Time-Limited Psychosocial Treatment for

Specific Panic Disorders and Agoraphobia

Gordon MacNeil, PhD

Although panic disorders and agoraphobia are widespread in the general population,
almost half of those afflicted with these problems do not receive treatment for them.
Additionally, there is no singular most effective and appropriate treatment for panic
disorders and agoraphobia, the use of psychotropic medications having met with mixed
success. This article reviews pertinent literature on this topic and presents an empirically
based, nonpharmacological brief treatment model that has been shown to be effective in
treating these disorders. A case study illustrates this model. [Brief Treatment and Crisis
Intervention 1:29–41 (2001)]

KEY WORDS: panic disorder, agoraphobia, brief treatment.

Less than 5% of the general population experi-
ence panic disorder, and only 6% develop ag-
oraphobia during their lives (Kaplan, Sadock,
& Grebb, 1994), but more than a third of all
clients coming for mental health services pres-
ent with anxiety-related problems (Hales, 1995;
Mclean & Woody, 2000). However, it is esti-
mated that only one in four people who have
anxiety disorders are correctly diagnosed and
treated (Hales, 1995). This is particularly alarm-
ing because anxiety disorders are treatable.
Many, perhaps even most, studies report short-
term success rates in excess of 70% (Craske,
From the School of Social Work at The University of Ala-
bama.
Contact author: Gordon MacNeil, PhD, School of Social
Work, The University of Alabama, Box 870314, Tuscaloosa,
AL 35487-0314. E-mail: gmacneil@sw.ua.edu.
© 2001 Oxford University Press
1999; Knapp & VandeCreek, 1994; Roth & Fon-
agy, 1996). To skillfully serve clients with panic
disorders, mental-health service providers need
to be knowledgeable about specific models and
techniques that have been shown to be effective
in treating these disorders. This article intro-
duces a treatment strategy that is consistent
with current literature about effective treatment
for assisting persons suffering from panic disor-
der and agoraphobia. This time-limited treat-
ment strategy uses a combination of exposure
and cognitive restructuring. A case illustrating
how this treatment strategy was used to address
a panic disorder is presented.
Recent reviews of literature about the treat-
ment of panic disorder and agoraphobia rein-
force the usefulness of brief treatment models
(Barlow, Esler, & Vitali, 1998; Craske, 1999; Roth
& Fonagy, 1996). Two points suggest the impor-

29
MACNEIL
tance of brief treatment models. First, psy-
chopharmacological intervention alone does not
appear to provide sustainable relief for those
suffering from these disorders. As noted below,
researchers are finding that brief nonpharmaco-
logical approaches, either alone or in consort
with medications, seem to provide the most
effective treatment. Second, recent literature
suggests that panic disorder, with or without
agoraphobia, is more chronic than previously
thought. Thus, even though clients report great
improvement from pretreatment anxiety levels,
most interventions are not curative, and clients
are likely to need additional help eventually (as
in booster sessions). Brief models are eminently
suitable for this kind of treatment.
Panic Disorder and Agoraphobia
Panic disorder is characterized by the recurrent,
unexpected occurrence of panic attacks. Panic
attacks are brief episodes during which the pa-
tient feels intense dread along with other phys-
ical symptoms such as a racing heart, sweat-
ing, dizziness, and hyperventilation. These at-
tacks begin suddenly, and the symptoms peak
quickly, usually between 10 and 20 min (Amer-
ican Psychiatric Association, 2000). Panic at-
tacks are classified as unexpected (uncued), sit-
uationally bound (cued), or situationally predis-
posed. Unexpected attacks are not associated
with any internal or external trigger; they are
thought to be spontaneous. Situationally bound
attacks are those that almost always occur as a
direct result of exposure to (or anticipation of)
a specific trigger. Situationally predisposed at-
tacks are similar to situationally bound attacks,
but they differ in that the attacks do not always
immediately follow the introduction of the trig-
ger. Some authors suggest that panic attacks are
not truly spontaneous; they are the result of
positive feedback physical sensations and fear-
ful cognitions that give rise to thoughts of dan-
30 Brief Treatment and Crisis Intervention / 1:1 Summer 2001
ger and anxiety (see Craske, 1999; Craske & Bar-
low, 1993; Wilhelm & Margraf, 1997). These at-
tacks can be differentiated from fear because
they are not associated with a known cause.
