Years of working with persons suffering from test anxiety and other forms of anxieties around performing (stage fright, music, acting, interviews) have led me to develop a nine stage approach, which can be flexibly adjusted and “tailored” to each person’s specific needs & style. Several practitioners have utilized different aspects of relaxation techniques and hypnotic imagery and suggestion to enhance performance and reduce anxiety. This paper will describe the deliberate application of an elaborate procedure which has produced very good results with a wide range of persons suffering from performance anxieties.

For several years now, I have been working with a wide variety of patients which have, as a common denominator, anxieties around performance. The latter, in turn have brought about the development of patterns of avoidance, a decrease of self esteem, and a sense of stagnation and paralysis in situations requiring the specific performance. As I began to take on their challenges, these patients led me to develop a nine step procedure which has led to very promising results. This paper will describe and elaborate the issues involved in working with these patients and raise questions about the directions which I have been “led” to develop.

 

Patient population.

 

The story began with a flurry of high school students referred to me a couple of months before their matriculation exams. Each had displayed an ongoing pattern of test anxiety for years, exacerbated by the extreme pressures around the preeminent matriculation exams. Meeting their challenge led me to gather different techniques, including the personalization of the latter to each case. Being the son of a tailor made it feel quite natural to “tailor” my approach to each person. Next came several musicians with various levels of stage fright as well as general inhibitions severely constricting their developing their musical skills. Patients with fear of presenting before audiences, different combinations of speaking before groups of persons followed. Next came a long line of graduates (Medicine & Law) who were failing their final residency exams. One specific sub-group consisted of Russian Immigrants whom had already practiced Medicine in Russia, and whom were being forced to start over again in a new language and orientation. As they began to succeed with their exams, they began to refer other colleagues. The last subgroup consists of a cluster of young, bashful men in their twenties, who function well until they have to face a woman. They all are passive and paralyzed when it comes to approaching women. This brings us to consider the extent to which this population consists of one or more diagnostic categories.

 

Diagnostic considerations.

 

It would seem that most of the patients described are suffering from a form of social phobia, which is characterized by a specific situation or demand characteristics. These patients fulfill all eight of the criteria listed in DSM IV for Social Anxiety Disorder (300.23). Whereas most of the patients have displayed adequate social functioning, abilities to interact freely with others, form close friendships and relationships with the opposite sex, all tend to “freeze” in a specific situation which entails performing in relation to/or in the presence of others. Osborne & Franklin (2002) examined the similarities of Rapee & Heimberg (1997) model of anxiety in social situations in music performance anxiety, & found them to be identical, thereby concluding the feasibility of including musical performance anxiety as a sub-type of social phobia, rather than a discrete phenomenon.

The last group of young men seem to be in a different category, as they tend to be suffering from a more generalized type of social phobia, even though I have included them, as the stimulus is specific, i.e. the opposite sex.

 

Common characteristics.

 

As I think about the population described, I can discern several common characteristics which apply to each one:

Each first and foremost exhibits a great amount of low self esteem and lack of confidence in the specific area of performance. However, upon further thought, it turns out that it is more accurate to contend that they are “suffering” from overconfidence! In fact, each is absolutely sure that he or she will not be able to……! So much so that I found myself challenging this absolute position (see the first step described below). In fact, they are characterized by a great tendency towards rigidity and dichotomous thinking: either or, all or none. There is no middle position, no gray areas, all is black or white.

The all or none predisposition goes along with perfectionism. Each strives to do more than the best. If their performance isn’t excellent, then it isn’t worthwhile at all. They have been brought up or have identified with figures who have had high aspirations.

Many have narcissistic issues: They display an inner need to impress, to overpower with their fantastic performance, to entertain grandiose fantasies of success. This brings each and every one to the other side of the coin: to feel actually inferior, small, unable, depleted and empty.

While each is very pre-occupied with succeeding, one gets the impression that there is an underlying fear of success. That actually, the deepest threat is of overcoming all of the constrictions and limitations. What is the symbolic outcome of success? Is it surpassing an important figure? Is there an aggressive component to achieving more than the latter? Are these oedipal issues?

