So we start with psychoeducation, to help Sarah understand how her patterns of behavior are working, also known as function, increasing her willingness to engage in exposure work. But before jumping straight into exposures, we introduce ACT skills to create a strengthening framework to facilitate improved ease and effectiveness of exposure work.
Sarah is asked to identify some of her values. Who and what are important to her? What qualities or characteristics does she want to embody when she goes out into the world?
This is going to be her “why”. Why would she want to go through the pain and fear involved in exposure work? Why put herself through experiences which might lead to panic attacks?
Sarah wants to be able to do things that are meaningful to her. For example, connection is important, which means strengthening her relationships, and being a supportive friend.
Her independence is also really important. It was a big step for her to move out of her parental home, and she loves living with her roommates, but is also starting to build a life independent of that. She loves being able to go out and have new and exciting adventures.
Sarah is only 25 and knows that one day she might get married and have children, so her life might become more stable and routine. She doesn’t want to waste these younger years due to being unable to go out and have fun and adventures, with her friends but also on her own. Sarah explained that being able to do things by herself, to explore the world, is a necessary step for her to be able to grow and become the person she wants to be.
So we have an emphasis on independence, growth, connection, and adventure. These are the four values to focus on and use as our North Star when approaching exposures with Sarah.
Defusion work allows us to put space between us and intense sensations. These can include panic symptoms as well as associated thoughts and feelings, such as worrying about having a panic attack, the possibilities of escape or getting to safety, and being able to get help. We can work toward defusion in a number of ways.
The Fish Metaphor
The first step is helping a client to truly see their experience, that of being hooked by the unexpected. It’s like we’re fish swimming around, and there are fishermen up above dangling hooks for us to latch onto. We all have hooks, maybe different hooks, but we all have them.
Our goal is not to eliminate the hooks, but to learn not to bite them. Yet we can’t learn not to bite something if we don’t even perceive it. So helping Sarah pay attention to things her mind says in response to simple urges, such as going for a freeway drive or a trip with friends, is invaluable. We can also help her to examine what happens when the initial sensations of a panic attack appear in her body and mind.
The more Sarah can see and describe those experiences, the more she’s able to notice the pattern of avoidance that arises. When she bites a hook, it yanks her off to another place far from her stated values. She reacts in fear, avoiding a potential panic attack by staying home, even encouraging friends to stay home with her, or spending the weekend with her family. Not because she truly wants to, necessarily, but because she can’t be alone.
Guiding Sarah through what she’s experiencing so she can understand it better is essential. But the eventual goal is for her to carry out functional analyses on her own, examining and analyzing her own experiences:
- What is the initial hook that appears?
- What happens in response to it?
- Do I remove myself from a situation?
- Do I ruminate on it, engaging in overthinking, overanalyzing, overplanning, and other mental avoidance tactics?
- Do I say no to plans?
Then Sarah is supported to identify how that feels in the short term and how it benefits her, in a way: she gets something from the negative reinforcement of avoidance, initially. She gets a reprieve from a potential panic attack, or something that feels scary or even life-threatening.
But she must also evaluate what happens in the longer term. It keeps her cut off from her friends. She can’t go to work meetings in the way she needs to. It impacts her growth and ability to be independent, to live her life the way she wants to and in concert with her values.
From there, Sarah can develop curiosity in place of fear about sensations: what it feels like when she has an egg in her throat, her body goes hot, or there’s a weight sitting on her chest. This is a precursor to the work of interoceptive exposure.
Some opportunities might arise during therapy. For example, when Sarah described even the idea of doing exposures or going on a trip, she would start to feel an echo of panic sensations, not causing intense distress, but enough to work with in the moment.
It’s easier to work with a sensation or experience while it’s happening in the therapy room than provide guidance on what to do outside it. The latter is not as raw and present, so it carries less power and possibility.