Panic attacks are not codable disorders in the
DSM-IV in and of themselves. However, when
a person experiences repeated panic attacks,
along with anticipatory concern or fear about
impending attacks a diagnosis of panic disorder
is suggested (American Psychiatric Association,
2000). The frequency with which patients with
panic disorder experience panic attacks varies
from multiple attacks during a single day to only
a few attacks a year. Persons suffering from
panic disorder are at increased risk for attacks
during stressful times such as the month of col-
lege exams or the weeks preceding an important
business meeting (Craske, Miller, Rotunda, &
Bartlow, 1990).
Panic disorder is commonly accompanied by
agoraphobia. Agoraphobia is a condition in
which a person fears or avoids places or situa-
tions from which escape might be difficult or
embarrassing, or in which help might not be
available in the event of a panic attack (Ameri-
can Psychiatric Association, 2000). Although
“agoraphobia without history of panic disor-
der” is codable, agoraphobia is generally not
coded by itself, but is a building block used to
help define other DSM-IV diagnoses (Morrison,
1996).
Panic disorders tend to be chronic in nature
(Barlow, 1988). Much of the data concerning
treatment effectiveness relates to relative im-
provement rather than absolute improvement
(Craske & Barlow, 1993; Jacobson, Wilson, &
Tupper, 1988). Thus, clients should be seen as
improved, not cured. The severity of pretreat-
ment symptomology of persons suffering from
panic disorders has some bearing on their prog-
nosis, as those with more symptoms at the be-
ginning of treatment tend to have poorer out-
comes two years following treatment, regardless
of the evidence of gains at three months post-

treatment (Brown & Barlow, 1995). The progno-
sis for persons suffering from panic disorder
with agoraphobia is even more guarded, as some
studies report that fewer than half achieve
symptom-free status (Burns, Thorpe, & Caval-
laro, 1986; Cohen, Monteiro, & Marks, 1984;
Munby & Johnston, 1980; Williams & Falbo,
1996). As many as 50% of patients who have
benefited clinically may relapse, although the
relapse tends to be transient (Craske, 1999; Ja-
cobson et al., 1988).
Treatment
Several medications have shown to be effective
in reducing levels of panic, but their ability to
address phobias (including agoraphobia) are
more limited. Even when psychopharmacologi-
cal agents are prescribed, the most effective
treatment includes psychological intervention
(see Stein, Ron Norton, Walker, Chartier, & Gra-
ham, 2000). This is in part due to the inability of
medications to address anticipatory anxiety or
the dread of future panic attacks (Reid, 1997).
Agoraphobia appears to be best treated with
a psychotherapeutic treatment that includes
in-vivo exposure to the stimulus of the ag-
oraphobia. Cognitive-behavioral interventions
have been shown to be most effective in ad-
dressing panic disorder. A brief review of perti-
nent literature follows.
Pharmacological Treatments
Many antidepressant medications have demon-
strated anti-anxiety properties independent of
their antidepressant properties. In fact, sero-
tonin-specific reuptake inhibitor (SSRI) antide-
pressants are the drug of choice for panic disor-
der (Ballenger, 1995), in part because the side
effects of tricyclic and monoamine oxidase in-
hibitor (MAOI) antidepressants are more pro-
Brief Treatment and Crisis Intervention / 1:1 Summer 2001
Treatment for Panic Disorders and Agoraphobia
nounced. Because these medications commonly
take up to six weeks to have significant antianx-
iety effects (Reid, 1997), quicker-acting benzo-
diazepine anxiolytics (anti-anxiety agents) are
still commonly prescribed. These drugs have
demonstrated an ability to control or reduce
panic for 70% of patients, on average (Craske &
Waikar, 1994).