 

The literature

 

A perusal of the literature of the treatment of performance anxieties reveals an abundance of evidence of behavioral interventions, some of pharmacologic intervention, and a trend towards relaxation & meditation. Of the studies relating to hypnotic interventions, most relate to test anxiety.

Prior (1990) utilized an Ericksonian approach in treating examination panic. He used exaggerated information gathering (worst case scenario), developed how to fail questions, instituted time distortion, relaxation, automatic writing (your pen will finds its way by itself to the most appropriate answer) , and time progression to achieve quick results, as most clients turn for treatment close to the exam date. Prior especially emphasized a therapeutically relevant diagnostic stage as enhancing rapid results.

Likewise, Stanton (1996) emphasized speed in proposing a “15 minute solution”, though the time frame consisted of the time that the patient practiced a combination of NLP techniques including the Switch (Zarro & Blum, 1989) (wherein the patient visualizes unwanted behavior in bright colors & desired behavior in black & white, which are switched upon the therapist’s clapping his hands), positive anchoring, belief installment & a rapid induction consisting of an EMDR variant focusing on moving hands. Stanton achieved significant results between the experimental procedure & controls.

Sapp (1991) utilized a cognitive-behavioral hypnosis to significantly reduce test anxiety in his subjects (0ver 4 sessions). Hart & Hart (1996) used a 30 minute hypnotic procedure during an examination anxiety workshop to induce relaxation and to modify attitudes about examinations.

Gruzelier et al (2001) compared self hypnosis instructions of enhanced immune function, with relaxation, finding the former to have greater effect upon health and mood and general well being at exam time in med school.

Laidlaw et al (2003) found self hypnosis as well as Johrei (a Japanese method of enhancing well-being) to buffer the effects of exam stress upon mood of students.

Some studies focus upon work with musicians:

Oliver (1997) found relaxation methods (progressive relaxation, bio-feedback, meditation & deep breathing) to be most effective with Hornists (vs. pharmacological & cognitive-behavioral therapies. Grishman (1989) found progressive muscular relaxation to be effective in reducing physiological, cognitive and behavioral symptoms of anxiety in performing musicians. Chang (2001) found nearly significant results in using 2 meditation techniques to reduce performance anxiety in Music Students. Likewise, Taylor (2002) investigated the use of meditation in reducing anxiety in singers. She found a majority of respondents to report that they had used forms of creative imagery with a high degree of success.

Two studies relate to sports performance anxiety.

Wojcikiewicz & Orlick (1987) received mixed results with fencers as to the relative effectiveness of post-hypnotic suggestion vs. relaxation with suggestion as to perceived level of competition anxiety, task difficulty as opposed to actual performance. Lodato (1990) found the addition of self-hypnosis training to increase the effectiveness of hockey performance when combined with behavioral rehearsal and visualization

In summary, we find components of hypnosis, relaxation, visualization, behavioral training and attitude change to be incorporated in the aforementioned studies as effecting reduction of anxiety in the various areas of performance anxiety. All of these components have been incorporated in my approach.

 

The Approach

 

Before I describe the various components of the approach that I developed over the past 15 years of work with patients suffering from performance anxieties, it should be noted that I am describing nine steps or stages in a general treatment approach, which functions as a general guide. With each patient, I have to tailor the approach to his or her needs, personality and style. I find the usefulness of a treatment framework to be a guide, its relevance to be reaffirmed with each case. Though I don’t use every stage with every patient, in most of the cases, it has been fully implemented. Thus I decided to present it here in it’s entirety.

The title of the paper needs here some amplification. Techniques aside, I find that what I am trying to repair in preparation for successful performance, is a weakness or basic injury at some level of the patient’s sense of being. All of the aforementioned characteristics (self esteem, narcissism, need for perfection) point in some way to a reservation as to how good these people feel about themselves. As these are generally well-functioning people in most areas, we are talking here about a partial reservation which seems to be acting as a sort of “Achilles tendon”.

