Imagine that you are an electrician and a client comes to your office and screams, “My house is on fire! There’s something wrong in the kitchen – smoke, burning stuff. Help.” I’m not an electrician but this is going to be an impossible job. This is the kind of situation that our patients with panic are looking to fix. They want us to fix their problems at their worst and most overwhelming, but there is a much simpler, more effective approach than battling the fire. Your patients will be grateful if you teach it to them.
We (therapists) are rarely in the prevention business. People come to us because life has gone sideways: crumbling marriages, suicidal thoughts, unbearable anxiety, and more. Problems are at their worst. It’s exactly what happens when people seek help with panic. They are asking for help at their worst. They want to stop the flood of emotions, the racing thoughts, and the surge of adrenaline that make panic so unbearable.
This plea to fix their worst problems is completely understandable, but we need to redefine what we’re treating so we can be more effective. During episodes of intense negative emotions, people are the least rational, the least flexible, and the least tolerant of change. Our ability to change is limited when it comes to dealing with panic during the midst of a panic attack.
Treat the Causes Not the Crisis
We need to redefine the problem from treating the panic attack to the treating underlying causes of panic. We need to shift from treating the crisis to treating the everyday causes of panic. Panic has many contributing factors: negative thinking, avoidance behaviors, poor stress management skills, intolerance of negative emotions, untreated trauma . . .
These are the areas where we can be most effective as therapists. We can certainly help our clients cope with the crisis but that shouldn’t be where we spend the majority of our time in therapy.
If we can shift patients from the turmoil of whatever problem they are experiencing to its roots, we have given our patients firmer footing to start dealing with their problems.
I often think of what I do in therapy as just taking the crisis and finding a more manageable way to address it. On top of this, your clients will be more effective in addressing panic (or other problems). The other advantage is that we are putting our clients in a proactive vs. reactive mode of coping by helping them to see and address the smaller ways their problems build up over time.
The Two Most Overlooked Causes of Panic
The everyday roots of panic (or really any disorder) are those things that are with us all the time: what you wake up with and what you go to bed with. The panic sufferer is really doing two things: the first is engaging in a never-ending search for the cues and warning signs that can cause panic (i.e., body vigilance) and the second is dwelling on past problems (i.e., rumination).
Often panic sufferers will think about how they feel throughout the day. They have an unconscious monitor that tells them whether their physical feelings might make them vulnerable to panic. There is a measure developed to assess this called body vigilance (Schmidt, Lerew, & Trakowski, 1997).
This measure assesses how much respondents monitor their physical feelings, e.g, numbness, tingling, and shortness of breath. Panic sufferers score higher on this measure than those with generalized anxiety disorder, specific phobias, and social anxiety disorder (Schmidt, Lerew, & Trakowski, 1997).
I find that most of my clients aren’t really aware of how much time and mental energy they put into monitoring their physical sensations. However, this constant monitoring reinforces the idea that their bodies are vulnerable to panic at any moment.
The other problem is rumination. Rumination is about thinking over oneself or one’s life in order to fix perceived problems, faults, or personal deficiencies. Panic sufferers ruminate about why they have panic, what life would be like if they didn’t, why do they feel so anxious all the time. These self-analyses are almost never beneficial because they have one question they are trying to answer, “What’s wrong with me?” The question isn’t about finding a solution but about reinforcing the idea that panic controls one’s life.
Using Mindfulness to Treat Panic
There are many causes of panic but body vigilance and rumination are the two I commonly see. These problems are essentially problems of being wrapped up in one’s head and fixated on one’s physical sensations. These problems disconnect us from the present moment and cause us to evaluate ourselves in a judgmental and negative way.
The importance of mindfulness is obvious. I teach my patients eight mindfulness techniques. Teach your clients to be involved in the present moment short circuits that self-analysis that fuels panic. I like mindfulness because it is easy to do and it is an approach to life. It is about living life in a more non-reactive and non-judgmental way. This is an “everyday” approach to treating panic as opposed to treating the panic attack itself (although you can easily use mindfulness to cope with a panic attack directly).
The benefits of mindfulness are to keep the person out of the self-critical mode of analysis and to bring them to the here and now. Mindfulness is also about cultivating a detached perspective (called non-judgment) about all things. With panic, the non-judgment is applied to one’s perceived faults, past experiences with panic, and the meaning of physical sensations (e.g., “I feel my heart beating. I must be having a heart attack”).
My goal is to teach my clients to be involved in the present moment and live life, to learn how to sit down and have a conversation with a friend without obsessing about blushing or to eat a meal and tolerate the fear that it will cause a strange tingling in the stomach.
Our most effective approach to panic is to help our patients see that coping with panic isn’t about stopping panic attacks but about stopping the mental processes that feed into it. If we do this, then we have given our clients the power to cope with panic when it is less intimidating, less threatening, much more manageable. If you can make this shift in your treatment, you can treat panic without treating panic and your clients will thank you for it.
Schmidt, N., Lerew, D., & Trakowski, J. (1997). Body vigilance in panic disorder: Evaluating attention to bodily perturbations. Journal of Consulting and Clinical Psychology, Vol 65(2), 214-220. doi: 10.1037/0022-006X.65.2.214
J Drwal. (2018, November 26). 8 mindfulness exercises that changed my clients’ lives. [web log]. Retrieved from https://www.createmeaningfulchange.org/8-mindfulness-exercises-for-panic-anxiety/