As reviews of literature supporting the use of
these medications are available elsewhere (see
Beidel & Turner, 1991; Mavissakalian & Ryan,
1997), they will not be detailed here. Regardless
of which medications are used, they should not
be prescribed “as needed,” but should be taken
at regularly scheduled rates. Neither should
their use be terminated in an unplanned man-
ner. Tapering off these medications is almost al-
ways indicated.
While many, if not most, practitioners utilize
medications to treat panic disorders, there are
compelling arguments against their use. Relapse
rates as high as 90% have been reported for
patients withdrawing from some anti-anxiety
medications (reported by Craske & Waikar,
1994). Roth and Fonagy (1996) note that behav-
ioral interventions have higher success rates
than those of placebo controls, and propanolol
and low-potency benzodiazepines show no
greater efficacy than placebos (success rates are
reported to range from 30% to 45%). Clum and
Surls (1993) found behavioral interventions to
be equivalent to antidepressants and high-
potency benzodiazepines.
Clark and his fellow researchers compared
Imipramine, relaxation training, cognitive ther-
apy, and a waiting list control group. They
found that all of the treatments were effective,
but cognitive therapy was significantly more
effective than the other two treatments. At the
one-year follow-up 85% of the cognitive ther-
apy group were panic-free, compared to 47%
of the relaxation training, and 60% of the
Imipramine groups. Five percent of the cogni-
tive therapy group sought further treatment
31
MACNEIL
during the follow-up time period, compared to
26% of the relaxation group and 40% of the
Imipramine-using group (Clark et al., 1994).
Combining benzodiazepines and behavior
therapy may even reduce treatment efficacy
(Barlow & Barlow, 1995; Otto, Pollack, &
Sabatino, 1995). At least two studies, Wardle
(1990) and Marks et al. (1993), suggest that ben-
zodiazepines interfere with the treatment pro-
cess. Some studies have found that although
Imipramine can enhance the effect of exposure
during treatment, follow-up data indicate that
this medication is (at best) neutral and may pro-
duce greater rates of relapse (Mavissakalian &
Michelson, 1986; Mavissakalian, 1993). Wardle
et al. (1994) suggest that the medication inter-
feres with therapy through the mechanism of
state-dependent learning, but Speigal, Roth,
and Weissman (1993) contend that the doses em-
ployed by Wardle and company were exces-
sively high.
A major issue presented by the use of medica-
tions for the treatment of panic disorder is the
effect medications may have on cognitive-
behavioral interventions. Because many of the
medications prescribed for panic disorder lessen
physical symptoms, behavioral interventions
that emphasize exposure to fear-provoking
stimula may be compromised. Further, client
gains resulting from their ability to overcome
their fears may be falsely attributed to the effect
of medications. This detracts from the intent to
empower clients to compensate for or overcome
their fears. It also has the potential to lead to
unnecessary dependence on the medication
(Craske & Waikar, 1994).
Psychological Treatments
Although approximately one-third to one-half
of persons diagnosed with panic disorder also
have agoraphobia, higher rates of comorbidity
are common in clinical samples (Kaplan et al.,
32 Brief Treatment and Crisis Intervention / 1:1 Summer 2001
1994). Though there is evidence that panic and
agoraphobic avoidance improve independent of
each other (Basoglu, Lax, Kasvikis, & Marks,
1994), most psychological interventions include
components addressing both issues. Cognitive-
behavioral interventions are the primary ther-
apy for persons presenting with panic disorder
stemming from distortions or misperceptions of
normal situations (Reid, 1997). In fact, a 1991
consensus statement from the National Institute
of Health recommended referrals to cognitive-
behavioral or medication treatments if changes
are not observed within the first six to eight
weeks of alternative (including hypnotherapy
or psychoanalytic therapy) treatment (Barlow &
Brown, 1998).
Typical cognitive-behavioral treatment for
panic disorder includes cognitive restructuring,
and in-vivo exposure components (Craske &
Waikar, 1994). While some researchers have iso-
lated and tested individual components of this
package, practitioners rarely use pure versions
of any psychotherapy in clinical settings, so the
bundling of these therapeutic components as a
“treatment package” should prove useful to
those in clinical settings situations (Reid, 1997).
