Steve was a 40-year-old executive who called my office asking if I was available to help him with his panic attacks. He suffered with these attacks for several weeks before calling, and unlike a few episodes that he said had occurred infrequently years ago, he told me these recent panic attacks were unrelenting. They caused him distress when they came upon him at work and even when absent he had significant worry that he wouldn’t be able to function in his demanding job. His life had become a cycle of panic attacks alternating with fear of more panic attacks. He told me he had recently “broken down crying” at home with his wife which was something he had never done before.
What struck me during the initial phone call was that he described his panic attacks as a frustrating nuisance, like one might describe rush hour traffic. It seemed he had no sense that he might have any kind of emotional problem. I agreed to see him in consultation the following week.
When I first met Steve in the office, he sat back with his arm casually resting along the back of the sofa; one leg rested on the other knee in front of him. He looked laid back and confident. When I asked to hear about what was going on, he spoke with clarity and confidence with little sign of actual emotional distress. Steve talked about episodes of panic and being afraid of having more. He spoke as if we were in a business meeting where he was making a sales pitch.
I interrupted him and asked, “Are you worried at all? What if I can’t help you? What if you need medicine? You look and sound completely fine.”
With the utmost confidence he replied, “I know things will get better. Doc, I was at a low point on Monday. It’s only up from there.”
“Really? It sounds like you’re selling yourself now. Maybe you’re selling us both.”
“I’d be willing to consider that,” he responded, sounding like he was coolly and “logically” considering my counteroffer. I felt clear that at that moment, Steve was not only unable to express his fear and anxiety, but he couldn’t do anything other than play his role of the “optimistic salesman.” The contrast between what he said about his panic and what little he expressed gave me the impression that he was clinging onto this role for dear life.
I asked him more about his educational background and work history. He told me how college wasn’t for him and that he worked his way up from selling door-to-door to managing sales teams and finally being promoted to an executive position in a very successful company. I envisioned him artfully painting a picture of the benefits of whatever he was selling to customers and selling himself on the idea that he could keep going to meet any quota even when he was tired and ready to quit. I asked Steve to share more about his home life and childhood. He succinctly described growing up as “Great!” and described members of his family in a wonderful light.
“You sold me!” I said, interrupting his glowing reviews. He smiled, let out a small laugh and then went on to sum up every aspect of his life outside of his panic attacks: “Life is great, Doc.”
At the end of the consultation, with only the faintest hint of concern, he asked, “Have you dealt with this before? Can you help me?” Having a sense of his drive and willingness to take on a challenge, I responded, “Yes, I’ve helped patients with this before. My initial impression is that you can overcome this, but it depends on how much you put into it. Panic attacks are a signal of feelings, you know— emotions, that are just below the surface. Your getting better depends on you facing your emotional life.” He confidently agreed, requested weekly appointments, and expressed zero interest in psychiatric medicine, even if just to head off a panic attack. I saw his disinterest in medicine as a good sign of his willingness to face his emotions.
At the first therapy session, Steve described various fears related to his work life: feeling and being seen as incompetent, as stupid, not being respected. He also described how he was now more successful than ever, without any pride or confidence in his voice. Instead, rising anxiously in pitch, he sounded uncomfortable and worried it wouldn’t last. He gave the impression that his success was too much for him to bear. However, in contrast, and strikingly, while he talked about this he looked content, and I, again, took note of his relaxed posture on the couch and his matter-of-fact attitude. “Steve, do you feel as comfortable as you look? You’re describing how anxious you can feel at work, do you feel that here, now, at all?”
“No. I feel fine.”
“You mentioned crying with your wife before, how often do you allow yourself to cry?”
His face softened, no longer looking unaffected, with a hint of sadness in his furrowed eyebrows and eyes. “I had the feeling to cry recently when I was reading about someone overcoming panic, like a cry of relief.”
“What happened?”
“I stopped it.”
“Why? And how?”
“I was at work, and I didn’t want anyone to see me. I don’t know how I stopped it.”
