Performance Anxiety

“I wonder if you would elaborate on the issue of performance anxiety and how to treat this problem.” Thanks to Alireza for this question.
Performance anxiety usually results from one of three causes: 1) insufficient preparation: thus, the patient should be anxious; 2) excessive self-attack, leading to a distorted view of one’s capacities; or 3) projection onto the audience, viewing the listeners as a bunch of critics.
As a former professional musician, I know all about this from personal experience. And musicians know the best thing to do first is practice extremely hard to master what you will perform. Once you have done that, if anxiety persists, then it’s time to do the psychological work.
If a patient asks you to help her with performance anxiety, remember: she will experience the therapy as a performance. If she engages in excessive self-criticism as a performer, she will engage in self-attack in session. If she is afraid of how the audience will respond, she will be afraid of how you will respond. This is not a problem, but an opportunity. You will work on her performance anxiety directly in the here and now of therapy.
Pt: “I know this sounds a bit ridiculous.” [self-attack]
Th: “Could that be a critical thought?” [defense identification]
Pt: “Yes.”
Th: “Could that kind of thought be making you anxious?”
Pt: “Yes.”
Th: “Since those are the kinds of thoughts that happen in performance, could we look under those thoughts and see what feelings are coming up here with me?”
Here, you help the patient with the resistance of repression: turning anger toward you or the audience back upon herself. By helping her face her anger in the here and now rather than turn it against herself, you build her capacity. As her tolerance for her inner life increases, she will gain access to the unconscious feelings which are driving her self-attack.
Pt: “You look like you are thinking I’m stupid?” [projection]
Th: “Is there any evidence I’m thinking that?”
Pt: “No. It just feels that way.”
Th: “So even though it feels that way, there’s no evidence for that feeling. Am I understanding you?”
Pt: “Yes.”
Th: “Since this thought often happens when you perform too, could we look underneath that thought and see what feelings are coming up here toward me?”
If you can help the patient face her anger without projecting it onto others, she will no longer project onto audiences, and, thus, will no longer be scared of them. Audiences are made of people like you, students yearning to know more so they can heal patients. When we project onto audiences, they become scary hordes ready to attack us. That’s why restructuring the resistance of projection is essential to help patients overcome their performance anxiety.
There are, of course, other causes for performance anxiety. For example, facing one’s wish to surpass others or one’s family and the resulting fear of being envied and devalued as a punishment for that forbidden wish. But if you start with the first two possibilities, you will have helped the vast majority of patients suffering from this problem.

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