Training and Research Institute for Systemic Psychotherapy
Current research has explored connections between panic attacks, difficulties in emotional expression and familial characteristics. The aim of this qualitative case study was to provide insight into a client’s experience with recurrent panic attacks. Interpretative Phenomenological Analysis (IPA) was conducted on a semi-structured interview with a female client in long-term enriched systemic therapy. The analysis indicated four overarching themes: i) focus on panic attacks; ii) focus on self; iii) focus on relationships and iv) focus on therapy . These themes, which summarized the client’s experience, were dynamic and interconnected and seemed to operate on many levels. In a capsule, the client experienced panic attacks not only as an unpleasant “whirlpool” but also as an opportunity for personal growth. Implications for clinical practice are drawn from the interpretative part of the study, which was based on systemic notions and attachment theory. Limitations are related to the single case study design.
**Key-Words: ** Systemic therapy, attachment theory, Interpretative Phenomenological Analysis, panic attacks
I was defeated by my fear – nothing exists. Lost in the roads, inside movie theaters,
I have outgrown my youthful naïve self. Panic left me stripped naked, staggered by its everyday, persistent blows. As the symptoms become even denser, fastening the knot inside, the span of silence shrinks. No one-not even mother can save me.
(The span of silence - George Ioannou)
The panic attack
According to Hoehn-Saric & McLeod (1988), anxiety is an experience most people are familiar with, which functions as a warning mechanism for security. The manifestations of anxiety, such as panic attack, could be perceived as a danger alarm system, put into motion by the human body when dealing with threatening or uncertain situations. However, in some cases, this mechanism may malfunction, producing "false alarms". For example, when distress continues to prevail even after the threatening source is no longer there, when it is experienced in a very intense way, when it appears with no obvious reason or when the situations connected to stress do not entail an actual threat or danger. Also, panic attacks are usually accompanied by a constant feeling of distress caused by the anticipation of a new panic attack and influence the behavior of the person involved. Often, panic attacks reoccur with agoraphobia and in these cases fear focuses on social context and on the difficulty to receive help (Sánchez-Meca et al., 2009).
Recent studies have shown that people suffering from panic attacks have difficulty in resolving interpersonal conflicts that emerge due to a feeling of losing control (Williams et al., 1997).These difficulties seem to be associated with emotional deficits, a difficulty in self-regulating negative emotions and problems with the development of a secure attachment style (Brisch, 2012; Chambless et al., 1996; Kemp & Neimeyer, 1999; Salas, 2002). Having caregivers who are unavailable or inconsistent seems to be related to the development of anxiety symptoms (Cassidy, 1995). Furthermore, researchers and therapists have been pointing out the importance of the family’s role in panic attacks through issues of triangulation, unresolved issues of life cycle and difficulty in resolving conflicts (Oppenheimer & Frey, 1993). To be more specific, the processes of interaction and communication in a family, as well as the intergenerational transference of patterns of emotional expression, seems to be related with the appearance of anxiety disorders.
Emotional attachment and the Systemic approach: Links and clinical applications
According to modern literature, the practice of systemic psychotherapy can be enriched and benefit from the inclusion of elements and ideas of attachment theory (Androutsopoulou, Bafiti & Kalarritis, 2013; Byng-Hall, 1995; Dallos, 2004; Kozlowska & Hanney, 2002). Attachment theory suggests that there is a biological predisposal of infants to connect with their parents that increases their possibility to survive. Hence, from a systemic perspective, the children and their caregivers retain a relationship that enhances protection: when the infant explores the surrounding environment, it reacts to possible threats by seeking security which in turn activates caring and protection from the caregiver. When the threat is dealt with, the infant returns to exploring the environment from a more secure base (Dallos, 2004). As far as family processes are concerned, this means that infants need the constant and emotional presence of their parents or caregivers in order to develop a secure emotional bond (Bowlby, 1969).
Bowlby’s attachment theory was supported through research and can be interpreted as a developmental theory of personality, also acknowledging the difficulties in adult life (Parkes et al., 1991). It connects these difficulties and the symptoms one might experience with the way a family functions, without attributing blame. Specifically, it spots the intergenerational patterns that transfer emotional insecurity to children and highlights the ways in which this insecurity influences and has an impact on adult relationships. According to Byng-Hall (1995), attachment theory stresses the importance of augmenting security within a family, helping at the same time all family members to be self-efficient. The most important characteristics of the processes of emotional bonds are the emotional regulation, the interpersonal understanding and the emotional response to close relationships. These features are not only manifested on a personal level but are also acknowledged within the family systems (Hill et al., 2003). In order to understand a family in depth, we have to study a system existing inside another system, which is also included in a separate system and to examine the relationships among these systems as well (Kozlowska & Hanney, 2002). Emotional security or insecurity could be detected in family narratives with emphasis given on the levels of cohesion. The emotional interaction between family members creates both specific patterns of attachment styles and influences the content and style of family narratives (Dallos, 2004).
