The Rowan Hour: A Year Inside Modern Psychotherapy: Maps of The Mind

The marker squeaked against the whiteboard, a thin, high sound that set Devon's teeth on edge. He stood close to the board, shoulder blades pressed against the cool plaster of Eleanor's office wall, and drew a circle in black ink. Inside the circle, he wrote a single word: THOUGHT.

"Right," he said, the word clipped, restless. "That's where we start. One thought."

Eleanor sat in the leather chair opposite him, legs crossed at the ankle, a cup of cold tea balanced on the armrest. The office smelled of paper and the faint, herbal sweetness of the lavender she kept in a small dish on her desk. Afternoon light came in through the sash window, catching the dust motes that drifted between them.

"Go on," she said.

Devon drew a second circle, smaller, offset to the right of the first. Inside it, he wrote SITUATION. He drew a line connecting the two circles, then stepped back, frowning at the diagram as though it had personally insulted him.

"Beck's model," Eleanor observed. "Cognitive triad."

"Yeah, well." Devon uncapped a red marker. The cap went between his teeth, then back into his fist. "Thought, feeling, behaviour. The holy trinity. Except." He drew a third circle, far larger than the others, sprawling across the board like a stain. "This one's the real bastard."

He wrote DISTORTION in capitals across the wide circle, then began to label the outer edges with quick, jagged strokes.

"Mind reading. Catastrophising. Personalisation." He recited the list like a man reading charges. "Black and white thinking. Should statements. Emotional reasoning." Each phrase earned a small node branching from the central mass. The diagram began to look like a tree, or a tumour, or a map of a city no one wanted to live in.

Eleanor watched, her chin resting on her knuckles. She did not interrupt. She had learned, over the years, that Devon talked faster when no one interrupted him, and the things he said at speed were usually the things he meant.

He drew a fourth circle, lower down, and labelled it CORE BELIEF. Then he drew a fifth, right at the centre, where all the lines converged. Inside it, he wrote I AM.

"I am what, though?" Eleanor asked, softly.

He didn't answer her. He was already reaching for a blue marker, drawing arrows that ran backwards from the distortion circle into the core belief, then forwards again into a sixth, smaller circle. He wrote CONSEQUENCE inside it.

"Behaviour," he said. "What I actually do. Which is usually nothing, or something stupid." He tapped the marker against the CONSEQUENCE circle. "Or both."

Eleanor nodded. The light from the window had shifted, moving across the carpet in a slow, golden band. A clock ticked somewhere in the room, a small, domestic sound that seemed to belong to a different kind of afternoon.

"Right," Devon said, and turned to face her fully. "Now we get to the fun bit."

He clicked the cap back onto the black marker and tossed it onto the small table beside the board. It rolled to a stop against a stack of printouts. He picked up a sheet of paper from the top of the pile, glanced at it, and then pinned it to the board with a magnet.

It was a list. Dates, places, a column of short descriptions in Eleanor's neat handwriting. The catalogue she had asked him to keep, week by week, of the moments when his mind told him lies.

"Eleven entries," he said. "Two months of work. Eleven times I caught myself doing it." He traced a finger down the page. "Most of them are from the last three weeks."

Eleanor stood and crossed to the board. Her shoes made no sound on the carpet. She stood beside Devon, close enough that she could smell the faint chemical sharpness of the dry-erase ink on his fingers, and read the list with him.

"Tell me about the third one," she said, pointing. "The one in the library."

Devon's mouth twitched. He recognised the entry. He had written it at half past two in the morning, sitting on the floor of his flat with a highlighter between his teeth, because the lamp had fused and he did not want to get up.

"Campus library," he said. "Third floor. Quiet section." His voice dropped into the lower register he used when he was being precise. "I was studying. Someone walked past. Looked at me. I assumed they thought I was a freak."

"Did they say anything?"

"No."

"Did they laugh?"

"No."

"So what happened?"

Devon exhaled through his nose, a short, controlled sound. He picked up the red marker again and drew a new node branching from the distortion circle. He wrote LIBRARY in small capitals, then underneath it, in even smaller letters: THEY THINK IM A FREAK.

