The following case study provides a real-life clinical example of using the ISP™ approach to stop panic attacks quickly. The work with a young woman suffering from panic attacks is an excerpt from the book The Practice of Embodying Emotions by Raja Selvam.
Petra started having panic attacks at the age of seven. As she remembered it, she was playing in her room by herself when she heard a voice speak to her from her lower right abdomen: “Petra, it is time for you to die!” This was the start of fourteen years of suffering that involved panic attacks, depression, difficulty in school, and stress in low-paying jobs after high school. Petra went to work, came home, ate, and slept up to twelve hours a day. She did not want her parents to leave the house when she was at home because she did not feel safe. When I saw her for the first time, I was in the Netherlands facilitating a six-day training. At the end of the first day, her uncle, who was an assistant at the training, asked me to see Petra to determine if I could be of any help.
What I remember particularly about that first meeting was how dispirited her parents appeared to be. It made sense that they were not hopeful. Petra was their only child, and they had done everything they could think of to help her: medical doctors, psychiatrists, and psychoanalysts. At the age of twenty-one, Petra had already been through two psychoanalytic treatments and was on multiple medications. When I told her I could see her twice at the most during my short stay in her country and that she might have to do follow-up work with someone I referred her to, Petra was very clear with me that she did not want to do more psychotherapy. Instead of insisting that she should agree to see another therapist to ensure she was adequately cared for after the work we did together, I told her that she had a much better chance of improving if she did the things I taught her during our sessions.
The work I and others had done in Indian fishing villages among the survivors of the 2004 tsunami had taught me that clients could be active participants in their own healing. Over a period of two years after that devastating natural disaster, I led five international teams of therapists to the state of Tamil Nadu to offer treatments, education, and training for the survivors and those involved in their recovery. Follow-up surveys from one of our trips to India found that respondents who practiced skills they had learned during treatment sessions were much more likely to report a greater reduction in their symptoms.
If you’re interested in using the Integral Somatic Psychology™ approach in your clinical practice to do deeper transformational work, explore the ISP Professional Training.
Panic attack symptoms
Petra’s uncle had told me that she had had two surgeries soon after she was born in order to correct a life-threatening congenital defect in her large intestine—the same location where the voice announcing her time of death appeared to come from. I was curious about how that area might be involved in the formation of her panic attacks. I knew from my own experience and the experience of those I have treated that symptoms often involve dysfunctional patterns in parts of the body that have been most traumatized. An example from my own life: because I nearly died during my own birth because I was stuck for a long time in a birth canal too small for my head, whenever my degree of physical or emotional stress increases beyond a certain extent, the right side of my head has a tendency to become constricted and uncomfortable. This symptom is less evident now than it used to be, but it still makes its presence felt to this day.
Underlying causes of panic attacks
I told Petra it was possible that unresolved traumatic patterns from her lifesaving surgeries might have something to do with her panic attacks. She was not surprised; one of her two psychoanalysts had made that connection already. I told her it is not unusual for energy to concentrate in an area of the body that has experienced trauma and to increase in intensity until it reaches an upper limit and triggers a symptom such as a panic attack, to reduce the intensity and bring about relief. The level of intensity at which the symptom forms is also referred to as the symptom threshold. I then suggested the following, both as a treatment and as a self-help protocol: whenever she felt stress in her life, no matter the cause, she should learn and practice ways to distribute the stress in her body so that it did not build and concentrate in the lower right abdominal area beyond the symptom threshold, which could trigger the voice and an ensuing panic attack.
A practice to resolve panic attacks
To start, we chose to practice how she could cope with her work situation, as her boss was often a source of stress. I asked her to imagine a difficult interaction with her boss and then to notice the buildup of constriction, arousal, stress, and discomfort in her lower right abdominal area. I guided her to work with the physiological defenses in her abdomen and legs to redistribute the unpleasant arousal, stress, and discomfort she felt in her abdomen to adjacent areas of the legs using simple tools of awareness, intention, movement, and self-touch. I invited her to notice how this helped ease the intensity of the unpleasantness in the abdominal area, and how that area eventually settled.