Clients with severe agoraphobia tend to respond
best to exposure and response prevention (Beck,
Stanley, & Baldwin, 1994). Thus, clients with se-
vere agoraphobia should receive cognitive ther-
apy only in consort with exposure (Roth & Fon-
agy, 1996).
Cognitive Restructuring
Cognitive restructuring targets misappraisals of
bodily sensations as being threatening. It is
based on the concept that cognitions precede
(or trigger) anxiety and panic, so the identifi-
cation of aberrant cognitive structures, and the
challenging of misinterpretations and biases
through reasoning and experience can eliminate
the anxiety. Margraf (1989) and Salkovskis,
Clark, & Hackmann (1991) suggest that cogni-

tive strategies in the absence of exposure can be
effective.
Others have noted that anticipatory anxiety
plays a major role in panic disorders, as the
people suffering from the attacks often report
concern that they will “be found out” or that
they will be humiliated if others discover their
problem (Kaplan et al., 1994). As a consequence,
the fear that others will discover their problem
creates a panicky feeling in persons suffering
from panic disorder. This phenomenon is crucial
in my work with persons suffering from this dis-
order, as the anticipatory anxiety is based on
the future probability of something occurring
rather than the present situation.
One of my primary goals is to have the client
experience the “here and now” of their situa-
tion. That is, one of the first steps of treatment is
to have the client clearly identify that “right
here, right now” he or she is feeling safe. During
the first intervention interview I notice when
the client appears to be relaxed. Once this is ver-
ified, I comment that he or she seems quite safe,
“right here, right now.” I ask the client to repeat
this phrase a few times, becoming comfortable
with it. This statement becomes an anchor that
clients use to assess the voracity of their sensa-
tions of panic. Some clients even wear loose rub-
ber bands on their wrists during particularly
stressful times so that they can snap them to re-
mind themselves to focus on “right here, right
now”—and that they are O.K. at that moment.
Persons suffering from phobias can be alert to
specific situations or things that trigger their
anxiety, but this is not the case for those who
suffer from panic disorder. Because panic at-
tacks can present at any time, learning to iden-
tify initial indications of panic, and how to re-
duce the physiological manifestations of that
panic, is an important element of treating per-
sons suffering from panic disorder. Of particular
interest for those treating panic disorder is
breathing retraining. Breathing retraining is an
important component of treatment for panic dis-
Brief Treatment and Crisis Intervention / 1:1 Summer 2001
Treatment for Panic Disorders and Agoraphobia
order because nearly 50% of these clients report
hyperventilation symptoms (Craske & Waikar,
1994).
Exposure Treatment
Early treatment of agoraphobia relied on sys-
tematic desensitization in which clients only
imagined they were in their feared situations, as
therapists feared that exposure to the real feared
stimula would be injurious to clients. It should
not be surprising that this strategy was not very
successful in helping clients overcome their
problems in the real world (see Barlow & Brown,
1998).
Current practice standards indicate that be-
havioral therapy involving exposure and re-
sponse prevention has been shown to be effec-
tive in reducing panic symptoms (Barlow &
Brown, 1998; O’Sullivan & Marks, 1990). Expo-
sure therapy has two primary forms, in-vivo
and interoceptive. In-vivo exposure is appropri-
ate for persons experiencing anxiety as a result
of being in specific places or situations. It re-
quires that the client “engage in exposure prac-
tices by which they systematically venture away
from safe places and into the situations they
had been avoiding” (Barlow, Esler, et al., 1998,
p. 291). Interoceptive exposure is a model de-
veloped primarily by Barlow and Craske (see
Barlow, Esler, et al., 1998; Craske & Barlow,
1990). It requires that the client be “systemati-
cally exposed to their own bodily sensations in
a therapeutic context so that they might eventu-
ally learn at an emotional level that there was
nothing [sic] to fear” (Barlow & Brown, 1998,
p. 41). This form of exposure is recommended
for those whose panic attacks are not related to
specific situations or places.