 

Loosening the certainty of failure

During the first stages of meeting the patient suffering from performance anxiety, it becomes vividly apparent that the area of difficulty is presented as impossible to surmount, yet with an absolute degree of certainty. That means the person is absolutely certain of not being able to perform the specific task. Therefore, I set out from the outset, once this picture becomes clear, to attempt, already during the intake process, to instill a sense of uncertainty and doubt. “I must say that I seldom meet people who are so sure of themselves!”” Isn’t there the slightest possibility that you might slip up sometime and succeed by mistake, as a fluke?” White & Epston (1990) inquired, following the externalization of the problem, whether the person ever succeeded in tricking the problem just once?These are suggestive directions which tend to reduce the totality and eventuality of the problem. Prove to be useful here as well. I must emphasize here that this a pre-hypnotic intervention, phrased in paradoxical terms as a reframe. The result is quite a lot of confusion.

 

Galli, a Russian immigrant doctor who had twice failed her oral residency exams was totally resigned to her fate as a failure, though she very much wished she could succeed. Her stubborn clinging to feeling of failure reinforced a depressive outlook and elicited much disphoric affect. Relating to her “certainty” was interlaced throughout every phase of the treatment, so much so that we were both surprised when she passed with honors! I am emphasizing here the role of repetition and perseverance in an atmosphere of a power struggle: who will persuade whom? (see discussion below).

 

Reframing of past concepts of self hypnosis to include phobic behavior

The second stage is still pre-hypnotic. During the history taking, as I get into specifics as to the difficulties and the symptom picture, I strive to explain the various phenomena as a sort of expression of hypnotic ability. This reframe has two aspects.

During the process of preparing the patient for hypnosis, we (in Israel) are bound by our Law of Hypnosis to fully explain the process. Here, I introduce the explanation that the patient is actually already quite an expert at hypnosis. In fact, what is experienced as distressful, is a result of some unconscious activity on his or her part. As the hypnotic process is already in use, it becomes easier to explain what hypnosis is, and to distinguish between positive and negative self-hypnosis.

To raise the awareness that hypnotic phenomena are in play, and are actually being elicited through a self-mechanism, is to invite the possibility, which therefore need not be remote, of gaining control over the hypnotic process, and thereby over the distressful phenomena.

 

Irma, another Russian immigrant doctor was very pessimistic about her chances after twice failing her orals. As she was describing her last exam, she was able to recognize that she actually entered a very definite trance state, which denied her access to her knowledge and ability to explain. The explanation that we would therefore be placing the emphasis upon de-hypnosis, exiting the trance state into which she automatically entered was eagerly accepted by her, and began to give her some hope.

 

Future Progression to a point in time following success

I often introduce, at the beginning phase of hypnotic work (following a general introduction with progressive relaxation work) an exploration of the extent to which the certainty of failure has begun to loosen up. This I have found most effective by using the age progression technique (Erickson, 1980). I thereby explore the motivation for improvement, and the extent to which the patient can “entertain the possibility of succeeding” The way I have developed the technique is as follows:

 