I paused for a moment, looked at him seriously, and said, “Maybe you need to cry.”
He stiffened his back ever so slightly and his face resumed its cool, unaffected appearance. “I’ll consider that,” as if considering my counteroffer. I realized that these “I’ll consider that” comments were a sign I was on target.
“I’d like you to lay down on the treatment couch and take some deep breaths.” I wanted to see how he responded when lying supine, unable to be “laid back” or put on a confident air.
“OK,” he replied confidently, as he sat up and walked over to the couch. On his back, he turned to me and asked with a slightly higher pitch, “Like this?” His confidence appeared to waiver for a few seconds and he looked uneasy.
“Yes, that’s just fine. I’d like you to take some deep breaths for a few moments.” I observed his overly big and deep breaths, as if he was trying to do it “the best.” I encouraged him to slow down and take his time. After a few moments he was able to take full deep breaths without forcing it. With this, his eyebrows lifted and his eyes showed sadness. It struck me how readily his feeling showed on his face after only taking several full deep breaths. He could appear laid back or even confident as he was just moments before, but his sadness was apparently close to the surface if he allowed himself to relax.
“Doc, I get emotional,…” he started to say, as he stopped breathing. Searching for words but unable to find them. He was now intellectualizing, getting “up in his head,” instead of just allowing himself to feel.
“Maybe words will come later. Just breathe and kick your legs like this,” as I demonstrated from my chair, kicking my legs into the air and allowing them to smack the floor. He kicked stiffly and continued to take deep breaths.
“Steve, have you had the impulse to cry at all?”
“Actually, just then a moment ago. It’s gone now.”
“What happened?”
“I stopped it. I’ll need time for that. I let myself cry in front of my wife just the other week which helped but now I feel vulnerable and weak.” Then he smiled with a curious smile and looked genuinely excited.
Laughing, he asked, “Doc, what just happened?”
I smiled, too, feeling excited about his discovery. “You made contact with what you were feeling. You have a lot of feeling in you. Breathing can help them come to the surface. It’s a nearly universal problem that we hold our breath to dampen down our feelings. Kicking can get your energy moving and help as well.”
Before the session ended, Steve asked what he could do going forward. In his question, I heard both his desire to push, plowing ahead and helping himself, but also difficulty letting things develop naturally in his therapy and in his daily life. I encouraged him to ask himself, from day to day, “How am I feeling?” and then do nothing more than let his feelings, whatever they were, come to the surface and stand them.
At Steve’s second session, he looked and sounded desperate, afraid, and anxious. His eyes were filled with anxiety. He was no longer laid back. Instead, leaning forward, there was no sense of confidence in his posture or voice. He was having anxiety daily, frequent panic attacks, and was “crying every day after work.” He asked me, sounding rattled, “What do I do? Breathing? Is there a book I should read? Should I take a beta-blocker? Should I use Xanax?”
I hid my excitement because although I knew he was having a hard time, this was a good sign. His confident attitude was no longer firmly in place. He was showing me how he felt.
I asked him how he was performing at work, despite his emotional tumult. He replied that he was managing, and no problems had arisen. I challenged him, “What if a big deal comes up? Do you think you might want medicine to help calm things before a big meeting?” “I wouldn’t have used anything this past week,” Steve replied after reflecting on his difficult week. He conveyed “I made it through.
I weathered the storm without medicine.”
“Have you considered that this is a good sign?”
“I hadn’t. What do you mean?”
“It sounds like you’ve been in touch with a lot of feeling recently. Perhaps, you’re more than just a confident successful salesman. Maybe there’s more to you!”
He paused for a moment. Thoughtfully, he took a deep breath and said, “I saw my family for the Holiday this past weekend.” He then described how his childhood wasn’t “great” or as perfect as he’d initially let on but chaotic at times with frequent fights between his parents and between them and him. He developed an attitude of being “the strong one” to help calm and reassure his younger sister. He started to tear up as he told me, “Looking back on it now,” as if he hadn’t recalled the memory in decades, “I remember running out of the house and into the street after arguing with my parents.” He started to cry and then continued, “I remember thinking, it’s too much! I remember feeling like it would have been better if a car came and hit me in the street.”