There are many variations of exposure treat-
ment, and no single model has emerged as supe-
rior to others. However, sessions must be suffi-
ciently long to allow the client to fully provoke
and reduce their feelings of panic (Chaplin &
33
MACNEIL
Levine, 1981; Marshall, 1985; Stern & Marks,
1973). Massing sessions on a daily basis has been
shown to be as effective as sessions spaced on
a weekly schedule, suggesting that treatment
can beneficially be offered as frequently as
the schedules of the worker and client allow
(Barlow, 1988; Chambless, 1989; Foa, Jameson,
Turner, & Payne, 1980). Although Feigenbaum
found a high-intensity (flooding) method effec-
tive, most practitioners favor a progressive
model (Feigenbaum, 1988).
Exposure-based treatments can be adminis-
tered by the therapist or by the client him- or
herself. There is evidence that the two models
produce comparable effects with some disorders
(Al-Kubaisy et al., 1992; Ghosh, Marks, & Carr,
1988), and there are clear cost benefits for hav-
ing the client self-direct in this regard. In fact,
recent research findings suggest that telephone-
administered self-directed exposure instruc-
tions for those unable to attend traditional ther-
apy sessions can be very effective, and perhaps
this medium could be used as a cost-saving al-
ternative to face-to-face sessions (Swinson, Fer-
gus, Cox, & Wickwire, 1995).
Exposure treatments usually require that the
client and worker develop a short schedule of
hierarchically ordered anxiety-producing situa-
tions relating to the panic attack. The client is
encouraged to repeatedly put him- or herself in
the least stressful situation, and remain in it as
he or she experiences anxiety. The client is ex-
pected to use coping techniques learned in ses-
sion to address and reduce the anxiety. This ex-
perience is repeated until the client no longer
experiences unmanageable anxiety in the situa-
tion. He or she then engages the next most
stressful situation on his or her hierarchy. Some
clinicians accompany their clients to these situ-
ations (logistical restrictions not withstanding),
and others simply rehearse the sensations the
client is likely to experience in their office.
There is some evidence suggesting that includ-
ing significant others or spouses in treatment as
34 Brief Treatment and Crisis Intervention / 1:1 Summer 2001
“coaches” has beneficial effects for the clients
(Barlow, O’Brien, & Last, 1984).
The model I use consists of three phases: edu-
cation about the nature of anxiety disorders and
panic disorders specifically, cognitive therapy
(including some work regarding identification
of physiological indications of panic and relax-
ation), and exposure of some form. Because trig-
gering events of agoraphobia can be either in-
ternal or external (Wilhelm & Margraf, 1997),
I target both the physical sensations that the
client identifies as being associated with his or
her panic attacks (the psychological or internal
aspect of these attacks) as well as physical situa-
tions that serve the same function.
Case Illustration
Ms. Anthony (some information has been
changed to protect her identity) was a 35-year-
old, White female. She was a secretarial support
person at a local college while she took graduate
courses in mathematics at the college in prepa-
ration to teach at the junior college level. Ms.
Anthony’s husband worked as a marketing di-
rector at an advertising agency in town. They
had been together for six years. Her husband
was very concerned about Ms. Anthony and
fully supported her decision to seek help. She
was referred to the community mental health
center by her medical doctor. The doctor con-
cluded that Ms. Anthony was suffering from an
anxiety problem, but she was unwilling to fol-
low his recommendation to take tranquilizers to
address her anxiety. She confided in him that
she had been drinking moderate amounts of al-
cohol in order to reduce her anxiety and didn’t
want to substitute one substance for another;
she wanted to “get rid of the problem.”
