Understanding and Treating Panic Disorder
“That suggests that what you fear most of all is—fear. Very wise, Harry.”
As a millennial psychologist I’m used to repressing the urge to reference Harry Potter when explaining something to a client. Just this once I’ve allowed myself to indulge this tendency, as I think Harry’s experiences in Harry Potter and the prisoner of Azkaban are one of the best analogies to panic disorder that I’ve come across in popular culture.
In the book Harry returns to Hogwarts to find dementors guarding the school grounds. Dementors are capable of making you relive your worst memories, and whenever they come near Harry the flashbacks of his parents’ death cause him to faint. What Harry finds particularly upsetting is that the other students don’t react like this. For them the dementors are unpleasant but manageable. They know the dementors projections aren’t real, and therefore can’t really hurt them. For Harry though the dementors present a very real danger. Passing out unexpectedly can cause physical harm (when he’s on a broomstick for example), and even when he doesn’t hurt himself, it gives more material to Draco and the other Slytherins to make fun of him. He starts to not only fear the dementors projections, but the dementors themselves.
If the worst thing your own fear can cause you is temporary discomfort, then being scared of your own fear makes no sense. If, however, fear can cause you to lose control, humiliate yourself, or make it feel like you’re dying, then your fear is something to be scared of. Any slight increase in anxiety is enough to fill you with terror, as the consequences for you could be catastrophic. You become hyper aware of any slight increase in your heart rate, any sign that your anxiety is increasing. Adding to your distress, you are surrounded by people who at best find your constant anxiety about fear perplexing, and at worst evidence of your own weakness.
Treating Panic Attacks
People who come to see me about panic attacks usually want to never have another panic attack in their life. This is understandable – panic attacks are unpleasant – but stopping panic attacks isn’t a good goal for treatment. For starters, they are already terrified of potential future panic attacks. Basing their treatment progress on stopping all panic attacks will just add to this stress. This is particularly unhelpful because stress about panic often contributes to panic attacks. If you get a detailed history of what someone was thinking in the immediate lead up to a panic attack, often the thought “oh my god, it’s happening again,” is what tips them from anxiety into full blown panic.
Instead, a better goal of treatment is to help the client be less concerned about future panic attacks. “Maybe I will have a panic attack, but I’ll be ok. I’ll just have to find a place to sit down and wait it out.” A client who genuinely believes this is usually a client who no longer has panic disorder. They might have the occasional panic attack, but this doesn’t stop them living their life, and if this belief is maintained, the panic attacks tend to go away entirely.
Of course, genuinely believing this is easier said than done. Panic attacks are incredibly unpleasant, and people understandably are desperate to avoid them. However, helping someone address a few common misconceptions about panic attack can help them get there.
Your panic isn’t trying to kill you
Almost everyone with panic disorder will at times worry their panic attacks are actually heart attacks or some other health issue. This fear is understandable, the intense physical discomfort of a panic attack can make it seem like something is wrong in our bodies. This is why consulting a doctor before treatment begins is important. Some clients may even need testing or consultations with a specialist to fully rule out physical causes of their panic attacks. Even if these tests don’t find anything they aren’t a waste of time. If a client has even the smallest suspicion that their next panic attack might be fatal, treatment of their panic disorder will be much harder.
Your panic isn’t trying to humiliate you
People with panic disorder often imagine having panic attacks at the most inconvenient or dangerous times. What if I had a panic attack on a crowded train? Or when my baby needs me? Or while driving? They imagine humiliating themselves in front of hundreds of people, seriously hurting themselves, or hurting someone else.
On the surface these fears seem reasonable, but panic attacks with disastrous effects are surprisingly rare. When people do faint, it’s almost always as soon as they found a safe place to sit down, or pull over, or when they know someone else is looking after their child. While at the time of a panic attack they can feel like they’ve lost all control, usually when looking back on the situation they did a pretty good job of looking after themselves and the people they were responsible for.
This makes evolutionary sense. Humanity wouldn’t have survived long if we collapsed while an animal was chasing us, or while swimming across a river. Our sympathetic nervous system evolved to protect us from danger, not to make us lose control in the most dangerous places possible.
To be clear, I’m not saying you should go out and drive on an eight-lane freeway if you’re currently worried about panic attacks. But the belief that panic will strike at the worst possible moments leaving you incapacitated is probably inaccurate.
Riding the wave
One good thing about panic attacks is they rarely last long. After adrenaline has been in our blood for 15 minutes or so it starts to break down, and our parasympathetic nervous system kicks in to return us to a more normal level of arousal. Unfortunately, people with panic disorder often aren’t aware of this, as they equate the end of the panic attack with something they did, rather than the limits of adrenaline. “I was feeling really awful in the shopping centre, but luckily I managed to get back to my car so I could calm down.” While perhaps sitting down in the shopping centre instead would have been more unpleasant, it’s likely their panic attack would have passed almost as quickly.