From the perspective of the systemic and attachment theory (Byng-Hall, 1995), a panic attack can be viewed in therapy as a symptom related to family traits, emotion regulation and management of life cycle events. More specifically, the onset of panic attacks can be linked to life events triggering non-processed fears of autonomy and/or rejection, as well as "forgotten feelings", whereas the fear of having a panic attack could be used as a mechanism to avoid deeper and more realistic fears (Androutsopoulou, 2012).
Aim of the study and research questions
This study aimed at comprehending on a more in-depth level the experience of panic attack through the eyes of a female participant and her perceptions as seen from a systemic perspective and through the lens of attachment theory. More specifically, our research questions were the following: i.) What is the lived experience of a person with panic attacks? and ii.) What are her perceptions and views regarding this experience?
Also, since the participant was a member of a long-term systemic therapy group, an additional goal was to reveal and explore the experiences and the important events taking place within the group process that she associated with change.
Interpretative Phenomenological Analysis was used on a semi-structured interview with a young woman suffering from panic attacks. IPA is a qualitative research methodology that focuses on the ways people give meaning to their life experiences and refers to the analysis of their lived experiences (see, for example, Reid et al., 2005; Smith et al., 1999). The understanding of the experience is both phenomenological and interpretative as the researcher tries to interpret and make sense of the individual account of the person who at the same time also makes an effort to interpret themselves (Smith et al., 2009). Meanwhile, as qualitative research sees the person’s willingness as part of complexity, the researcher must take into account factors of chaos. In this specific research analysis of the participant’s experience was made not only from a systemic perspective and in the context of attachment theory but through a connection between the two as well, as analyzed above.
In many cases where IPA methodology was applied, (see, for example, Crouch & Wright, 2004; Latif et al., 2004; Nunn, 2009; Walker & Tobbell, 2015), it seems that this kind of analysis enables a thorough understanding of personal experiences of specific persons, facilitates the development of theories and helps creating links between research and clinical practice (McLeod, 2001).
A semi-structured interview was conducted with a young woman suffering from panic attacks. The interview questions gave emphasis on the personal meaning a person gives to these attacks and the way they make sense of their own experience. During the interview, the main aspects of focus were time, space, body and relationships. Analysis showed four higher-order themes that included some lower-order themes. The analysis was conducted separately by each of the two researchers and a common ground was reached after discussion. In our effort to protect the quality of our research, our assumptions were based on the following guidelines: owning one’s perspective, situating the sample, grounding in examples, providing credibility checks, coherence and resonating with readers (Elliot, Fischer & Rennie, 1999).
Eleni is a 35-year-old woman who was raised in a small village in Greece and came to Athens to study. She has a job in marketing and is a member of a systemic therapy group for the past 6 years.
The analysis, which took place separately by the two researchers, found four higher-order themes that include some sub-themes, and are the result of negotiation.
1. Focus on panic attacks
This specific higher-order theme refers to the way Eleni focuses on the panic attack, on the difficulties this has caused her and on how she speaks about her thoughts and emotions regarding the panic attack.
- The panic attack as an everyday nuisance
Eleni’s life was affected by the consequences of panic attacks on a daily basis. Her narrative referred to the somatic symptoms, the thoughts she had before, during and after the panic attack and to the overall impact it had on her life:
"My hands and feet were tingling, I felt fatigued and dizzy, as if my feet couldn't hold me anymore. My heart was beating fast, I was trembling and gasping for air… but what made it even worse was the feeling that I was going to die."
"One panic attack would follow another and then it became a daily experience because I was sure that once I would step on the train I would have a panic attack. So, I did."
Eleni has faced difficulties on many aspects of her everyday life such as food intake and as a result she had to deal with issues concerning her weight and her social relationships:
"Food became an issue for me. Just a few bites of food would cause me stomach pain, discomfort, I had difficulty in breathing and having a meal away from home was not an option for me. So, whenever I was out all day, I just wouldn't eat. Or I would eat a breadstick, or just a few bites of food."