Upon arriving at my office, Ms. Anthony indi-
cated that she had been very anxious during the
past month (finals of the spring term at school),
and was concerned that she was “going to die”

because of her racing heart. She reported that
she also experienced dizziness, mild nausea, and
fear that she was “going crazy.” She disclosed
that she first noticed these feelings two years
ago, and that they had become progressively
worse since then. Although she had had only
one attack prior to this year, she reported expe-
riencing symptoms of panic attacks “once or
twice a week” during the past month. Ms. An-
thony commented that only in the past two
months had her attacks been debilitating, caus-
ing her to take longer lunch breaks in order to
avoid staying in her office, where most of her at-
tacks occurred (suggesting that the attacks were
situationally predisposed to some extent). She
commented that she was well liked in her place
of business, and that she liked her coworkers as
well. She had experienced panic attacks lasting
up to “about fifteen minutes—but that doesn’t
count the hour and a half it takes to wind down
from the experience.” The duration of these at-
tacks had increased by about five minutes, and
they had become more frequent in the month
prior to our first session. Ms. Anthony did not
think they were related to the time of the school
year, as they had continued after her finals were
over. Although she was concerned that her
coworkers would discover her problem, she was
most concerned that her professors would find
out about it and use it as a reason to avoid rec-
ommending her for possible teaching jobs in the
future.
During the first session I obtained information
pertinent to her problem. Although she initially
appeared quite nervous, she quickly relaxed
and was able to fully answer all of my questions.
I showed her the DSM-IV classification for
panic disorders, and we reviewed the criteria for
this disorder. We also looked at the classification
for agoraphobia. While Ms. Anthony admitted
that she didn’t like being in situations where she
would look foolish if she had an attack, she in-
dicated that she had not needed to actually
avoid going anywhere. (In fact, she indicated
Brief Treatment and Crisis Intervention / 1:1 Summer 2001
Treatment for Panic Disorders and Agoraphobia
that one aspect of her attacks that was particu-
larly troublesome was that she typically wanted
to run away from wherever she was in order to
“get out of the situation,” causing her heart to
race, but that “where” she was physically
wasn’t the problem—and thus, physically run-
ning away didn’t help!) She commented that she
was relieved to know what her problem was. She
was comforted by the knowledge that her prob-
lem is highly treatable, even though she would
likely experience less severe relapses on occa-
sion.
I emphasized the idea that panic attacks are
often only exaggerated reactions to fearful situ-
ations. Because of this, learning to control our
responses can bring tremendous relief. As an ex-
ample of a way she could alter her response, I
taught her a breathing exercise in which I had
her concentrate on breathing diaphragmati-
cally, with deep breaths. I asked her to do this
exercise at least twice a day (and more if it was
beneficial in stressful situations).
Our second session was later in the same week
as the first. During the second session we iden-
tified the specific sequence of thoughts she went
through when she was experiencing a panic at-
tack. As noted by Barlow and Brown (1998), it is
important to help the client become sufficiently
specific so that these thoughts accurately and
fully describe the thoughts most responsible for
producing the panic attack. We listed these on
paper, and went through them item-by-item to
confront their logic. Although she was aware
that these thoughts were not rational, I thought
it was important to review them step-by-step in
order to introduce a new thought process and
begin to dispel her old, routinized thought pro-
cess. Ms. Anthony reported that her panic at-
tacks often began with her noting that her heart
was beating fast or hard, and this realization ini-
tiated a sequence of thoughts about being anx-
ious that grew into a full panic attack. Barlow
has commented on the phenomena of persons
suffering from panic disorder becoming hyper-
35
MACNEIL
sensitive to their own bodily sensations, to the
point where they attempt to avoid these sen-
sations (Barlow, 1988). In this manner these
people are agoraphobic not of places or situa-
tions, but of sensations. While I was concerned
that this might be the case with Ms. Anthony,
she did not report behaviors attempting to avoid
these body sensations before they presented.
During our third session we reviewed the list
of the thoughts she had during panic attacks. I
also had her elaborate on the worst conse-
quences she could imagine if she were to really
lose control of herself. Other than others using
this information against her, she was most con-
cerned that she would be unable to continue
with her normal daily activities—that she
would be paralyzed in some fashion. She com-
mented that she had experienced an attack dur-
ing the previous week, but that it didn’t seem as
powerful as previous attacks since it didn’t last
as long. I asked her why she thought this was so,
and she answered that she had concentrated on
her breathing.
