of the situation. For instance on me hearing a noise, I live in a good neighborhood and know most of my neighbors. It sounded like a car door and is more than likely my neighbor just got home from school/work/day with the kids/ etc. So living in this good neighborhood, and knowing my neighbors, and never having anything bad happen in the neighborhood, is it reasonable for me to feel threatened if I do not go investigate the noise? No. Is this still my reaction that I won’t feel complete until I investigate? Yes. Is what I am doing causing any harm to anyone other than annoyance? No.
So in other words this is where we take our trigger and assess the environment and everything related to this situation/timeline/etc. We then ask ourselves if it’s reasonable or justified. We also ask what other things could we have done? We want to really assess this as if we are a Non-Commissioned Officer (NCO) evaluating one of our soldiers on their tasks. Did he do the right steps? Was it required? Did it fix the situation? Could he have been doing something else with his time? Etc.
CBT Step 4: Other solutions? (a.k.a. Normal solutions)
I always called myself crazy in front of my counselor. She hated that because PTSD is not crazy. I know this but I like to fuck with people and it was funny. I use the term loosely when I say “normal” solutions. In other words we are assessing the trigger (the noise we heard) and the non-threatening things that could have made that noise and the actions that would be taken for those.
In these situations we analyze the likely causes and if I went and saw that it was just a neighbor what’s my reaction after? Now we gather a list of how we feel and how we react to hearing a noise and look at the probable causes to making the noise and how we would react if to those and compare the “normal” reaction to neighbor getting home to the over-reaction of ISIS just pulled into the driveway.
CBT: Step 5: Change the wiring of our brain.
The fifth step is one of the most challenging steps as well as the step that will/should take the longest. I now need to train my brain (rewire it) so that when the neighbors come home from work I don’t have to freak out to get eyes on them walking to their own house’s doorway. Doing this takes practice. Think back to your days of training your body for muscle memory of shooting. You were never a pro after day 1. The memory was not memory by day 1. Accept the fact that rewiring your brain takes much time, much practice, and something I learned for myself, sometimes it takes meds to help me even have that moment (fraction of a second) to think over the situation BEFORE acting/re-acting.
I used to go from zero to 100 MPH with nowhere in between to figure out the situation. I knew all the different ways to breathe and calm my gut feeling but I didn’t have that moment of clarity when I could realize “hey I’m triggered I should take a moment, calm down and assess the real cause to this event.” Personally I ended up having to take some meds because I was so consumed by my brains wiring that I had no time between hearing a noise and checking it. Most the time I did not even realize it was going on until after the fact. Thank God I have an understanding wife!