Category Archives: Anxiety

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.

When do you need to integrate the personality first?

Forming a relationship with another human being always triggers mixed feelings based upon our attachment history. As these mixed feelings rise, patients respond in one of five ways:

  • they tolerate the rise of feelings, sharing with you, and becoming more intimate;
  • they tolerate the rise of feelings, but start to unconsciously detach from the feelings;
  • they tolerate the rise of feelings, but start to detach from their feelings and from you;
  • they tolerate the rise of feelings, but protect you from their anger by turning it upon themselves
  • they cannot tolerate the rise of feelings, so they relocate their feelings and desires in other people.

This last group is known as the fragile group. When mixed feelings rise, they become overwhelmed with anxiety (cognitive/perceptual disruption). If anxiety continues to arise, to get rid of the anxiety, they get rid of their feelings through splitting and projection.

Once they split off and project their feelings onto others, they interact with the projections they place on other people, not with the people themselves. For instance, a fragile patient may project her anger onto others. Then she fears others upon whom she projects. Then she fears going out of her house. Another fragile patient, projects his anger upon others, imagining they are talking behind his back all the time. In response to this imaginary stimulus, he becomes chronically angry at his projection (the supposedly critical people).

Exploring feelings with this group becomes problematic. First of all, as soon as you explore feelings, the patients begin to split off their anger from themselves and project it onto others. Secondly, often, when these patients report being angry, they are reporting anger at a projection, not toward a person. If you explore their anger toward a projection, they merely become better at projecting!

Our first two tasks with this group are restructuring the unconscious pathway of anxiety discharge and restructuring the resistance system of projection. Doing these two things is referred to as “integrating the personality.” That is, we help the patient integrate within himself the feelings, impulses, and desires he formerly located in others.

Maury asked here, “When do we do that?” When patients are fragile. Signs that they need help with integrating what they formerly projected include: cognitive/perceptual disruption, splitting, and projection. Signs that patients are using projection (with loss of reality testing) are rapid speech (to keep a projection on you from criticizing her), speaking loudly (to drown out the projection the patient has placed upon you), urges to run from therapy or leave the session early (to leave the projected feeling in the room and run away from it), severe anxiety or panic in your presence (fear of the projection the patient has placed upon you).

Often, the patient will tell you about problems in her outer life that indicate projection is active in the room: “I’m afraid of people”; “I’m afraid of what people think, so I avoid them”; “I get into fights a lot”; “People are extremely critical”; “You can’t count on anyone at all”. Sometimes, projection emerges clearly in the room: “I’m afraid you will hurt me”; “How do I know you won’t misuse those videos!” “You look angry.”

One sign therapists often miss is the lack of signaling when the patient reports being angry. When the patient is angry at a projection, you will see no sighing or tensing. Why? No unconscious anxiety is mobilized because this is conscious anger toward a projection. Likewise, the patient will use no defenses to interrupt or ward off his anger toward a projection. Why? Because the anger is already toward a defense: the projection he placed on someone else.

Once you realize he is angry with a projection, stop exploring anger toward the projection, and start restructuring the projection.

Another sign is that when you ask if it is his will to do look at an important issue, he may agree, but not sigh. The absence of signaling always tells us that the patient’s will is not on line. But in this group the lack of signaling tells us that the patient is relating to a projection, not to you. There can be no conscious alliance if he is relating to a projection he thinks will hurt him. Thus, you have to differentiate yourself from his projection so he can have an alliance with you instead of misalliance with his projection. He lives in a world of projections, people he fears will hurt him. Once he owns his feelings internally, the world will become a much more benign and less frightening place. This is your first task.