Because her description of the circumstances
surrounding her panic attacks suggested that
they were not situationally predisposed, I had
decided to use interoceptive exposure with Ms.
Anthony. Because she had indicated that tight-
ness in her chest and a racing heart were princi-
pal symptoms during her attacks, I had her do a
hyperventilation exercise to produce facsimiles
of these symptoms. She was unable to complete
the exercise because she became so anxious. She
began to perspire and blink rapidly. She was
breathing rapidly and became flushed. Still, she
was able to perform physical tasks when di-
rected to do so. I asked her to bring me a partic-
ular book from the shelf behind her, for in-
stance. I was able to show her that she was fully
functional despite her discomfort. She was
somewhat surprised by this realization.
The hyperventilation exercise and its follow-
up took approximately 20 min to complete. Af-
36 Brief Treatment and Crisis Intervention / 1:1 Summer 2001
ter Ms. Anthony had relaxed, I commented that
she hadn’t taken very long at all to recover from
her “attack.” She agreed, and suggested that
having someone there who knew what she was
experiencing—and focusing on her panicky
feelings, even—probably helped her. I asked if
her husband could provide this service, and she
agreed that this would likely help. She agreed to
bring him with her for the next session.
Ms. Anthony came for her fourth session with
her husband. He indicated that his wife had
been “filling him in” on our sessions, and that
she seemed very pleased with the way things
were going. I asked him if he had an idea of what
it felt like for his wife when she experienced a
panic attack. When he indicated that he didn’t,
I had him do a hyperventilation exercise in
which he panted as quickly as he could without
stopping until I told him to quit. Although I
only had him pant for thirty seconds, he re-
ported feeling light-headed and scared. When I
told him, “That’s a little bit what it feels like for
your wife, but she doesn’t know when it’s going
to start or how long it might last. And she tells
me that these feelings last for over fifteen min-
utes at a time,” he quietly took her hand.
I explored with Ms. Anthony how her physi-
cal sensations led to exaggerated thoughts about
her situation. For instance, her racing heart
caused her to think that she was “out of con-
trol.” Her tight chest would cause her to be un-
able to walk around to get help if she needed it.
I suggested that these physical sensations (al-
though they might be caused by totally unre-
lated events) are protective if they aren’t exag-
gerated. Consequently, she might take the op-
portunity when she first noticed one of her
sensations to explore if she was in a dangerous
situation. She laughed as she commented that
she wasn’t ever in a “real dangerous situation,”
but acknowledged that she must have been
scared of something when she had attacks.
I commented that at that time, at that moment,

she seemed to be safe. She agreed, and I had her
repeat the phrase, “Right here, right now, I’m
O.K.” I mentioned that most of us worry about
things in the future and forget to pay attention
to the fact that “right here, right now” we’re
O.K. She agreed that she did this a lot. I had her
describe a few of the things she worried about.
They were all situations or events at least a
month away. I noticed that as she mentioned
them her heartbeat increased and she began to
blink more rapidly. I grabbed her hands in mine
and made sure she was looking right into my
eyes as I quietly said, “Right here, right now,
I’m O.K. Repeat it.” She did, four times. I made
sure she was looking into my eyes as she did so,
and that she noticed my exaggerated slow, full
breaths as she said the phrase. Following this I
asked her how she felt. She said, “I’m O.K. I’m
glad I didn’t go in the other direction, because I
really thought I was for a minute.” I remarked to
Mr. Anthony that helping his wife continue to
take full breaths when she became anxious
would be an important coaching task. I sug-
gested that she review her list of “irrational
thoughts” at least twice in the next week, and
that she continue to concentrate on her breath-
ing, perhaps using her “new mantra.”