All of this did not take very long. I asked her to practice what we had done during the session on a daily basis whenever she felt that she was getting stressed, regardless of the cause, and to come back in five days, on the last day of my training. During the treatment, I found Petra receptive enough to my suggestions; but I also found her somewhat skeptical, which was understandable, given how long she had suffered without relief.
When Petra came back five days later, I noticed a change in her. She appeared to be in a better mood. I asked her whether she had been able to practice what she had learned in the previous session, and what changes, if any, she had observed in herself since. She said she did “the exercise” regularly, and her mother had observed that her energy had somehow changed for the better. What she told me next, however, surprised me. Petra had suffered from severe constipation all her life and was able to eliminate only once or twice a week, with a great deal of difficulty. Since our session, however, she was greatly relieved to be able to have an easy and regular bowel movement every morning. The “exercise” seemed to have really worked, she said, adding that she did it as often as she could. She now really believed in “the method” and was looking forward to learning more about it.
The method I taught her, on the basis of what I had observed had worked well for her during the first session, was simply this: Whenever she felt stress building up in her abdomen, she should move her legs to relieve any constriction in them. Then she should place one hand on her abdomen and the other on first one leg and then the other, to draw the energy down and distribute it more evenly between her abdomen and her legs, and then observe the changes that occur in her body, especially for the better. For example, the high level of arousal might automatically come down, and the body might feel better overall.
Years later, such quick changes in long-term, persistent, and serious symptoms in some clients no longer surprise me as much as they did when I saw Petra, even for symptoms such as asthma, migraine, and chronic pain, when they are psychophysiological in origin. People can form serious psychophysiological symptoms, such as chronic fatigue, at low levels of emotional stress. Psychophysiological (formerly called “psychosomatic”) symptoms are physical symptoms that are caused or exacerbated by psychological conditions. (This book uses the term “psychophysiological symptoms” instead of “psychosomatic symptoms” because the latter has acquired a negative meaning of being only in one’s head.) Teaching people how to experience emotional stress in a more distributed and regulated way within the larger container or space of the body can achieve a number of beneficial outcomes:
- It can create a greater capacity for emotional suffering, which helps by increasing the threshold or level of tolerance at which symptoms form.
- It can decrease the level of stress and dysregulation and increase the level of self-regulation throughout the organism.
- It can increase the body’s connection to the environment, improving the possibility of interactive regulation.
- It can resolve symptoms more quickly and shorten the treatment period.
- It can make a person’s overall system more resilient, so that symptoms do not form as easily in the face of stressors; and if symptoms do form, they can resolve more quickly.
Back then, knowing less than I do now, I could not rule out the possibility that Petra’s constipation cure was just a “transference cure”—a sudden cure that can happen because the client idealizes the therapist or the method—which does not always last. Putting those thoughts aside, during my second session with Petra I turned my focus to the work she and I could do before I left the country the following day. It seemed as though she had come prepared to jump in with both feet and do a lot, encouraged by what she had been able to achieve in just a week. As soon as we started to process a stressful situation in her life, she reported a more coherent emotion of fear emerging in the chest area.
Emotions in the body often emerge first in the chest area. That she could sense it there right away was a good sign that she had developed a greater capacity to not shut her body down in the face of the difficult emotion of fear. It is not unusual for people to continue to heal on their own and develop greater capacity for emotions once they learn how to use more of the body to process them.
Emotion can be thought of as an assessment of how a situation affects or impacts the well-being of the whole body.2 This implies that the more the impact is distributed throughout the body, the easier it is to tolerate it subjectively. We have a tendency to use physical and energy defenses, such as constriction, to limit emotions to a few places in the body as a way of coping with them. All of us have a tendency to resort to this strategy for relief quite often, in a misguided attempt to reduce our necessary suffering. It is all too understandable, given our shared aversion to unpleasant experiences.
Physical and energy defenses against emotions such as constriction, low arousal, or numbing can disrupt the various flows (blood, nervous system, lymphatic, interstitial or intercelluar fluid, and electromagnetic and quantum energy) that are vital for brain and body regulation and physical and psychological well-being.
Expanding the body to stop panic attacks
In this context, I use the phrase “expanding the body” to mean working to undo such physical and energy defenses to improve all of these vital flows from one part of the body to another, to help distribute the emotional experiences to more places in the body to make it more bearable, and to improve the level of regulation throughout the brain and the body to resolve psychophysiological symptoms.