I create a comfortable setting within, with focal attention set upon a screen. “Soon, a picture will appear. of a scene sometime in the future. I don’t know how near or how far, but there is a good chance that a picture of your face will begin to appear. You might be pleasantly surprised to discover that it is your face smiling a smile of contentment and pride, because it will be your face after you have overcome your difficulty! When a picture comes up, give me a sign…yes it might be quite a wide smile, because you really deserve to feel proud after all of the time you were suffering! ({Almost every time, this clear leading suggestive approach leads to a picture of the face with positive affect. If a different image emerges, I accept it and deal with it accordingly}. Great, now let yourself really absorb this picture, paying attention to the minutest details of your expression…and when you’ve really take it in, why don’t you press the appropriate button on the remote to zoom out the picture, so that you can take in the bigger picture, the setting in which you are after you have overcome your difficulty. Let me know when you see it. Great, now describe it to me. (I then proceed to relate to the patient’s description reinforcing any positive productions.) When the production seems stable, I invite the patient to shift from the spectator position, to the experiencing mode. I would like you to try to step into the picture, and really feel what you have been watching. When you really sense it all, let me know. {At times, the patient might find it difficult to achieve the ego experiencing position, and we will end the procedure here with full reinforcement of what has been achieved. Often, the patient succeeds really entering the picture, and we proceed as follows:} I would like to invite you now to experience something really special. I would like you to look back in time, maybe to the days when you sought help for your problem, when you were so exasperated and doubtful as to your ability to succeed. Then I would like you to see a series of scenes, each one consisting of a step forward that you took, until you reach today, after you have solved the problem. This is something like Ingemar Bergman’s “Pictures of a Marriage” (I give a short explanation of the film, especially of the discrete scenes representing ach time you see a new stage or scene, let me know…Great, now describe it to me. We continue exploring each scene till we reach the “present” which is in the future. This procedure can of course develop over more that one session. If there is a need to finish before completing the entire sequence, I invite the patient to insert a “bookmark” so that it will be possible to continue right where we left off (if it is relevant!). When the entire procedure has been completed, I reorient the patient progressively to return to the present, while reinforcing every positive aspect of the experience, as being now an active part of his or her potential

Eddie, a pianist suffering from stage fright as a lecturer, and difficulties in forming a relationship with a woman was able to see himself with a woman, with background music of Chopin. This had previously been his safe haven in the positive anchor. However, he was unable to “see ahead” from this scene, to envision “a future” with this woman. He thereby again gave an indication of hypnotic ability which he needed to block and prevent fulfilling a relationship. Characteristically, he broke off the treatment before completion as he was not willing to touch deep seated issues within the family that led to the development of the phobias.

 

Galli had her first breakthrough in the therapy process as she was able to experience assertiveness and determination for the first time in the context of an exam which she saw herself passing. (an accurate “prediction” of her eventual success).

 

This procedure exemplifies one of the components of my approach with these patients: I am very suggestive and uni-directional. I repeat the same message over and over, that you can succeed, and it begins with entertaining the possibility. Of course, if I see any signs of discomfort, or if the patients bring up different images, I invite them to make room and give respect to any needs they might have not to succeed. In such a case, I will shift to hypno-projective techniques to allow a full exploration of the issue.

 

The age progression technique allows to hypnotically test the extent of the patients’ motivation to overcome their problem, to assess the extent of hypnotic ability (focus of attention, imaginal production and absorption, ability to shift from observer to experiencing, flexibility to move forward as well as back in time), and to gage the coping capacities, allowing the patients to suggest possible critical factors in the process wherein they succeed in overcoming their difficulties. Usually, patients are cooperative and successful, and experience a real surprise. This provides a further reinforcement, and usually begins to fortify the therapeutic alliance.

 

Creation of a positive anchor (resources/setting which fosters success)

A vital step in the direction of enhancing the belief that the patient has a chance of succeeding, is to enable a connection to abilities and capacities wherein the patient feels confident, successful, and especially relaxed and able to “flow” without extraneous self-consciousness. This is most efficiently achieved by “installing” a positive anchor (Grinder & Bandler, 1981) to such positive resources;

 

I would like to invite you to approach the gate to the reservoir of your memories. When you reach it, try to pull out an event wherein you felt natural & at ease. So much at ease, that whatever you did or attempted to do went so smoothly & effortlessly, that it was very successful. This is the kind of event where only in retrospect, do you begin to grasp how much fun it was not to think about it, to think what others thought about you, but just to flow & enjoy what you were doing, probably just to be yourself. When you’ve found an event that matches my description, or feels right, let me know…Great, now allow yourself to really experience all of the aspects and dimensions of the event. What you see, hear, feel, smell, taste. When you really feel the flow, the ease, the enjoyment, the satisfaction., let me know….great, now I’d like you to make a kind of personal reminder of this state of being, by making a personal sign in your (dominant) hand, such as gently bringing your forefinger & thumb, as a kind of symbol of connecting, feeling together. Great, now play with it a bit, making it stronger as the feelings intensify, looser as they subside a bit. Right…Stay with the feelings until they reach a natural conclusion. Only then, release your personal sign. In order to really increase your ability to access these wonderful feelings, you’ll want to practice, just like we’re doing now, later when you’re on your own. What’s important is to choose a different event, with the same general feelings. Or, if you happen to naturally experience the same kind of flow, make the sign.