Ms. Anthony came in for her next session re-
porting only one “minor” panic attack during the
previous week. She stated that she was able to use
her “I’m O.K., right here, right now” phrase to
calm herself, and that she had intentionally
walked the halls of her office in the middle of the
attack to show herself that she really was O.K. Af-
ter offering my congratulations I asked if we
could try to provoke another pseudo-attack so
that I could see if additional tools would be help-
ful. I had Ms. Anthony breathe through a couple
of straws for three minutes in order to provoke
shallow breathing or a sense that her breathing
was not normal. Her breathing became shallow,
and she became a bit flushed. However, she didn’t
report feeling anxious, only silly.
Brief Treatment and Crisis Intervention / 1:1 Summer 2001
Treatment for Panic Disorders and Agoraphobia
I asked her to review things that she thought
were worrying her. However, she did not be-
come anxious in doing so. We then did a short
role-play in which I assumed the role of her
boss. I repeatedly accused her of not being pre-
pared with a business report I had supposedly
asked her to prepare. I raised my voice and
spoke harshly. Finally, I noted that she was
breathing quickly and she blinked her eyes rap-
idly (as she had on a previous occasion when she
felt panicky). I continued to keep my voice
raised for about ten minutes, even keeping it
raised as I asked her if she felt out of control. She
stated that she didn’t like feeling that she had
let someone down, but that she knew if she
just kept taking “as big a breath as I [sic] can”
she would be O.K. When we completed the exer-
cise she commented that seeing her husband
struggle with his breath in my office had been a
big help for her; seeing that anyone might feel
“scared” when they aren’t breathing normally
had given her reassurance that her own re-
sponse wasn’t really crazy after all.
I saw Ms. Anthony two more times. Although
I tried to provoke feelings of panic, I was un-
successful. At each session she reported less
concern about her feelings of panic. Although I
cautioned her that her feelings of panic might
reappear in moments of stress, she felt confi-
dent that her coping tools would help her over-
come these attacks. I indicated that she should
not be embarrassed if she needed to see me
again because her feelings of panic became un-
manageable; this is a common occurrence for
those who have experienced panic attacks. I
asked how much she was drinking, and if she
continued to drink to help her deal with her at-
tacks. She said she hadn’t had a drink in almost
a month, and that drinking hadn’t really helped
at all anyway.
I phoned Ms. Anthony four months later to
find out how she was doing. She stated that she
had only had one attack of any consequence,
37
MACNEIL
and that focusing on her breathing and “staying
right here, right now” had gotten her through it
without problems.
Conclusion and Future Directions
In this case illustration, a combination of client
education, cognitive restructuring, and intero-
ceptive exposure was employed. Had Ms. An-
thony indicated that she was avoiding any situ-
ation or place I may have introduced in-vivo
exposure to transfer her skills to those “real
world” places that were problematic. I also
sometimes use self-anchored rating scales in or-
der to provide concrete feedback to clients who
do not think they are making progress. These
scales allow for the quick assessment by both
the client and the social worker about the pro-
gress and attainment of session expectations.
It is important to also note limitations. Al-
though the model presented here is entirely ap-
propriate in the current managed care environ-
ment, not every client will benefit from it. Ap-
proximately 30% of clients do not experience
relief from panic attacks with this kind of inter-
vention package. Treatment efficacy is reduced
for those with comorbid conditions, and it is
sadly the case that approximately 70% of clients
with panic disorder have Axis I comorbidity
and 50% have Axis II comorbidity (Steketee,
Van Noppen, Cohen, & Clary, 1998).
Certainly not every client will make the quick
gains Ms. Anthony did. Some will progress at a
much slower pace, perhaps prompting ques-
tions about whether the treatment is working at
all. It is important in these instances to be hon-
est about the progress (or lack of progress) that
is occurring, and to insure that the client does
not reintroduce negative cognitions previously
employed. Finally, perhaps we should remember
that our goal need not be absolute elimination of
panic attacks, but rather increased functioning
38 Brief Treatment and Crisis Intervention / 1:1 Summer 2001
despite these attacks. Clients typically seek our
help because their lives are impaired. Our task
in helping them is to assist them in improving
the quality of their lives. The treatment package
offered here is one way to accomplish this task
with clients suffering from panic disorders.
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