This is why the concept of riding the wave can be a nice metaphor for dealing with a panic attack. To make a panic attack go away, we generally don’t have to do anything. All we need to do is wait it out, and our arousal levels will eventually fall back to normal levels. Breathing exercises can make this happen faster, but the most important thing is to just let time pass. Feeling a panic attack advance and recede without doing anything can be a liberating experience for someone with panic disorder. The thought, “what if this lasts forever,” often make panic disorders particularly unpleasant, and learning they go away quickly can make future panic attacks more manageable.
Doing it on your own is tough.
Some of the principles of treating a panic attack can seem straightforward, so there is a temptation for some people to treat panic attacks without therapy. There are even self-help books available on how to treat your panic disorder. While for some people this might be useful, research shows therapy remains one of the most effective ways for treating panic disorder. Everyone’s own fears and insecurities regarding panic will be different, and these concerns are best addressed when they can be explored fully and without pressure over the course of therapy. What’s more, as with most mental health issues, what works for one person will be completely ineffective to another. A good therapist will be sensitive to these differences and help tailor an approach to treatment that is right for you.
On Sincerity
Lately I’ve been trying to be more sincere with my clients. I let them know what is on my mind when appropriate, try to only ask questions when I genuinely want to know the answer, and express myself in a way that is authentic with who I am.
Textbooks tend to mainly talk about being warm and engaging for a good therapeutic alliance, without really mentioning sincerity. To me this feels insufficient. Think of your own interactions where you noticed insincerity, a pushy salesperson or someone at a party with the wrong vibes. They were probably trying to appear warm and engaging too, but something about them put you on guard. As a result, you were probably mistrustful, self-conscious, careful not to share too much. All characteristics that would get in the way of good therapy.
Sincerity might be behind one of the more puzzling findings in therapeutic research. Studies has consistently found no difference in client outcomes between experienced and inexperienced therapists (Germer, et al., 2022, Goldberg, et al., 2016, Vocisano et al., 2004, Wampold & Brown, 2005).
Experienced psychologists will tell you they are more effective than at the start of their career, thanks to knowing more techniques and having more clinical experience – so what explains this discrepancy? One advantage inexperienced therapists have is sincerity. As a new therapist, your clients can read you like a book. You’re too terrified of saying the wrong thing for any subterfuge. Perhaps this authenticity makes up for the increased knowledge and techniques of more experienced therapists.
I’ve found that the way a lot of therapeutic techniques are taught make it harder to be sincere as a therapist.
“Ask a client about what emotions they are struggling with, and when they tell you, explain how that relates to the techniques we are teaching.”
Countless therapy textbooks outline suggestions like this, I recently heard something similar in an Acceptance and Commitment Therapy (ACT) course. In this moment, the therapist isn’t really interested in the client’s emotions. The question is just a rhetorical device, designed to increase the client’s commitment to therapy. Put more simply, the therapist is being insincere.
Criticising a therapeutic technique when no one is defending it is easy, so let’s imagine what the ACT course presenter would say in response.
“But this question isn’t central to the therapy,” they might say. “The therapist is just increasing the client’s commitment to the treatment. What matters is when the therapeutic techniques are taught. When that happens the therapist will be sincerely trying to help the client, and that’s what counts.”
To me, this underestimates how unpredictable therapy is. We can’t tell what moments of therapy our clients will find particularly meaningful. Research suggests that the reasons clients improve in therapy are much more complex than the techniques they learn (Wampold & Imel, 2015).
In the above example, perhaps no one has asked them what emotions they are struggling with before. Perhaps just by answering they will learn something about themself, gain insight into their problems. Only in this moment their therapist isn’t interested in what they have to say. For the therapist the question is nothing more than a pre-determined stop on a set of questions they will ask countless clients.
“Ok perhaps some clients will find answering that question meaningful..” “But that can still occur in the above scenario, it’s not like the therapist won’t let them answer.”
And this gets to the heart of my argument. Just asking the right questions then nodding attentively isn’t sufficient for good therapy. You must be sincerely engaged with your clients, genuinely interested in what they have to say. I think this quality of attentiveness is as important as the things said in therapy. Research suggests that the relationship between therapist and client is the best predictor of client outcomes, more important than the type of therapy used (Lambert & Barley, 2001).
Individual therapeutic techniques aren’t the only impediment to sincerity in therapy. I think a lot of the language we use as psychologists can make it harder to maintain a sincere therapeutic presence.
One of my favourite things about being a therapist is the fascinating ways people describe their mental health. I’ve yet to come across two clients who described their mental health in similar ways. It is perhaps useful for researchers to take these descriptions and group them into neat categories like ‘depression’ and ‘anxiety’ but my role with my clients isn’t as a researcher. If I tell myself my client just has ‘depression’ then it is harder for me to muster that same level of curiosity when listening to them.
I find myself classifying the different things they say into DSM-5 checklists. “Ah yes, anhedonia!” while ignoring what makes their anhedonia different from everyone else’s. If, however, I try to understand the client using their own language, it is much easier to maintain a state of curiosity. I’m naturally more interested in what the client has to say, as I’m genuinely trying to understand their story using their own language and ideas.
To be clear, this is all based on my own preferences. Other therapists may be more interested in diagnostic labels, and therefore find it useful to think about their clients in terms of DSM-5 diagnoses and sub-types. The point is I am making a conscious effort to prioritise my own engagement. I do not believe that faked interest in my clients is sufficient, so I need to think about my clients in a way that helps me feel attentive.
