Acceptance and Commitment Therapy for Panic Disorder: The Case of Sarah
Dr. Jessica Borushok presents the clinical case of Sarah, a 25-year-old woman with panic disorder and agoraphobia. Adopting an acceptance and commitment therapy (ACT) conceptualization, the therapist guided Sarah to develop self-confidence and flexible action guided by values. The treatment plan included psychoeducation, acceptance, and cognitive defusion techniques, as well as interoceptive and in vivo exposure exercises.
<> Values and Defusion Exercises in ACT for Panic Disorder
Exposure work in panic disorder is guided by client values, while defusion promotes psychological distance to develop curiosity and understanding.
1. Values are the North Star guiding a client’s motivation to follow the therapeutic process. Sarah focused on four key values: independence, growth, connection, and adventure.
2. Defusion allows the creation of space between symptoms and the client, to obtain perspective and develop an observational psychological stance without symptoms. Its goal is to promote curiosity about experiences rather than fear. Curiosity is a precursor to interoceptive exposure work.
3. A useful narrative structure for presenting defusion is the fish metaphor. The client learns to identify their hooks, as the first stage in a functional panic attack pattern analysis.
<> Defusion and Mindfulness Exercises for Panic Disorder: Playfulness, Giving an Avatar to the Mind, and Grounding
ACT defusion and mindfulness exercises help clients to be curious and playful when discussing panic symptoms, enabling adoption of different perspectives.
1. One defusion technique is to use playfulness when talking about symptoms; for example, using cartoon characters to represent panic sensations. This helps clients to take a pause and consider their experience from a more distant perspective without labeling it.
2. Another defusion exercise is to give the mind an avatar, by naming it and/or representing it with an animal. It allows the client to express themselves in a way which isn’t overwhelming, and creates a common narrative for talking about difficult things playfully.
3. Mindfulness can be taught through grounding exercises such as contacting the five senses. As the extremities aren’t usually primary sites of panic symptoms, we can refocus client attention onto them and those milder sensations, to increase presence and a sense of control.
<> ACT for Panic Disorder: Interoceptive Exposure and Acceptance
Interoceptive exposure is carried out through physical exercises, to modify the client’s relationship with anxiety and to promote more value-based behaviors.
1. Acceptance or willingness is essential for engaging in interoceptive exposure work. This can be framed as an experiment for clients to explore values-based behaviors and create better outcomes in their lives.
2. Interoceptive exposure exercises should start with the least distressing symptoms and work up to the most distressing. The goal is for the client to understand that anxiety and discomfort are manageable.
3. Exercises should always be debriefed and clients encouraged to practice on their own.