" For example, I remember one day when my boyfriend Fanis and I had gone out to dinner, and I was full after eating just three bites of food. And then, when he came home one day and saw me eating like a normal person he asked me if I hadn't liked the place he had taken me. I told him that I had... But he insisted that I hadn't eaten anything that night so he just thought I didn't love food. The difference he saw in me that day in my house compared to the night we went out was so big, as if I was a different person. "
"…in a crowded place and I had made a connection in my head between being in a crowded place and having a panic attack… I don't know, but when I am with other people… like now, I feel more in danger.
- The panic attack as an alarm reaction
Today, Eleni thinks of panic attacks as an alarm reaction that helped her take the initiative and protect herself. Therefore, panic attack was treated as an "opportunity" to process her feelings and her relationships on many levels:
"something dawned in me, and now I feel very happy that it actually happened, because if it hadn't, I would still be the same person and this is something I wouldn't want for myself."
"…I was given a chance to come to terms with myself, to give him what he wants at some extent and to see my relations with other people more clearly."
2. Focus on the self
This issue reflects Eleni’s sense of self and the changes that occurred after the panic attacks started. It seems that after the attacks, her sense of self-dependence was replaced by a view of the self as fragile and inadequate. Her self-perception of inadequacy was strengthened by comparing herself to other people.
The experience of the panic attacks made Eleni reassess the way she viewed herself:
"Before the first panic attack, I thought I could do everything on my own... (pausing for a moment), yes that was it. Do everything on my own. Which basically meant that I didn't need anyone. The truth is that I didn't have anyone to help me… but I also didn't need anyone, this is how I felt. I didn't care if someone was there or not, because I knew I would do everything alone. Everything. That… I would be solely responsible for my own self growth… theoretically speaking… for all the daily stuff and anything else that would come up, I would deal with it on my own."
"If I can't do it, that means that I am either inefficient or too weak. That's it. It means that I am not capable... Why do others… why could he do it and I can’t? This is what I told myself. Weakness and incompetence were the underlying factors in all."
3. Focus on relationships
This higher-order theme expresses the link between the symptom and her interpersonal relationships, the way her relationships changed after the panic attacks and the awareness concerning her relationship patterns.
- Family dynamics
The panic attack influenced Eleni’s relationship with her parents and the role she had in the family:
"…as I said, I used to call my mother, and at some point she lost her patience and didn't talk nice to me… sometimes she didn't pick up the phone and and and… or she would make a comment about my comedown and how I ended up this way and things like that, which actually had to do with the kind of person she was in general and… the kind of relationship we had, it wasn’t something new to me, I knew that this would happen."
" I felt disappointed, very sad and... helpless. Because I felt that she couldn't help me either, because… I felt that no one could help me… not even my family who stayed away. Because I believed that they could have supported me differently … and… then I felt it from her as well, so I said to myself, here goes one more person not being able to do something for me. Later on, I tried to make an approach… but there was no reaction, so I gave up. (pause). So, there. I felt disappointed. "
"… I started shouting and screaming, calling my father and telling him that I could not breathe, when in fact I was breathing. I was actually breathing heavily, but I kept telling him that I couldn't". And he would say, "But you are breathing normally." "Calm down, you are breathing normally." And I insisted that I couldn't. This lasted about fifteen minutes and then it was forgotten. Nobody seemed to care."
- Patterns of interpersonal relationships
Eleni gradually realized that for a long time she had been focusing on other people’s needs. Also, she became aware that when she started to differentiate herself, many people distanced themselves from her.
"… I felt drained by people around me because I helped everyone, everyone, even those… and my family… well, mostly my family who was away, I took care of everything […] and I gave one hundred percent of myself, leaving nothing for me. Nothing at all. What I mean is that there was no room for my needs. There never was…"
_"when you can't go out and have fun, those people will withdraw, but when there is someone with whom you have a close relationship, or at least you think you do, you expect that he will understand you. But… in my case this didn't happen. And after that I started having... and still have... a big difficulty in approaching new people." _
4. Focus on therapy
This theme referred to Eleni’s therapy and to the realizations she made through the therapy process. It also highlights the importance of the group in the therapeutic change.
- Therapy as a vehicle of understanding
Through therapy, Eleni managed to connect panic attacks to the events that have stressed her, helping her to give meaning to her reactions.