As I taught Petra how to “expand” her body in order to expand the emotion of fear, and to stay with it and tolerate the sensations in more places in her body, the level of fear as well as the psychophysiological arousal became extremely high—so high that I wondered if I had helped Petra to open up too much too fast. This made me very concerned that she might decompensate or fall apart during or after the session.
We hung in there—Petra and I and her uncle, who was observing the session—for a long period of time, as the fear turned into terror, a response clearly disproportionate to the situation we had started with. I got Petra to split her attention between what she was experiencing inside her body and what she was noticing in her surroundings, to reduce the subjective intensity of her suffering. I had her make statements such as “My body is afraid; I am not” to introduce mindfulness. I interpreted the fear for her as possibly the fear of dying after her birth from the congenital defect and from the surgeries, so as to provide a meaningful frame to contain the fear. This anchored the context that it was not a fear of an unknown in the present, which would be harder to contain, but a fear response to something in the past.
Working with the physiological and psychological defenses
Most importantly, I remained focused on working with the physiological and psychological defenses against her terror so she could expand her body in as regulated a manner as possible, in order to distribute the emotion to as much of her body as possible (the rest of the chest, the abdomen, the arms, the legs, the head, the neck, the spine, the brain, the front, and the back). This was intended to manage but not eliminate the states of physiological stress and dysregulation that are inherent in the generation and experience of unpleasant emotions such as fear. The purpose of all this was to have Petra experience the emotion as being as regulated and tolerable as possible.
The notion that the body is involved in emotions might sound strange to those who have been taught that only the brain is involved in emotional experience. The idea that the entire body can be involved in an emotional experience might sound odd even to those who do not dispute the body’s role in emotion. As we will see later in this book, cutting-edge research on emotions has established that the experience of emotion depends not only on the brain but also on the entire body and its environment. Once we accept the idea that the entire body can be involved in the experience of an emotion, it is easy to imagine how using more of the body to process an emotion might be to one’s advantage, even though the scientific explanation might be indeed complex.
Resolving psychophysiological symptoms in a surprisingly efficient manner
It was indeed a difficult and lengthy session for everyone involved, with a great deal of uncertainty about whether it would be helpful or harmful to Petra. I did not then have the confidence I have now that this method could or would work. In a way, I had no choice. The intense suffering was there all of a sudden, and I had to support her in managing it somehow to avoid another panic attack. Back then, I only had theoretical assurance: from neuroscience, that emotions could potentially involve the whole body; from intersubjective psychoanalysis, that healing involved greater affect tolerance; from cognitive behavioral therapy, that healing sometimes involved prolonged exposure to intense suffering; from Jungian psychology, that healing involved the development of a greater capacity to tolerate opposites; and from Eastern psychology, that the capacity to tolerate opposites in the body is a prerequisite for enlightenment, the highest possible spiritual achievement for the human psyche.
Looking back, one could say I was being shown through treatments such as Petra’s that increasing the capacity for necessary suffering in a regulated manner, by using as much of the body container as possible, can help resolve psychophysiological symptoms in a surprisingly efficient manner.
The length of the cycle, with fear and then terror, was nearly forty minutes; but Petra eventually settled. Exhausted yet relieved, I educated Petra about the additional things we had done during the second session to manage her fear, stress, and dysregulation, and I encouraged her to continue to practice these techniques to manage stress or other feelings as they came up, as often as possible. I referred Petra to a local colleague just in case she needed help, and I also asked her to keep me informed of her progress through her uncle. Probably shaken by the session, Petra took the colleague’s contact information, although I learned later that she never used it.
I left the country the following morning, and I might have said a prayer or two before leaving! Just in case you do not know this, there is evidence for the effectiveness of prayer, even in the treatment of cancer. Researchers have observed higher rates of remission among cancer patients who had others praying for them than among control group members who were not prayed for.
