Michael Otto, Associate Professor of Psychology at Harvard Medical School and Director of the Cognitive Behaviour Therapy Programme at the Massachusetts General Hospital, recently visited South Africa as a guest of the Depression and Anxiety Support Group to conduct a series of seminars on the use of Cognitive Behaviour Therapy (CBT). In particular, the use of CBT in the treatment of Panic Disorder and Post-traumatic Stress Disorder was illustrated and discussed. Over 200 doctors, psychiatrists, psychologists and associated health-care providers attended the seminar in Johannesburg, while the venues at Cape Town and Pretoria each hosted 80 professionals
Professor Otto is a world-renowned expert in the treatment of anxiety disorders with CBT, and has developed unique and effective clinical and behavioural programmes for the treatment of such disorders. A fellow of the American Psychological Association, Prof. Otto has published over 100 papers spanning fields as diverse as strategies to aid medication compliance and novel treatments for substance abuse.
Because of the very high levels of violence and trauma in South Africa, PTSD came under the spotlight. It has been reported from international studies that PTSD is found present in between one and nine per cent of the general population, and in a staggering 57% of all rape victims. The disorder is most likely to develop when the trauma experienced is uncontrollable or life-threatening, and can be diagnosed when symptoms in three domains endure for longer than one month. The domains are re-experiencing phenomena, persistent avoidant behaviour (and resulting emotional numbness) and increased arousal. Of particular interest to the audience was a specialised CBT programme developed for the treatment of PTSD. Prof. Otto outlined several key points that could be incorporated into any CBT treatment programme :
· The patient must be provided with an overview of the disorder – reviewing DSM-IV criteria with patients has been shown to empower patients with a greater level of understanding and trust in diagnosis and subsequent treatment.
· A model of “what is learned in PTSD”, including an explanation of the Trauma Network Model must be presented to the patient. The trauma network model is a basic illustration of the way in which stimulus and response cues, and subjective meanings and propositions, contribute directly to the development of trauma and further suffering. Learned cues (such as sounds, sights, emotional states and sensations pertaining to the traumatic event) result in conditioned emotional and cognitive responses, such as anger, anxiety, dissociation, fear and intrusive memories. These in turn alter the way in which danger is interpreted, heightening sensitivity to, and fear of, danger. Hypervigilance (characterised by exaggerated startle responses) and subsequent Chronic Autonomic Arousal allow for the development of avoidant behaviour and conditioned emotional responses – emotional numbing, behavioural avoidance, cognitive avoidance as well as external avoidance strategies (most notably, substance abuse) typically present as facets of a PTSD sufferer’s disturbed functioning. Long-term effects resulting from these avoidant behaviours, such as insulation from corrective emotional responses and the maintenance of the new conditioned emotional response, may appear to be beneficial to the patient, but aggravate normal functioning in terms of problem-solving skills, assertiveness and emotional regulation.
· In order to help patients tolerate the symptoms that will inevitably be experienced later in treatment – as a result of exposure to anxiety resulting from recollecting the traumatic experience in therapy – patients should be given instructions on coping techniques throughout treatment. Exposure should ideally be brought on in stages – initially, the patient should describe the experience to the therapist. Later, the therapist presents the experience to the patient in order to bring about a confrontation with the emotions and negative beliefs that were brought on by the traumatic event.
· The crux of CBT treatment involves Cognitive restructuring, which enables patients to identify cognitive distortions, and to change these negative cognitive responses into more positive, realistic responses. Rehearsal of rational responses will allow core beliefs to be identified and challenged more easily. Core beliefs following a traumatic experience typically include such beliefs as “The world is unsafe”, “I cannot be well” and “I am a coward”.
· Goal-setting, problem solving and training in relaxation and diaphragmatic breathing are emphasised throughout treatment, equipping patients with the necessary resources to live in the present. Support groups co-ordinated by the Depression and Anxiety Support Group fulfil an important function in providing support to recovering sufferers, enabling them to further develop coping skills. (The Depression and Anxiety Support Group can be contacted at Johannesburg 783-1474/6 or 884-1797)
In addressing these and further points in the treatment of anxiety disorders, Prof. Otto has developed a structured 12-session treatment programme, which can be implemented in the individual or group therapy context. The first three sessions involve the presentation of information pertaining to the fear cycle, and the initiation of cognitive restructuring. Cognitive restructuring is initiated early on, and an introduction to exposure is brought in during the second session. The following three sessions focus on significant practice of exposure procedures, and review the role of catastrophic cognitions and avoidance reactions. Exposure is continued through sessions seven to nine, where simplified interoceptive exposure is substituted by naturalistic and in-vivo exposure in more anxiety-provoking situations. During the final three sessions, greater emphasis is placed on naturalistic and in vivo exposure. Patients are also encouraged to guide their own treatment using techniques and principles taught earlier in treatment.
Cognitive-Behaviour Therapy is rapidly gaining momentum as a useful and practical form of Psychological intervention, particularly when used as an adjunct to medication treatment. Given the shortage of adequately trained CBT therapists and the high incidence of PTSD and anxiety-related disorders in South Africa, Prof. Otto reiterated the relevance of researching and developing new, culturally-appropriate interventions. A considerable obstacle to be overcome in improving PTSD treatment is the relative lack of knowledge about the disease – the calibre of the symposia resulted in considerable progress being made in providing professionals with the very latest information on PTSD. The hosting of the Michael Otto symposia was the largest education initiative undertaken by the Depression and Anxiety Support Group to date, and has been praised for the contribution made in furthering the understanding of treatment options available to patients.