Monthly Archives: April 2018

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.

“I’m glad she’s dead!”

“I’ve gotten to the point in my training where I can start helping patients with murderous rage. However, some patients switch to a cold, hateful position toward the object, with no signs of anxiety. My thinking is that they’re splitting or shutting down their mixed loving feelings, and that portrayal of this black-and-white rage would only be destructive. I’ve tried reminding them that they are angry with someone they love. But some patients lose the anger and become anxious instead. How can I help these patients tolerate and experience their full mixed emotions?” Thanks for this important question!
In life our loved ones can only deliver, delay, or disappoint. Thus, the experience of love and anger toward the same person is inevitable. The question becomes: how do we deal with those mixed feelings? Some people detach from their feelings. Some people feel love toward us and turn the rage upon themselves, becoming depressed, suffering somatic problems. And others, unable to tolerate these mixed feelings, split them apart, and project them onto other people.
The patient feels rage toward a neglectful parent. Yet this neglectful parent almost always was at times kind and loving. The patient, when facing his feelings, feels both rage for the harm she did and love for the good she did. But if he cannot tolerate the grief, pain, and guilt aroused by these mixed feelings, he will split his love apart from his rage. He will claim, “She was never any good to me.” He will devalue her, calling her a “bitch” or worse. If he admits loving feelings toward her in the past, he will maintain that, “It was only because she fooled me.” Typical comments that indicate splitting are: “I’m glad she’s dead.” “I would just burn him up.” “I would spit on his body.” These are not expressions of guilt but of contempt and devaluation, the results of splitting.
Now he views her as “all-bad” and feels only rage toward her; no love, no grief, no guilt. Thus, no anxiety. Remember: anxiety is not triggered by rage; it is triggered by the mixed feelings of love and rage. If the patient splits his love off, and feels only rage toward this “all-bad” person, he will feel no anxiety over expressing his rage.
If we mistakenly encourage the patient to feel and express this split-off rage, we will only help him get better at splitting and devaluation! That would be destructive. Rather than explore his split-off rage, we need to address the splitting of his rage from his love. That way he will be able to face the love and rage within himself and the good and bad of the other person.
When we remind him of his love toward the person toward whom he feels rage, these mixed feelings will trigger guilt and anxiety. This is a positive sign, building his capacity to tolerate mixed feelings without splitting or projection. In the example, the patient stops being angry and feels “anxious” instead. In fact, the patient is feeling anger, plus love, thus anxiety. At that moment, simply remind the patient, “So you feel this anger toward your mother whom you love, and this mobilizes some guilt and anxiety.” Later, you can point out how he devalued his mother to avoid his love, rage, guilt, and anxiety.
Take home point: therapy is not about rage, it is about embracing the fullness of our humanity (our love and rage) and embracing the fullness of the other person, who has both good and bad qualities. If we encourage splitting, the patient never learns to embrace his humanity nor the humanity of those he loved.