Panic attacks had stopped
Three months later, Petra’s uncle emailed me with very good news about her that he wanted to share with me over the phone. Extremely curious and much relieved, I called him as soon as I could. What he had to tell me was very good news indeed: Petra no longer had any panic attacks, a symptom that had persisted for fourteen years. She had been using the skills she learned during our sessions to prevent an attack from occurring if she sensed that she was on the verge of one. She was feeling much better and more positive about her life. She was no longer sleeping as much and had even started jogging with her father. I told him I was so glad we were able to help a young woman move forward in her life.
The next time I saw Petra for a session was six months later, when I was back in the Netherlands to teach the second and final part of the training. It was late November, and the spirit of Christmas was already palpable. I saw her only once during this trip. The session was mostly about catching up and reinforcing the skills she had learned during the earlier sessions. She had made significant changes in her life: she had quit her old job and had found a new one that she liked more, she still was no longer having panic attacks, and she was working with her psychiatrist to get off all her medications by the end of February. Her psychiatrist, intrigued by her progress, wanted to know what “exercises” I had taught her that worked so well.
At the end of the session, Petra wanted me to tell her story to others—and even gave permission to use her name in the telling—so others could benefit from “the method” as well. I was very touched by the sincerity, gratitude, and generosity of this remarkable young woman.
The next and the last time I spoke with Petra was in the spring of the following year. She had reached out to me through her uncle because she was having a difficult time. Her grandfather had just died. I was in the United States, so we talked on the phone. By then, Petra was off all her medications and was still free of the panic attacks. She was in general feeling much better. What had been difficult for her was the loss of her grandfather, who had always been a special person in her life. I told her that such a loss is indeed a painful experience. It takes time to heal and come to terms with that kind of experience, and we need the support of others to get through it. However, she could use the skills she had learned to cope with fear to cope with her sadness as well.
We then worked on how to undo the physiological defenses, such as constriction, that easily form against unpleasant emotions such as sadness. We also practiced ways to redistribute the sadness from her chest area to the rest of her body in a regulated manner, using again the simple tools of awareness, intention, movement, self-touch, and expression. This time, she learned more consciously how working to more fully embody an unpleasant emotion such as sadness in a regulated manner made it more bearable to be with it for a longer period of time. We sat with the shared sadness for a while.
I was about to end the session to prepare for my next appointment when Petra asked if I had the time to help her with another thing that had been of concern to her. She said she used to be depressed, but now she often had so much energy that she did not know what to do with it—a level of energy she had formerly only experienced during panic attacks. I explained to her that when the body is no longer symptomatic and shut down in defense against unbearable experiences such as emotions, its energy is free and available for constructive and life-enhancing purposes. I asked her if she could think of anything she could use her extra energy to accomplish in her life. Petra responded that it was interesting that I should ask her that, because she had been thinking about going back to the university to get a degree. I encouraged her to do it. I even pushed her a bit by sharing with her that old symptoms could come back if she did not use the newfound energy constructively.
That phone session was the last time Petra and I worked together. I write “Petra and I worked together” instead of “I worked with Petra” because I believe that much of her progress had to do with her willingness to learn and to use more of her body as a container to deal with overwhelming experiences of emotion, and the stress and dysregulation that accompanied them.
Like a proud parent, I have been tracking the strides that she continues to make in her life, through my contact with her uncle: She has a boyfriend. She has graduated from college. She has a new job. She has an apartment of her own. She and her boyfriend are now living together. And the last thing I heard, years ago, was that Petra and her boyfriend were on a long motorcycle journey through an Asian country. I am curious if that country is India, where I am originally from. One of these days, I intend to find out.
From The Practice of Embodying Emotions: A Guide for Improving Cognitive, Emotional, and Behavioral Outcomes by Raja Selvam, published by North Atlantic Books, copyright © 2022 by Raja Selvam. Used by permission of North Atlantic Books.
About Raja Selvam, PhD
Raja Selvam, PhD, is the author of The Practice of Embodying Emotions and developer of Integral Somatic Psychology™, a new paradigm in body psychotherapy based on state-of-the-art research in neuroscience, affect theory, cognitive psychology, and emotion. He has helped over 1,500 therapists in 20 countries graduate from his ISP Professional Training.
His articles on trauma, embodiment, and spirituality have appeared in several scientific journals.
Raja is also Senior Faculty at Peter Levine’s Somatic Experiencing® Trauma Institute and works as a licensed clinical psychologist with a PhD in Psychology.