This doesn’t mean I ignore research using clinical terms either. They still inform my treatment plans and formulations. However, I recognise that these terms tell only part of the client’s story, and the more I think of the client in their own language, the more engaged with the client I am.
What Makes Therapy Meaningful?
As a psychologist, I’m always judging what I’m doing. Is what we are talking about right now useful? Was today’s or last week’s session more helpful? Did the client understand that thing I said? Or would it have been better if I’d just been quieter and let them talk more?
The tricky thing is these decisions always feel subjective. Before I started seeing clients I thought I could base everything I do on empirical evidence, but for these moment-to-moment decisions research or data can’t help us. An outcome measurement might tell you that a client has shown some improvement over the course of therapy, but was that due therapy, or something else in their life? And even if we accept that therapy played a positive role, what parts actually made the difference? Client feedback can be helpful in those situations, but is often vague, and a client new to therapy can only give you feedback on what you’ve already done. The more experience I gain, the more I realise how often you have to rely on on your own clinical judgement.
As a result, I’ve been trying to think about this systematically over the last few months. What are the things that happen in therapy that feel particularly meaningful? What causes a client to say they found a session helpful? If I can clearly articulate what good therapy looks and feels like, maybe it will feel less like I’m just relying on my gut the whole time.
It Depends on the Client
The more I’ve thought about this, the more I think the effectiveness of a session depends almost entirely on what my client does. The best sessions weren’t when I’ve said the most insightful things or set the clearest agenda. They were when clients showed compassion for a part of themselves they have previously treated with disdain, gained understanding of why they continue to act in a certain way, or decided to undertake something that a few weeks ago seemed completely beyond them.
Thinking about therapy in this way has felt like a revelation. If the most effective moments of therapy are when clients do something meaningful, then my role as a therapist is to help clients do meaningful things. Therapy is therefore less about what I say, and more about helping clients reach states where they can express themselves meaningfully. These states can be achieved in a variety of ways, from free exploration to a more structured intervention, but whatever I do is only effective if it leads to meaningful expression from the client.
Characteristics of Meaningful Expression
So what is meaningful expression? While this looks different for every client, I have noticed a few common elements that seem to apply to meaningful moments in therapy. Below is my own completely subjective list of these factors.
Speaking Slowly
This might sound basic, but I think people have a way of talking when they are learning something new about themselves, or expressing something profound. They speak with complete concentration, but slowly, as if each word is being drawn up out of some deep interior. It bears no resemblance to the quick, fluent way people talk when they are telling you their life history, or complaining about someone at work. A client might need to talk about something where they speak quickly, when they are giving you background information for example, but these moments are unlikely to be profound. If a client is spending every session speaking quickly, and a question I ask makes them pause, and answer in a slower, more thoughtful tone, then it was a good question to ask.
Emotional Content
Meaningful moments of therapy generally had some degree of emotional charge to them. Some clients find dry intellectual discussions engaging, but these moments are rarely remembered in subsequent sessions, or lead to a deepening of the therapeutic relationship. This isn’t to say that therapy is only meaningful if the client is crying their eyes out, but some degree of emotional intensity is important. If a client who is consistently detached in sessions becomes more emotional, they generally comment on that interaction positively in the next session. While I can’t force a client to be more emotional (and I worry that some techniques psychologists promote in this area are manipulative), directing their attention towards topics that are emotionally significant for them generally enriches the therapeutic experience.
Novelty
This is the most important characteristic I can think of. Meaningful moments of therapy are characterised by clients expressing something that they haven’t expressed before. The type of expression doesn’t even have to be particularly constructive or healthy. It’s great for a client who has been consistently bitter and despondent to express hope for the future, but it can be just as meaningful for a client who constantly talks about how committed they are to getting better to admit how hopeless they feel. What matters is that the client have allowed a part of themselves that they have previously kept hidden to see the light, or expressed something that they genuinely weren’t aware of until that moment.
I think novelty is so important for therapy it trumps my previous two points. A meaningful moment for a client who constantly speaks in a halting fashion might be when they express themselves fluently, or for a client who spends session after session in heightened emotional states to become clear headed and rational. After all, clients come to therapy to change, and therapy offers them a safe space to experiment with and enact that change. If they are unable to change in the relative safety of the clinical room, what hope do they have of changing in the outside world?
This isn’t a Comprehensive Theory of Therapy
Whenever I come to a realisation about therapy, I seem have an experience that makes me question everything. In the middle of writing this piece I asked a client what they found most useful about our sessions, and they mentioned a piece of practical advice I’d provided in an early session. That moment of advice giving had no resemblance to the meaningful deep exchanges that I’ve been attempting to explain in this piece. Of course, I could say that my client was only able to take on that advice (and perhaps I was only able to give it) because of our deeper exchanges, but that would be just shoehorning their observation into my new understanding of therapy. Instead, I think the more honest approach is to admit while I find thinking about therapy in this way useful, it doesn’t capture all the different ways therapy can be effective.