I was learning that Steve had indeed become “the strong one.” He was successful and using his natural tendencies to further himself in his professional and financial goals, but he was also intolerant of not being “strong.” I encouraged him to continue to reach out to his wife and express himself to her.
In Steve’s third session, he explained how he had been more closed off from himself and his wife over the past week. A friend was staying with them and he was less open to expressing himself emotionally. He stopped asking himself how he felt. The day before the session, after his friend left, he was again alone with his wife and he allowed himself to cry. This gave him some relief from bodily tensions that he didn’t even realize were there.
Steve and I discussed how before he began therapy he didn’t allow his feelings to see the light of day and that at that time he wasn’t even aware he had feelings. However, in the past week he kept his emotions at bay because he felt it would be too much for him while around his friend. I educated him on the difference between holding back feelings unconsciously as he did previously by being “the salesman” versus feeling it was most satisfying for him to hold back until he could more fully express himself when alone with his wife.
Steve also brought up how a fellow executive at the company commented to him about how good his work had been to date and how he was responsible for things coming together so well as the company has grown and developed over the last few years. Steve said to me, “I realized it…but I never really took it all in. My head was always down, pushing forward.”
“As you feel your fear and sadness, maybe you can also allow yourself to feel satisfaction and pleasure, too,” I said to him before directing him to lay down on the treatment couch. “Just take some deep breaths.”
I observed him allow his body to relax, breathe in and out, and just “be.” For as stuck as he could get in his confident “salesman” attitude, he also allowed himself to “let go” rapidly. He then started to show sadness as his forehead wrinkled and with his mouth open slightly, he said, “I started to feel emotional, sad…but it went away, it felt held back.” I palpated the muscles of his head, neck and jaw and felt considerable tension in the masseters of his jaw.
“Steve, just allow your mouth to relax and stay open as you breathe and as you exhale let some sound out like this, ‘Ahhhhh’,” as I made the sound myself. He did this two or three times and then quickly sat up.
“I just felt a jolt of adrenaline and…I needed to sit up.” In contrast with his statement he showed only a look of mild concern on his face. I had the sense that he felt too vulnerable lying down.
“Just continue to breathe sitting up.” He continued to do so quietly. The tension in his jaw was closing his mouth which inhibited his breathing, and his connection with his feelings.
“Let some sound out as you exhale,” I reminded him. He let out a breath and crying burst out of him. His crying intensified as he looked down and gave in to his feelings as his chest heaved up and down. He sobbed for several minutes before it slowly waned. He looked up at me with an expression of sadness in his eyes. I didn’t say a word but sat with him quietly.
At Steve’s fourth session, he presented looking and feeling well. He didn’t look artificially laid back, overconfident, or overwhelmed and desperate. “The last two weeks have been good, Doc. If any feelings came up, anxiety or otherwise, I took the time to process it. Feel it. Accept it. Then, I moved on. Yesterday, something came up, but I didn’t have time to process it. It was one thing after another at my job and I felt anxious, but I didn’t have a panic attack. Do you think that’s because nothing built up?”
“Yes, allowing yourself to feel whatever comes up, not just anxiety, reduces your risk of having a panic attack.”
“Doc, after our last session, I was thinking, ‘Can I do this? Should I quit? Am I capable?’ I decided that I could and that I am.” He paused and then asked, “Do you think I’m selling myself again?” I had the impression that although he obtained relief with his crying, he also struggled with the intensity of what he felt during the last session.
“No. You sound genuine. Like you’ve taken stock of what you’re facing and have been showing courage to face whatever feelings have come up and want to continue to do so going forward. Good for you.”
“I feel good.” “Pride,” I responded.
“Yes, I’m proud of facing my feelings.”
“I’m proud of you.”
Edited and posted with permission of the ACO.