Working with Clients Prone to Panic Attacks

Many of your clients with extensive trauma with have a history of panic attacks.  Those with extensive trauma that do not have panic attacks may have frequent rage episodes instead.  Some have both.

In community mental health, you are unlikely to have any clients who go from being very calm to having a full panic attack within a few seconds.  Nearly all of your clients who have panic attacks are severely anxious most of the time and very anxious the remainder of the time.  Panic attacks in this population are like a circuit breaker that trips on a circuit that is already near saturation.  Almost any additional stress can trip it.

Once a full panic attack starts, there isn’t much that can stop it.  They can’t think themselves calm.  They probably can’t relax their way out of it.  It’s going to run its course and when it is done, they will be exhausted.  Many clients report that they are not able to feel much of anything for the remainder of the day… it’s that exhausting.

Panic attacks are an involuntary bodily mechanism that compresses a full day’s worth of anxiety symptoms and energy into a short and extremely distressful packet of time.  In some ways, a panic attack simply is anxiety turned exponentially high for a short period of time.  Clients report that they feel like their hearts are pounding out of their chests, that they cannot not breathe, that the “normal” pressure in their chest suddenly feels like the leg of an elephant, and that they have an overwhelming desire to flee (but can’t, because what they need to flee is inside their own bodies).  They will likely be sweating and shaking.  During a panic attack, they may be fairly certain that they are dying.  Panic attacks feel horrible.

Panic attacks that occur in the therapy office or clinic are also distressing for new therapists.  As you work with your clients to develop anxiety management skills, you will also learn to better read the body language of your clients and you will be able to work to keep the “amps” below the client’s panic zone.  Clients who have frequent panic attacks around people will need to be escorted to your office quickly.  Your lobby is likely to be highly triggering for clients near panic, so be aware of your schedule and try to stay on time so that you can greet these clients as they come in.  Let these clients know that it is acceptable to stay in their cars until the appointment time, then come in to be escorted directly to your office.  If clients are more comfortable in their cars, you may also be able to work with office staff to call clients on their cell phones when you are in the lobby and ready to greet them.  These are often effective short-term strategies that may help clients avoid panic attacks. These are small accommodations to help ensure that these clients are able to keep coming to see you.

If a client has a panic attack in session (more likely to occur in initial sessions), speak softly and slowly to the client.   Keep yourself calm.  Tell the client that you are here for him.  Do not ask the client to tell you anything that is not absolutely essential during the panic attack, since trying to talk is likely to cause more distress.  Do not approach the client.  Do not reach into the client’s personal space.  Repeat: Do not touch or attempt to physically comfort the client.  Keep your distance, but not leave the room.  Obviously, stop whatever you are doing or were talking about before the panic attack started.  You can try to work with your client to slow down breathing, but this is unlikely to work well until the client is already deescalating. Your client will probably be exhausted and cognitively shut down after a panic attack.  If your client decides to stay, continue to speak slowly and to not engage in any emotionally or cognitively demanding activities.  Your client may feel intense shame from having a panic attack in your presence.  Continue to provide supportive care and normalize this experience.

If your client has frequent panic attacks, your very first intervention needs to be working to develop more awareness of changes in anxiety and starting breathing exercises.  I often start with breathing first or second session.  I also tell clients that they can expect that panic attacks will become less frequent once these skills are in place.  Clients should be instructed to use deep breathing anytime that anxiety rises.  The client might be able to avoid some panic attacks.   It is just as important for the client to practice deep breathing daily during those times when anxiety is not rising, as this can help lower the baseline level of anxiety and provide more “cushion” between triggers and panic.