"This," he said, tapping the node, "is emotional reasoning. I felt exposed, so I assumed the reason I felt exposed was because people were judging me. The feeling came first. The story came after."

Eleanor tilted her head. "And the story was?"

"That I was visibly broken. That everyone could see it." He drew a quick line from the node down into the core belief. "Which connects to the usual. I am defective. I am not like other people. People can tell."

The marker squeaked again as he drew the arrow. Eleanor watched the ink settle into the board.

"And now?" she asked.

"Now I know it's a thought." Devon said it flatly, the way a man recites a fact he has been forced to memorise. "Not a fact. A thought. It happens in my head, not in the room."

"And what does that change?"

He looked at her. There was a flicker of something in his expression, a kind of tired amusement, the look of a man who has been asked the same question so many times he can almost hear the answer before it arrives.

"It changes whether I believe it," he said.

Eleanor smiled. It was a small smile, the kind that lived mostly in her eyes. She moved along the board to the next entry.

"The fifth one," she said. "The phone call from your father."

Devon did not reach for the marker. He leaned against the wall, arms folded, and stared at the ceiling. There was a water stain up there, in the shape of a long, thin country no one would want to visit.

"That one was different," he said.

"Different how?"

"It wasn't a distortion. Not exactly." He unfolded his arms and picked up the blue marker, but he didn't draw anything. He held it loosely, turning it between his fingers. "He actually did say it. He actually did mean it. The thought that I am a disappointment to him is not a thought. It's a fact."

Eleanor was quiet for a moment. The clock ticked. A car passed in the street below, its engine a low, distant hum.

"Even facts," she said, eventually, "can be examined."

Devon looked at her. There was a sharpness in his gaze that she recognised, the sharpness that came when he was deciding whether to trust her.

"Go on, then," he said. "Examine it."

Eleanor took a step closer to the board. She pointed at the core belief circle. I AM.

"This," she said, "is the centre. Everything else feeds into it. The distortions, the situations, the consequences. But the belief itself, the statement you carry around, is not fixed. It can change. It does change."

"In theory."

"In practice, too." She turned to face him. "You sat in this room six weeks ago and told me you believed you were fundamentally broken. Unfixable. Do you still believe that?"

Devon was silent for a long moment. The marker turned in his fingers. The light from the window caught the edge of his jaw.

"Sometimes," he said.

Eleanor nodded. "Sometimes is honest."

She reached for the red marker in his hand. He let her take it. She drew a small, neat circle at the bottom of the board, separate from the rest of the diagram. Inside it, she wrote EVIDENCE.

"This is where we start," she said. "Every belief you have, we look for the evidence. For it, and against it. And we see which side weighs more."

Devon watched her draw. His shoulders, which had been tight, loosened slightly. He reached for a green marker from the tray.

"Evidence against," he said, and wrote it inside the circle. "Evidence for. I can do this myself. I've done it before. The night I filled in your wretched catalogue."

"Yes," Eleanor said. "You did."

The afternoon had thickened around them. The light was lower now, the dust motes moving more slowly, as though the room itself had begun to settle. Devon uncapped the green marker and drew two columns beneath the EVIDENCE circle, one for each side.

He wrote, in the left-hand column: I SHOWED UP TODAY.

He wrote, in the right-hand column: I ALMOST DIDNT.

Eleanor read it. She did not comment on the second entry. Instead, she reached past him, took the black marker, and wrote a single word at the very top of the board, above the entire diagram, where there had been nothing before.

She wrote BECK.

Then, underneath it, in smaller letters: AARON BECK, 1967.

She drew a small arrow from the name down to the first circle. THOUGHT.

"Every map," she said, "starts with someone who got lost first."

Devon looked at the name. He looked at the diagram. The tangled mass of circles and arrows, the labelled nodes, the catalogue pinned at the side with its neat, dated entries. Eleven moments of his life, pinned to a board, reduced to ink and shape.

He began to laugh.

It started small, a short breath through the nose, then a fuller sound in the back of his throat, then a real laugh, the kind that came from somewhere below the ribs. He laughed until his eyes watered, until he had to press the back of his hand against his mouth, until the sound filled the small office and bounced off the walls and the ceiling and the water stain shaped like a country no one wanted to visit.

