--- title: "Panic attacks: a strategic protocol for the first three sessions" canonical: "https://strategictherapy.eu/panic-attacks-strategic-protocol/" lang: en description: "In panic disorder the effort to prevent the next attack keeps the alarm primed. A three-session strategic structure, and an honest account of its timeline." author: name: "Maurizio Iengo" url: "https://strategictherapy.eu/author/strategictherapy/" title: "Psychologist" registration: "Ordine degli Psicologi della Regione Campania 9624" date_published: 2026-09-19 date_modified: 2026-09-19 publisher: "Strategic Therapy" section: "Clinical applications" keywords: "panic attacks strategic therapy protocol" --- # Panic attacks: a strategic protocol for the first three sessions > In panic disorder the client's effort to prevent the next attack is usually what keeps the alarm primed. A three-session structure, and what three sessions can't do. ## In short - Avoidance, self-monitoring and reassurance-seeking are the three solutions most often maintaining panic. - A scheduled worst-case writing task can loosen the involuntary grip of catastrophic thoughts within a fortnight. - Reassurance is reduced by delay, not by prohibition. - Three sessions can start the change; published case reports describe full remission taking considerably longer. Ask a client with panic disorder what she does to stop the next attack and you get a long list. Avoiding the places it happened. Scanning her heartbeat for the first irregularity. Keeping a phone, a companion, a strip of medication within reach at all times. Every item on that list exists to prevent an attack. Together they are what keeps the alarm primed. ## Three solutions worth separating Panic is usually held up by some combination of avoidance, self-monitoring and reassurance-seeking. Avoidance covers places, activities and sensations linked to a past attack. Self-monitoring means scanning the body for the earliest signal, which reliably manufactures the sensations being watched for. Reassurance-seeking means checking with a doctor, a partner or her own memory that everything is fine. [Which of the three dominates](https://strategictherapy.eu/?p=35) decides which prescription comes first. ## Session one: name it, then prescribe the writing Once the pattern is named, often the first time she has heard it described as a pattern instead of experienced as chaos, a useful opening task is scheduled worst-case writing. At a fixed time twice a day she writes out, in detail, her worst fantasy of what an attack might do to her. This converts a thought that arrives uninvited at unpredictable moments into a bounded act performed on a schedule she controls. It is not full symptom prescription in the sense covered in [the article on paradox](https://strategictherapy.eu/?p=39), but it runs on the same logic. Deliberate repetition on your own terms drains a thought of the urgency it has when it simply appears. ## Session two: avoidance and reassurance Two or three weeks later, review the writing, then take whichever of avoidance or reassurance-seeking is louder. For avoidance, ask her to choose one avoided situation to re-enter, at a scale she picks. For reassurance, do not ask her to stop. Ask her to delay the next request by a specific agreed interval and to notice whether the urge weakens before the interval is up. Outright prohibition tends to produce covert reassurance-seeking rather than less of it. ## Session three: consolidate, and say what is left By the third session most clients report measurable reduction in frequency or intensity. This is the point to review what remains, not to close the case. Iengo’s brief conference paper on brief strategic therapy for panic disorder frames the model’s honest claim well: it improves quality of life early, which matters given how disabling the disorder is, and its brevity makes it worth considering as a first-line option. That is a smaller claim than remission by session three, and it is the accurate one. (It is a four-page congress contribution rather than an outcome study, and carries the weight of one.) The recently published case work is useful precisely because it does not hurry the ending. A 50-year-old man with daily attacks, already on medication, showed meaningful reductions in avoidance and dependence on others from the first session; complete cessation came after eleven (Martín de Pozuelo Saucedo et al., 2025). Figures summarised by Bartoli and De la Cruz Gil (2023) put the Arezzo centre’s average across all presentations at around seven sessions, though those are the centre’s own archive data rather than trial results. Three sessions start the work. [The first one](https://strategictherapy.eu/?p=42) starts it well. Neither finishes it, and telling a client otherwise sets up a slower course to be misread as failure. ## Before session one Panic symptoms overlap with several medical presentations, including thyroid disorder, cardiac arrhythmia and the effects of stimulants or withdrawal. Where a client has not had a recent physical review, arrange one before building a protocol on the assumption that the attacks are psychological in origin. This is not defensive practice. A client who half-suspects something has been missed will keep seeking reassurance no matter how well the prescription is designed, because the reassurance-seeking is doing a job nobody has closed off. A comparable arc, worked through to the end, is in [the case study on ending panic attacks](https://strategictherapy.eu/?p=49). ## Frequently asked questions ### Can panic disorder really resolve in three sessions? Three sessions can reliably start the shift by loosening avoidance and reassurance-seeking. Published case reports on this protocol describe complete cessation of attacks over a longer course, in one recent case eleven sessions. ### What if the client is already on medication? Concurrent pharmacological treatment does not rule out the protocol. Several published cases involve patients on medication whose panic had not fully resolved. ## References 1. Martín de Pozuelo Saucedo M., Aza Blanc G., Caperos Montalbán J. M., Martínez Díaz M. P. (2025). Treating panic attacks with brief strategic therapy: A case study. https://doi.org/10.1080/2692398X.2025.2590776 2. Bartoli S., De la Cruz Gil R. (2023). Epistemology, history and foundations of Brief Strategic Therapy. Giorgio Nardone's Model. https://doi.org/10.23923/pap.psicol.3009 3. Iengo A. (2020). Brief strategic therapy in panic disorder treatment. https://hrcak.srce.hr/262494