"… I can't always find it. But I am trying (laughing). That's it. To find the reason. Yes, this is the instruction. This is something that… my therapist has also mentioned. That when this happens, I should ask myself why it happened so that I break the chain of this vicious circle. To try to find the reason why this happened to me, so that I know there is a reason behind it and stop thinking that it will happen again tomorrow. So that I know there is a reason for this."
- Therapy as a supportive context
Eleni managed to find support and help through group therapy. This was especially important for her since she had spent the longest part of her life being self-dependent.
"Sometimes I would leave in the middle of the group therapy and go to another room to… take a few breaths because people were… we are seven people in the group and I couldn’t handle it. But… the group's presence helped me a lot, in that… I managed to relax around other people, opened myself to others… Basically, people whom you didn’t know showed affection to you which was very touching and supportive. Being supported by people who don’t know you whereas people you do know and are closer to you… are not that supportive. So, I guess that if I didn’t have this kind of encouragement, I wouldn’t have opened the door to an understanding of what’s going on".
**Metaphor ** " In a whirlpool "
In her interview, Eleni referred to a metaphorical image, which seems to express her experience of a panic attack:
Eleni: "… It feels like a whirlpool, inside my head. Yes, like a sudden wind that blows really really hard and makes a mess of everything. Of my mind and everything else."
**Researcher: ** And where are you?
**Eleni: ** "Right at the center of it all. Yes, yes, it comes and blows you away… and twists you. Just like that. I have this image in my head right now; It’s… twisting you suddenly, out of the blue. Very suddenly and unexpectedly. But it’s more like making a mess out of you. At least that’s how I see it. It won’t manage to break you in the end… Or at least that’s my experience".
Panic attacks were experienced by Eleni as a whirlpool affecting her everyday life, driving some people away from her and isolating her. The world seemed to be a threatening place and eating was a life-threatening process for her because she could not enjoy her life. Being stress-free was not an option and, as a result, she was always tense. However, panic attacks also served as an "alarm" that helped her realize the relationship patterns she was following in her life, the situations that put her under pressure and several stressful factors. They motivated her to begin therapy, which helped her understand and start processing facts and emotions by giving them personal meaning. Eleni’s important step forward was that she managed to process and accept her deeper feelings instead of placing all her feelings and fears in the possibility of having a panic attack (Androutsopoulou, 2012). Therapeutic work served as a restorative experience for her, as she finally got the support she needed from people unknown to her. In her narrative, one could see how she linked group therapy factors with her change and the symptom of relief such as universality, corrective recapitulation of the primary family and group cohesion (see also Yalom & Leszcz, 2005).
Furthermore, the interpretation of the analysis which followed the systemic approach and the attachment theory converges with the findings of previous studies. To be more specific, Eleni’s difficulty to express disagreement, assert her needs and communicate a wide range of feelings are related to understanding the symptom of panic attacks (Williams et al., 1997).
Finally, in Eleni’s case, family seemed to play an important part as far as her difficulty in processing negative emotions is concerned (Androutsopoulou, 2012; Oppenheimer & Frey, 1993) and contributed to her sense of lacking a secure base (Brisch, 2012; Byng-Hall, 1995). It also seems that the lack of a supportive social network which can offer understanding and acceptance played an important role in her difficulty to manage stressful events during her adult life (Androutsopoulou, 2012).
The findings of this study can be used to enrich clinical practice with in-depth observations and suggestions for a better understanding of similar cases.
Firstly, through the analytical description of various symptoms, we can facilitate the detection of less common panic manifestations. For instance, in Eleni’s case, the difficulty in eating was put under the general category of panic-like symptoms.
Secondly, emphasis is given on how the therapist can find areas where he can focus his interventions through the investigation of aspects of the patient’s experience, i.e. the emotionally secure family climate.
Another important aspect shown in this study is how a panic attack can be positively experienced by the person, contrary to the common perception of therapists that panic attacks are seen in a negative way. As a result, it may not be necessary to reframe when examining a patient’s different views of the symptoms, as the patient might be ready to provide alternative interpretations by himself.
In the end, as already stated, the important role of the therapeutic relationship is underlined along with the function of group therapy as a source of support and as part of the process of therapeutic change.
Suggestions for further research
Even though case studies are powerful as they contain rich and complex information (Smith et al., 2009; Yin, 1989), further case studies of clients with recurring panic attacks would be helpful so that the meanings identified in the current contribution could be explored in more depth and restated (McLeod & Balamoutsou, 1996). Furthermore, future studies could use different methods of qualitative research to explore meanings and experiences, such as the method of narrative analysis, in order to emphasize the importance of the development of the stories in time and the social context.
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