Eleanor watched him, and after a moment, she began to laugh too.

It was not a long laugh. It was a brief, surprised thing, a kind of recognition, the laughter of a woman who had spent twenty years drawing diagrams of the human mind and had never quite seen one look so absurd. The diagram was, in fact, ridiculous. It was a tangle. It looked like the kind of thing a spider would produce if a spider had been asked to map a personality and had lost its nerve halfway through.

"It looks," Devon said, when he had recovered enough to speak, "like a knot."

"It does," Eleanor agreed.

"It looks like someone took my brain and dropped it in a lake."

"A very specific kind of lake."

"The lake of me." Devon wiped his eyes with the heel of his hand. "The lake of Devon. It's shallow and it smells."

Eleanor picked up her cold tea and took a sip, grimacing slightly at the temperature. "Shall we start untangling it?"

Devon looked at the board. The laughter was still in his face, but his eyes had settled again, the way the dust motes had settled in the lower light.

"Yeah," he said. "Let's start."

He took the green marker back from her and turned to the first node on the diagram. He drew a small cross through it, then wrote, underneath, in quick, certain letters: CAUGHT.

Eleanor set her cup down and reached for a fresh sheet of paper. She wrote the date at the top in her neat hand. Then she wrote the time. Then she began to take notes.

Outside, the street was quiet. Inside, the clock ticked. The diagram grew. The room filled with the faint, chemical smell of fresh ink, and the slower, herbal smell of lavender, and the warm, human smell of two people working together at the end of an ordinary afternoon, trying to map the shape of a mind that had, until very recently, refused to be mapped at all.

At half past twelve on a Thursday, Eleanor Vance sat in her car in the staff car park and ate a sandwich she had made that morning, ham and mustard on brown bread, and read on her phone about a man named Aaron Beck who had, in the early years of the nineteen-sixties, become interested in the strange idea that his patients at the University of Pennsylvania did not, in fact, have anything wrong with their unconscious minds. They had, he had come to suspect, something wrong with their conscious ones. They were depressed because they believed things that were not true. They were anxious because they had learned to interpret the world as a place that confirmed their worst suspicions about it. They sat in his consulting room and described their week, and Beck, listening, had begun to notice patterns. A man who believed he was fundamentally unlovable would, with uncanny consistency, interpret a colleague's brief silence as evidence of contempt. A woman who believed she was incompetent would, with similar consistency, hear a compliment as a form of mockery. The patterns were so reliable that they had to be more than coincidence. They had to be, in some sense, the architecture of the suffering itself.

Eleanor read about Beck's collaboration with a psychiatrist named Paul Emery, who had devised a test to measure the speed at which depressed patients could read a sentence and identify the colour in which the words were printed. Depressed people, Emery had observed, could not do this task. They got stuck on the meaning. The meaning was the trap. Eleanor read this twice. Then she read it a third time, because she wanted to remember it exactly.

She read about the early clinical trials of Beck's therapy, conducted in the nineteen-seventies, in which patients with depression were randomly assigned either to Beck's new cognitive therapy or to the standard treatment of the time, which was imipramine, a tricyclic antidepressant. The results had been clear. Cognitive therapy worked. It worked as well as the drug, and in some measures better, and it had none of the drug's side effects. She read about a later, larger trial, conducted across the United States and Europe, which had confirmed the earlier finding and extended it to anxiety, to panic, to the particular stubborn misery of people who had survived difficult childhoods. She read about a meta-analysis, which was a study of studies, in which researchers had collected the results of hundreds of smaller experiments and subjected them to a single, sweeping statistical procedure, and which had concluded, with the cautious confidence that the language of science permitted, that cognitive behavioural therapy was, in the language of the report, an empirically supported treatment for a range of disorders.

She read all of this on her phone, in the staff car park, while the sun came and went behind a layer of high, featureless cloud, and she felt something she had not felt for a long time, which was a kind of quiet, scholarly excitement, like the feeling she had had as a postgraduate student when she had first understood the elegant mechanism of a particular experiment and had known, with a certainty that bypassed language entirely, that she wanted to spend her life doing this work.