 

Irma began the exercise quite depressed. Surprisingly, she was able to let go of her mood and connect quite deeply to entering a forest, and really being totally within, accompanied by a floating feeling. Being in the forest led to a series of different strong emotions. Her experience in the forest became her connection to flow and freedom, and turned out to be a clear turning point. The next week, she seemed clearly out of her depression, having begun several activities. We were able to continue to use the forest as a place for integrating resources. Two weeks later, she passed her exam with top grades.

 

Mirna, another Russian immigrant doctor had also failed her orals for her residency. She chose swimming in the sea for her anchor. The floating in the sea, along with feelings of calm and flow became her symbol and setting for integration. The best phrases just seemed to float to the surface effortlessly. Again, this became a “predictive” experience for the actual exam that turned out successful.

 

This is the first time that we begin to touch upon enhancing a comfortable sense of being. We are reinforcing confidence and self esteem, while still staying away from the difficult situations wherein the problem arises. As I have mentioned before, these are people who have shown competency in other areas of their life, so that this step is not especially difficult. What is important here is the emphasis upon flow, natural, comfortable, at ease, each of these being diametrically opposed to the feelings aroused in the situation. that tends to arouse the anxiety. This is also the stage where self-hypnosis is encouraged. While this is standard practice with most patients, it is especially crucial here that the patient begins to feel control over the techniques, and to personalize them in order for them to be available later on when called upon to perform.

 

Creation of negative anchor (arousal of the anxiety response, and channeling it out)

After making sure that the positive anchor is well in place, and that the patient has practiced, we move to approaching the anxiety provoking situation, by beginning to teach a first means of obtaining some control, some means of modulating the overwhelming affects & sensations that are aroused. This we achieve by now installing a “negative” anchor:

I’d like you now to get comfortable, and return to the gate of your memories. This time, I’d like you to choose one of those events that you’ve already mentioned to me, where you begin to be overwhelmed by those feelings. It could be the last time it happened, or one of the strongest times. When you’re there, let me know…Great (I apologize here for inviting distress, but explain that the aim is to gain control). Now allow yourself really to experience the event & the feelings aroused. Try to notice if there is any specific part of your body where you feel the strongest? (When signs of distress begin to emerge) Good, now that I see that you’re really allowing yourself to experience, I’d like to invite you to make a fist in your (non-dominant) hand. Good. Now really increase the pressure in your hand. You’re beginning to send out the message to the rest of your body, that you taking charge. You decide when to apply the pressure. Slowly, you might imagine how those sensations and feelings in the rest of your body are beginning to move towards your hand. Continue till a significant amount has reached the palm of your hand. Only when you feel that your hand is bursting at the seams, that it’s really enough, then begin to open your fist, thereby releasing all of the extraneous feelings that you were able to gather within. Great, now really shake your hand, letting each and every drop fall, till there’s nothing left. Now let yourself get back to your center, to a point of balance. You can unwind now and get yourself relaxed. . In order to really increase your ability to access the ability to gain control, you’ll want to practice, just like we’re doing now, later when you’re on your own. What’s important is to choose a different event, with the same general feelings. Or, if you happen to naturally experience the same kind of pressure, make the fist.

Progressive work with Galli on displacement and attenuation was also provided by using the Hot air balloon technique (Livnay, 1996). She saw herself throwing out the sacks filled with tension and anxiety. She was so freed by this experience, that she was able to achieve her first considerable dissociation of letting herself really take off, high and away without being aware of where she was.

