When I trained as a CBT therapist, I thought I knew all the answers, to all the mental health problems. I believed in the CBT model so much that whenever someone did not resonate with a CBT application or piece of work, I thought that maybe I didn’t explain it well enough, or that the client just did not fit the suitability criteria for CBT.
Don’t get me wrong, CBT is one of the best things I have EVER done! It has helped so much in my own and the people I work with’s understanding of how different mental health presentations live and thrive. But in my years working as a therapist since, I realized more and more, that there are major blind spots. I want to address a lot of things but for this particular blog post, I am going to be focusing on the limits the CBT has with panic disorder. I’ll be using an example of where CBT worked like a charm for panic disorder and two other examples of where other things needed to be considered.
My client came in for her third session and we were about to try some CBT applications. We had already mapped out her panic disorder into the classic “Trigger –> Anxiety –> Bodily symptoms –> Catastrophic misinterpretation –> Increased Anxiety –> Safety behaviours“ maintenance cycle. This helped her slow down the process and be mindful of each component between sessions. We had also tried a behaviour experiment where we intentionally induced panic-like symptoms. We hyperventilated as fast as we could together and then I stood up and invited her to do the same. We walked around and monitored our symptoms together until our symptoms left on their own. This gave her the experience of “uncoupling” the panic-like bodily symptoms with the perceived threat, helping her lean into trusting her body. But it was not until we did a “Theory A/Theory B” exercise though that something really clicked for her. Through this, she discovered that she would not die if she stopped breathing, because she would faint first and then her body would resume breathing again.
Suddenly, it was like the fear had left her. Like she realized that the monster in the corner was just a coat hanging on the wall. She did not have any more panic attacks after this session in the weeks after I checked in on her. Healing her panic disorder with CBT felt awesome as her therapist. I felt like I had just slayed a dragon and I could have floated home on the hot air balloon that was my ego.
I had more experiences similar to this one until years later during work with one particular client. We had gone over the CBT model of panic disorder and he worked through various applications to help heal his panic disorder with CBT. Although there was some understanding, (which helped to some degree) the panic was just not budging between sessions. This knocked my confidence a bit. Pretty soon, I noticed the same outcome in other people who I was working with. This challenged me to get more curious about the people living with panic disorder and I was able to look beyond the CBT model (thank goodness!).
It turns out that…the body wants our attention. And if it doesn’t get it, it will scream for it. A panic attack is one of the ways the body immobilizes us to get that much needed attention. For this particular client, he was living in an emotional climate where he had to make himself as small and inconspicuous as possible. He didn’t want to upset his dad because he often becomes angry, rageful and domineering. He did not want to talk about how tough this was with his mum because she gets upset. The last time he felt emotionally regulated was when he was living by himself, but circumstances meant that he had to live back with his parents for a while.
That’s the thing with toxic, difficult or abusive circumstances. You can do all the therapy in the world. You can keep working on yourself. But if you are heading back into that stressful situation, then your healing is just going to feel like is taking one step forward and two steps back. We kept working together, and we found alternative ways of managing his anxiety. He already had all the tools he needed to “ride the wave” of the panic, whenever it popped up. So, we focused on other things, such as learning and practicing making healthy boundaries, embracing who he is as a person, instead of trying to fix something into what society deems desirable or acceptable. His anxiety and panic seemed to really improve after taking these additional steps of focusing on his relationships with others and his relationship with himself.
The next example was during a class I was facilitating, in teaching CBT and mental health promotion skills. I demonstrated the CBT model for panic disorder and someone in the class shared their debilitating experience with panic, that she had since managed with medication. With her permission, I related the model to her experience as best as I could, in full “teacher” mode. Without knowing much about her, or her life, I noticed that every time I caught her eye in the class, she would stare back, expectantly, hopefully, but blankly. I do no know for sure, of course, but I could tell that this model hit the same blind spots I knew other people had experienced. It reminded me that CBT is great at offering a basic understanding, but when it comes to applying this to people’s real lives, there is so much more to consider.
If you are living with panic disorder and have tried overcoming it, please know that there is nothing wrong with you! You just haven’t found the answers to your experience just yet. But I wonder if you could maybe consider the following:
- If your panic disorder could speak, what would it say to you?
- If in some twisted, misguided way, your panic disorder was here to protect you from anything, what would that be?
- If your panic disorder just suddenly upped and left you one day, what would it be afraid would happen to you?
I hope this was helpful in some way. Please reach out if you are thinking about getting some further support. And please let me know if you are interested in learning about anything else related to mental and emotional wellbeing, because then I can write a blog post about it!