She thought of Devon. She thought of the diagram on the whiteboard, and the word he had written underneath the first node, in green ink, with the quick, certain hand of someone who had known, in that moment, exactly what he meant. CAUGHT. She thought of the way he had laughed when he saw the diagram, and the way the laughter had not quite reached his eyes, and the way she had not pointed this out, because pointing it out would have been a kind of cruelty, and because she had known, also, that he knew.

She took another bite of her sandwich. She chewed. She read about the concept of the cognitive triad, which was Beck's term for the three core beliefs that characterised depression: a negative view of the self, a negative view of the world, a negative view of the future. She thought about how neatly the diagram on her whiteboard corresponded to this. The tangled knot, which had looked like a lake, or a web, or the inside of someone's skull, was, in fact, a representation of a cognitive triad in its native disorder. Devon's negative view of the self was there. His negative view of the world was there. His negative view of the future, the particular bleakness with which he had spoken about architecture, was there. And the thoughts, the automatic thoughts, which were the threads of the knot, were the thoughts that maintained the triad and were maintained by it, in a closed loop that had no outside and no exit.

She thought about how this loop was also, in some sense, the loop she had been trapped in for the past two years. The loop of grief, which had its own cognitive triad, its own automatic thoughts, its own architecture. She thought about James, who had been dead for two years, and who had been, in his own quiet and difficult way, the love of her life, and who had not been, in any ordinary sense of the word, a man with a positive view of the world, but who had been, in the privacy of their marriage, a man of extraordinary tenderness and intelligence, and whose absence she still felt as a kind of weather, a constant low pressure that made everything slightly harder to lift.

She finished her sandwich. She wiped her hands on a tissue. She opened her email, and she composed a message to Devon.

Subject: Empirical evidence.

Dear Devon,

I have been doing some reading on my lunch break, as I said I would, and I wanted to share some of it with you, partly because I think you will find it interesting and partly because I want to ask you a question I cannot answer on my own.

The reading is about a man named Aaron Beck, who is, in many ways, the founder of the kind of therapy I am trying to do with you. In the early nineteen-sixties he was working at the University of Pennsylvania, and he noticed something that sounds obvious but which, at the time, was genuinely new. He noticed that his depressed patients were not just sad. They were thinking in particular kinds of ways, and the kinds of ways were consistent from patient to patient, and from week to week, and from situation to situation. He noticed that a depressed person would tend to interpret ambiguous events in a negative way, would tend to remember negative events more vividly than positive ones, and would tend to believe that negative events were caused by their own deficiencies, while positive events were caused by luck or by the kindness of others. He noticed, in short, that depression had a shape, and that the shape was made of thoughts.

He then did something that sounds even more obvious but which was, at the time, genuinely radical. He designed a therapy that was based on this observation. The therapy consisted, very largely, of helping patients to identify the thoughts, to examine them, to test them against the evidence, and to replace the ones that did not survive the test with thoughts that did. He called it cognitive therapy. Later, when other researchers, particularly in Britain and Australia, had extended his work to include a focus on behaviour, on what people actually did as a consequence of what they thought, it became known as cognitive behavioural therapy, or CBT.

The question I want to ask you is about the empirical evidence. There is a great deal of it. There have been hundreds of randomised controlled trials, in which some patients with depression or anxiety are given CBT and others are given some other treatment, or no treatment, and the outcomes are compared. There have been meta-analyses, which means studies that collect all the smaller studies together and look at them as a single body of evidence. The consistent finding of all this research is that CBT is effective. It is effective for depression. It is effective for anxiety. It is effective for panic disorder, for obsessive-compulsive disorder, for the long-term consequences of trauma. The effect sizes are, in the language of the field, moderate to large. They are comparable to those of the most commonly prescribed medications, and they tend to last longer after treatment ends.

I want to ask you what you make of this. I want to ask you whether it changes anything for you, to know that the work we are doing together is not just my opinion, or my intuition, or something I have invented to fill the hours of our sessions, but is, in fact, supported by a substantial body of evidence, accumulated over more than fifty years, by researchers in many different countries, using methods designed to guard against bias and self-deception.