 

This stage marks the first meeting of the anxiety-provoking situations under hypnosis. From the outset, we aim to begin to attenuate the symptoms of anxiety by simple displacement, using a combination of kinesthetic and imaginal dimensions. The making of the fist provides a certain “pace” to the general anxiety, and the relief by releasing the fist is the lead. Both anchors involve simple Pavlonian conditioning by repeated trials. In this case, we use a two stage conditioning: First to gather (and displace), then to release. Again, self-hypnosis is encouraged.

 

Rehearsals of positive performance

After the anchors have been reinforced, and the patient shows signs of learning, we move on to using hypnosis to provide a studio or stage for experimentation. Baker (2000) proposed understanding the hypnotic experience and hypnotherapeutic relationship as providing a sort of transitional space, in Winnicott’s terms. This transitional relatedness between the two parties fosters the maturational process. As we embark in the rehearsal, we begin to accompany the patient in imagining the performance, this time in a positive manner. This can entail many retakes, and in this sense can be seen as a form of a refractionation technique, going in & out repeatedly, thereby deepening the hypnotic effect with the therapist actively providing reinforcement for change in the performance. There is much value in the patient experiencing the previously frightening experience in the company of the therapist, sensing the support and participation in dealing more positively with the anxiety-provoking situation.

 

Treatment of examiners & judges.

One of the sources of anxiety in performing, and especially in examinations is preoccupation with the examiner or “judge”, what he or she thinks, how he or she is assessing performance. In general, the patient suffering from test anxiety finds the examiner to be an intimidating figure whom is perceived to be rejecting, critical etc. On a dynamic level, we can conceptualize a mechanism of projection of self-critical attitudes upon the external figure, and can ponder whether furthermore transferential processes have been activated, from possible significant figures in the patient’s past (i.e. Parents, grandparents, uncles or aunts etc.). These are themes to be explored, discussed, and to be worked through.

However, as a starting point, I strive to achieve a kind of defusing or depotentiation of the intimidation, by inviting the patient to imagine the target figure in a bit of ridiculous or humorous light. The aim is to bring across the suggestion that the examiner is just a fallible human being, like you or me, with two legs etc. This can be achieved by visualizing the figure with an open fly, or tuxedo with short pants, or…I begin to give examples of absurdities until the patient gives out a laugh.

A second means of bringing the figure down to size is by reframing the situation by emphasizing the examiner’s tensions, anxieties or insecurities, and setting the task as such that the patient attempts to soothe and relax the examiner.

In working with patients who have failed several driving exams, I invite them to think how the examiner feels, as he is at the patient’s mercy, not knowing if he really knows how to drive, whether he will be able to safely complete the test without placing the examiner at risk & etc. Please try to look at the subtle signs of worry & insecurity, in his eyes, posture, gestures & speech. Try to be understanding and try, through your competent driving skills, to ease his mind! Try to notice, as you relax, and begin to drive smoothly, with growing confidence, how he seems to begin to respond by sitting back just a bit more, sinking into the seat just a bit more content and relaxed.

In working with schoolchildren towards exams, I ask them to consider how anxious the teacher is that all of the children get good marks on the exam. Actually, your teacher is totally dependent upon you, upon how well you do. Do you know what her grade is? (bewilderment) Well it’s quite simple. It’s just the average of all of the children’s grades on the particular exam. While you’re in the driver’s seat, actively doing the exam, your teacher is passive and totally helpless! Poor woman. Maybe you can do your part in helping her to relax, by simply relying on what you already know, and letting yourself simply meet the questions with the knowledge which you’ve accumulated while studying.

Mirna was quite caught up with feelings of being threatening to female examiners. (She was quite naturally endowed and not modest about it). Though she never entered deeply into trance, she went with the orchestra conductor metaphor which I use, getting absorbed in the fantasy of positively affecting the examiner, and even getting her to dance during the exam!

These paradoxical interventions exemplify the hypnotic approach. It is not enough to talk about. That is helpful (pre-hypnotic suggestions) for preparation. What is essential is bringing the patient to experience the changed view of things, to actively participate in this new drama!

 

Visual & auditory effects in the “treatment” of the audience.

