Dr Robert London

Treating Stage Fright

Clinical Psychiatry News - Volume 34, Issue 2, Page 27 (February 2006)

Treating  performers with stage fright—when the anxiety and avoidance are stressful enough to become a social phobia—is therapeutically challenging and rewarding. With our help, however, many patients suffering from this disorder can learn to push beyond the phobic response and go on to perform magnificently.

Many times, DSM-IV designations are not helpful when it comes to treating patients. But I have found that approaching this problem within the confines of the DSM-IV is therapeutically rewarding.

The origins of phobias vary for each patient. The genetic model, the learned model, and the psychoanalytic approach all improve our understanding of phobias. The strategy that best conquers stage fright, in my experience, is the learning, philosophizing, and action (LPA) technique, which I developed at the short-term psychotherapy program at New York University Medical Center, in New York. The experiences of four show business people whom I've treated—two dancers, a guitarist, and a singer—illustrate this very well.

None of these patients had underlying depression or a generalized anxiety disorder, nor were they substance abusers. All four performers also had one problem in common: an irrational fear of going onto the stage to perform. In each case, their dreadful, irrational thoughts had different origins.

Using the LPA technique—in which you review the different concepts of phobia development, question why the fear developed, and then proceed to an action-based strategy—proved very helpful in all four cases.

Of the two dancers, one had the constant thought that she was overweight; the other had fallen while performing and, as a result, worried about falling again. In evaluating the dancer who felt she was overweight, it was clear that she had no underlying mental issues about weight. She had participated in extremely physically demanding work on stage. But during some segments of her performances, she danced behind a transparent curtain—which she believed showed her weight in a negative light.

She became concerned about her “show business image,” which gave her an irrational fear of performing. Further, thoughts of getting older often were on her mind before performances, which led to anxiety. As the years went by, she became less able to perform. In her treatment, the philosophizing part of LPA was as important as the later action phase.

The guitarist worried that he would lose his concentration and make errors, showing his group in a bad light. Those mistakes, he feared, would lead to fewer club dates.

The singer, who had once vomited on stage, was obsessed with getting sick.

In all four cases, the key issue was paralysis from irrational anxiety and fear, which prevented them from doing what they had to do to earn their living: perform on stage. Sometimes, when they forced themselves to perform, the anxiety went away; at other times, however, it did not. When a patient's phobic response leads to anxious states and possible avoidant behavior, clear thinking is hampered—and that, in turn, leads to errors or no shows. So each performer sought help.

Two of the patients' phobic responses had a direct relationship to the world of action. The dancer who had fallen and the singer who had become ill on stage had learned to be phobic. Directly learned phobias are the simplest to address. The learning phase and the action phase of LPA were critical to treatment for them.

The other two patients' phobic problems were more in the world of perspective. For the weight-obsessed dancer and the guitarist who feared losing concentration, the philosophizing and action phases of the LPA were the focus of their treatment.

Taking a good history and focusing on the nature of the patient's precise request for assistance—along with using sound clinical judgment focused on the problem—make for a good short-term behavior modification approach to resolving social phobias.

Whether the LPA technique, other behavioral methods, or medication is used, the focus on relieving the presenting problems is more critical than in other techniques that try to address “deeper” meanings. Those traditional techniques not only “tear down the house but the whole town as well,” as a friend I've quoted in a previous column has said (“Placing Short-Term Psychotherapy First,” CLINICAL PSYCHIATRY NEWS, October 2005, p. 28). Clearly, tearing down the entire town would be a drastic step in treating a social phobia.

In the action phase of treatment for these four patients, I used a modified systematic desensitization program, developed by Dr. Joseph Wolpe, combined with in vitro flooding and reciprocal inhibition. I have found that combining and modifying these three methods give me the best results in the action phase of LPA.

First, the patient relaxes comfortably in a chair. Then she is taught a simple relaxation technique: Take a few deep breaths; slowly inhale and exhale. Usually in a few moments, the patient finds herself in a restful state, able to concentrate on specific thoughts.

After the patient comes out of the restful stage, I engage her in a conversation about her problem, focusing on the learning and philosophizing aspects of the phobia. I instruct the patient to again reenter the relaxed state, this time doing it by herself or with only a little help. In this way, the patient learns the relaxation technique on her own and will be able to use it long after leaving the treatment setting.

Once the patient is in the relaxed state, I have her visualize a large movie screen. I ask her to project herself on this screen, approaching the phobic situation—her performance anxiety. The patient should get closer and closer to the phobic situation, really seeing it on the screen but not truly experiencing it.

The patient is leading herself into a hierarchy of desensitizations that begin to help extinguish the phobia. I add another technique in which the patient can switch the screen to a pleasant experience and take a break from the phobic scene if she wishes. This adds a reciprocal inhibition segment to the treatment program.

The patient repeatedly watches the phobic situation on the screen, with her anxiety rising and subsequently dissipating; this is called in vitro flooding. We have now combined three behavior modification techniques into one continuous action phase of the program. It's a triple-strategy therapy and, in my experience, leads to good results, particularly for performers, who have a unique ability to imagine and project themselves into different situations.

It also allows the patient to choose which action phase treatment she likes or finds most effective. When these techniques are used, there is rarely any stress on the patient since she realizes that she is seeing the phobic response on the screen.

Once I have worked with the patient long enough that she is able to practice this 8–10 times with me in the room, I let her decide which technique she wants to use most—or whether she'd rather work with a combination of techniques.

I have the patient practice these action techniques for a minute or two 10 times a day in order to know exactly what to do when the time comes for a performance and the possibility of stage fright enters the picture.

It's important to note that I used the learning phase more for the dancer who had fallen and the vocalist who had become ill on stage.

I placed a greater emphasis on the philosophizing phase for the “overweight” dancer and the guitarist who feared losing concentration. These two had issues with perspective regarding their phobia; the previous two were linked to the world of learning, since something specific had happened.

The psychiatrist's or psychotherapist's judgment and clinical skill are used to decide what to focus on in these behavioral treatments, as is the case in determining which medication model is best for these same issues. The key is to avoid the open-ended theories of conflict and conflict resolution that may lead us to the explorative psychotherapies. Too many times, that's when the house—and the whole neighborhood—get torn down. And the phobia remains.

Let me know your experiences in treating stage fright, and I'll try to pass these along to my readers.

PII: S0270-6644(06)71164-X


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