I know that evidence is not the same thing as proof, and I know that you, of all people, are entitled to be sceptical of the claims of experts, and I know also that the question of whether a particular therapy will work for a particular person is not a question that evidence, in the aggregate, can answer. But I wanted to share the evidence with you anyway, because I think you deserve to know what we are doing, and why we are doing it, and on what foundation the doing rests.

I will see you on Tuesday.

Eleanor

She read the email through twice. She made a small correction. She sent it.

She sat for a moment longer in the car. The car park was quiet. Somewhere a pigeon was cooing with the insistent, mechanical optimism of a creature that had, in evolutionary terms, solved the problem of motivation. She thought of Devon reading the email on Tuesday morning, on his phone, in his flat, with the curtains closed, and she hoped he would read it carefully, and she hoped he would not be put off by its length, and she hoped he would, somewhere in the reading, recognise the version of herself that had been a younger woman in a library with a highlighter and a sense of purpose.

She put her phone down. She started the car. She drove home through the slow, rain-glossed streets, and the afternoon unfolded, and she did not feel, for the first time in many weeks, quite so heavy.

On Tuesday morning, Devon read the email. He read it twice. He did not reply to it. He folded his phone and put it in his pocket and walked, slowly, in the direction of the tube station, with the particular, deliberate slowness of a man who had somewhere to be and was not yet ready to arrive.

Eleanor told him, at the beginning of the session, that she had a task for him. She explained it carefully. She explained that the purpose of the task was not to cure him, or to make him feel better instantly, but to give him a piece of information about himself, an observation, a small fact, which he could then bring back to the room and examine.

The task was to take the lift to her office, which was on the fourth floor of a building in Bloomsbury, without listening to a podcast.

Devon looked at her.

"That's it?" he said.

"That's it."

"That's the whole thing?"

"That's the whole thing."

He thought about it. He tilted his head slightly, the way he did when he was working out whether he was being mocked.

"Why?" he said.

"Because," Eleanor said, "you have been telling me, for several weeks, that you cannot cope with your own mind in unstructured situations. You have told me that the lift, in particular, is a problem, because it is small, and it is enclosed, and there is nothing to do, and your mind, in the absence of anything to do, begins to produce the kinds of thoughts that we have been writing on the board. I would like to test this prediction. I would like to see what happens when you take the lift without the podcast. I am not promising you that nothing will happen. I am promising you that we will look, together, at whatever does."

Devon was quiet for a moment.

"And if I can't do it," he said.

"Then you will have learned something very important about yourself, which is that you cannot do it, and we will work from there."

"And if I can do it?"

"Then you will have learned something very important about yourself, which is that you can."

He thought about this for a long time. Eleanor could see the calculation happening behind his eyes, the rapid assessment of risk and reward, the weighing of what it would cost him to fail against what it would mean to succeed.

"All right," he said.

On Thursday morning, Devon got into the lift at the ground floor of the building in Bloomsbury. He pressed the button for the fourth floor. The doors closed. The lift began to rise, with a small, mechanical shudder, and a faint, electrical hum.

He did not listen to a podcast.

He stood, with his back to the wall of the lift, and he looked at the floor indicator, which was a small rectangle of illuminated numbers above the doors, and which changed, with a soft click, as the lift passed each floor. One. Two. Three. He could feel his heart beginning to beat harder. He could feel the sweat starting at his temples, and at the backs of his hands, and at the small of his back. He could feel the familiar, automatic thought beginning to assemble itself in his mind, the thought that he was going to die, that the lift was going to fall, that he was going to be trapped, that no one would come, that he would be found too late, that he would have failed, that he would have failed again.

He did not listen to a podcast.

He stood in the lift and he sweated, and his heart beat hard, and the automatic thoughts came, and he let them come, because he had been told, in a session that felt now like a very long time ago, that the thoughts were not the enemy. The thoughts were the data. He let them come, and he noticed them, and he did not believe them, or rather, he believed them, and he also noticed that he was believing them, and that noticing was a different act from believing.