A similar dimension to the foregoing, is the preoccupation with the audience, this being specific to those performing before a public (musicians, public speakers, actors etc.). Again, psycho dynamically, there is a projection of the self-critical function onto that of the spectators. It has been shown that those suffering from social anxiety have a distorted view of other’s judgments of themselves. I find again and again, that those patients suffering from social anxiety have ‘ideas of reference”. Though not psychotic, they are overly concerned with others’ opinions of themselves and their actions. They actually place themselves in the center of the universe, as if everyone else is mainly concerned with them and their actions. Part of the treatment entails adjusting this distortion. Of course, we return here to the narcissistic dimension of the problem> The need to impress and be noticed, loved and to overwhelm the audience, which leads to the counter-position of feeling inferior, little, humiliated and ashamed. Though all of these issues are addressed in discussion, reflection and interpretation, the hypnotic work begins with a defusing and attenuation of the audience effect.

 

 

I invite the patient to create the setting wherein he or she feels comfortable (re-invoking the positive anchor) and able to smoothly perform. When this is stabilized, it is anchored. Then I invite the patient to imagine the audience, and next to superimpose the picture and experience of the positive setting, thereby eliciting a partial negative/positive hallucination. That is, we reduce the negative dimensions and enhance the positive dimensions. Alternatively, I may invite the patient to concentrate upon the audience, and to choose a certain spectator. When zooming in upon this person, the patient might begin to play with his perception of that person, distorting him along the lines described for the examiners, or “taming” them in seeing them especially enraptured by the patient’s performance. This of course means indulging in the narcissistic fantasy, which will lead to an interesting discussion following the hypnotic work.

 

Ned, a 17 year old played in a band as a drummer, and suffered from stage fright and from an attentional disorder (ADH) . His focus was upon being overly self conscious about the audience. After extensive preparations with relaxation and rehearsal, we began to “play with the audience”. I had him fantasize seeing several different students (student audience) being put into trance by his drumming. He was invited to begin to elicit different effects in the particular individuals. He became quite empowered by the imagined effects, overcoming his previous over concern. The night of the performance, he “forgot” the audience, and found himself totally focused upon the music and the interaction of the band.

 

 

“Dress rehearsal” with suggestions of positive discrimination (this time, you can ….)

 

The final stage before an actual performance or examination, is bringing together all of the previous components into a running through of the dress rehearsal. Throughout the rehearsal, I will repeat the suggestion that this time will be different, this time you will succeed in endless variations.

 

 

I begin the rehearsal inviting the patient to imagine the day prior to the event. I suggest special self treatment all along the way, in the direction of “spoiling” oneself, being kind and positive. The previous day is usually the time to complete the preparations, reinforcing positive study habits and so forth. The evening before is a time to unwind, and maybe do something special and different, out of the ordinary! The normal ritual before sleep will be changed somewhat, leading to a restful night’s sleep’ with constructive and supportive dreams. Waking up the day of the event leads to another change in routine, maybe a special shower, something special for breakfast. We move on to preparations for leaving to the event. The patient is invited to take something special, that will be useful for the performance. The way to the event is a further opportunity to signal difference. The patient is invited to take a slightly different, more innovative  route. Entering the building might be through a different entrance. Eventually, we reach the performance itself, which we will have rehearsed already often in the past. This is the time to utilize all of the tools and effects learned, with might encouragement & accompaniment. Completion will elicit proper and positive response (audience applauding, going over the exam and being pleased, etc.). Upon leaving, following the sense of relief and pride at a positive performance, the patient is (when appropriate) encouraged to experience celebrating the success following the performance (the risks involved will be discussed below). During de-hypnosis, further reinforcement is given for positive changes, innovations, and post hypnotic suggestions for generalization and positive actual outcome (because now you are really ready to succeed). During all of the rehearsal processes, whenever there are signs of regression or failure, there is opportunity to explore (ideo-motorically or in discussion) the possible unconscious fear of success.

 

 

Discussion

 

Though the approach has led to highly successful performance on the part of most of the patients, some questions arise about certain aspects of the approach.

 

Throughout, I emphasize an optimistic outlook, based upon a belief in the patient’s capabilities and resources. If I am convinced that the basis of the patient’s difficulties lie in conflicts and needs to constrain or block success, and not in low potential, inadequate skills or resources, then I consistently reinforce the possibility which I want to transform to the probability of future success. By constantly repeating these suggestions, I am hopefully creating a new supportive environment for the actualization of the patient’s potential. Three questions emerge at this point:

 

 

1. Am I just replacing a parental pressurizing figure by continually repeating my urging that the patient can succeed? If I am actually re-enacting a previous dynamic, then the issue will emerge, and can be worked through by exploring transferential/counter-transferential aspects. The hypnotic medium is very useful for working through such themes. I am reminded of Diamond’s (1987) excellent description of the relational dimension of the hypnotic relationship. While he emphasized the amplification of transferential themes in the patient as the first dimension, I may be expressing a parallel dimension of the therapist’s trance, in the amplification of counter-transferential themes (see Livnay, 1992, 1995 & 1996 for elaboration).

 

 

2. Am I setting up the patient for a possible letdown, in case of subsequent failure, with consequences of a depressive reaction and reinforcement of feelings of failure and inferiority and incompetence? In the few cases where the next performance or exam was not successful, I related to the event in a positive and constructive manner, alongside reflecting the patient’s disappointment in the result: “We’ve been given an opportunity to refine our efforts by learning from what didn’t work this time. Let us look carefully at what exactly happened here, so that we can learn from it. We learn much more from our mistakes than from our successes!” My experience has been that whenever I continue to be open and responsive to the patient, there is room for positive development. In cases where short-term treatment does not lead to the desired results, I have found that if we have a positive therapeutic alliance, then more general psychotherapeutic exploration is indicated and becomes fruitful.

 

 

Jack turned for treatment in the later stages of his medical studies, reporting a lifetime of test anxiety alongside good academic achievement. Hypnotherapeutic work helped him in several stages to finish his studies, and to advance to interning & residency where he tended to excel beyond all comparisons. He returned towards the end of his residency while contemplating taking the final exams. This time, we combined specific training with general exploration of themes, as his father happened to have died suddenly before he came. Despite positive work, he did not pass the exam, and we continued more long-term, general work, integrating his hyper-functioning and overwork with his unconscious need to restrain himself in exams.

 

 

3. Does the positive and directive orientation leave room for psychodynamic exploration of conflicts and unconscious needs? I have attempted to express throughout that a positive and optimistic orientation does not preclude ignoring “resistances” and “regressions”. On the contrary, I welcome setbacks as an opportunity to “fine tune”. This leads to listening, looking, inviting internal dialogues by using hypno-analytic tools as well as the Gong (Livnay, 1995).

 

 

Rina turned to treatment because of stage fright as a pianist. Though she rather quickly responded to hypnotic work by becoming freer on stage and to begin to achieve her potential, she chose the Gong as a non-verbal medium to do important symbolic and in-depth work into the complex roots of her difficulties.

 

Ron was nearly paralyzed by the thought of his Bar Exam. Though he progressed very positively with the various methods aforementioned, he regressed close to the exam date. We began to explore the conflicts using the pendulum, thereby integrating a highly important factor of a close family member who was proving to be a competitive barrier. Working through this issue paved the way for his passing the exam.

 

 

In summary, the method proposed in this paper has shown very positive results, and can provide a general framework for treating patients suffering from a wide range of performance anxieties. While the emphasis has been focused, directive, leading and short term, when appropriate for the specific patient, there is room for longer-term exploration. The bottom line always has to be of the therapist being in tune with the patient’s needs, and not with fitting the patient into the therapist’s method. As long as the therapist remains open, accepting and supportive, the patient will go along and even thrive from a positive leading direction, thus leading to a maturation which previously was not extended to the area in focus in the therapy. The enhancement of “being” during the interaction with the therapist, within the transitional space provided by the hypnotherapeutic experience fosters the corrective experience that enables the smooth “doing” required in the performance. This paper is intended to invite further exploration of the issues raised here.

 

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