Performance Anxiety - Research Paper Example

?PERFORMANCE ANXIETY Performance anxiety (PA) is a collection of cognitive, behavioural and physiological symptoms felt surrounding a performance. Atmost times, this disables the affected person to perform to the best of his abilities. It has been the interest of many researches as many people can be affected. However, differences in the definition of the disorder make studies more difficult. This may explain why studies on PA are incomparable with one another (Kenny, 2005). Barlow (2000) gives a simple explanation on the development of PA. Genetics and previous life experiences provide the foundation for PA as it produces a generalized depressed mood. Specific environmental stimuli then initiate a heightened sense of anxiety. Among performers such as musicians, the stimulus is usually social evaluations. This then trigger development self-evaluation that disrupts concentration and performance. In effect, a person with PA acquire cognitive, behavioural and physiological responses to anxiety. BASICS OF HYPNOTHERAPY Hypnotherapy is a guided process into a state of relaxation. It does not remove the uncontrollable symptoms, such as anxiety or addiction, but only provides a means to manage them (Nongard and Thomas, 2009).The use of hypnotherapy in managing stress during performances has been supported by clinical and experimental data. Admittedly, however, the efficacy of applying hypnotherapy in improving performance is still inconclusive (Kenny, 2005; Yu, 2006). According to Wagstaff (2000), there is no scientific evidence that says hypnosis can trigger psychotic disorders among patients. In contrast, Gruzelier (2000) reported that among the adverse effects of hypnosis include transient headache, chronic psychopathology, seizure, stupor, and schizophrenia. In such disagreements on the safety of hypnosis, the risks mentioned above should be disclosed to the patient. Hypnotherapy are said to be effective in solving uncontrollable urges, emotions and feelings, such as alcoholism, anger management, asthma, depression, drug addiction, eating disorders, eczema, insomnia, migraine, obsessive compulsive disorder, pain control, past life regression, psoriasis, sexual abuse, sexual problems, stammering, and smoking. Despite the seemingly wide range of conditions in which hypnotherapy can be used, those with epilepsy, schizophrenia or clinical depression need to get their psychiatrist’s consent before taking sessions (http://www.thehypnotherapyassociation.co.uk/whatcantreat.php). ASSESSMENT OF PROBLEMS As is the case in the study of Yu (2006), it should be asked what she thinks causes the anxiety during performances. The patient was then made to answer two questionnaires, Subjective Units of Discomfort Scale (SUDS) and Achievement Anxiety Test (AAT), in order to objectively quantify the amount of anxiety. If, through AAT, it was found that the anxiety was more facilitating than debilitating, then it is possible that anxiety did not interfere with her presentation (fear that she did not enunciate properly, that her thoughts were not clear, etc.), but were instead directed toward the results of her speech (Did her clients like it? Will they invest?). In addition, a traumatic event leading to the feeling of anxiety must be elicited, since hypnotherapy alone had been found to be ineffective against Post-traumatic Stress Disorders (PTSD) (Cukor et al., 2010). In such cases, a multifaceted therapy is needed. Finally, the patient was also made to identify the emotional, behavioural, physical and mental symptoms of stress through a checklist prepared by Palmer and Dryden (1995) and Burns (1980). SESSION PROPER After identifying the problems of the patient, the intervention was then planned. There are many choices of therapy mode, meditation, biofeedback, hypnotherapy, systematic desensitization, behavioural rehearsal, cognitive and behavioural-cognitive. Studies on the effect of hypnotherapy on music PA had been inconclusive. The use of systematic desensitization on music PA did not prove to be effective anxiety, heart rate and performance quality. Behavioural rehearsal, specifically muscle relaxation and breathing exercises, although proven to decrease PA and heart rate, was not able to significantly improve performance (Kenny, 2005). In addition, the relaxation they give seem to attract patients, thus making them more cooperative (Schmidt et al., 2000). Both behavioural rehearsal and behavioural-cognitive were found to decrease significantly the behavioural and physiological symptoms of anxiety, with the latter providing a greater improvement than the former. Cognitive restructuring techniques were also seen to improve PA (Kenny, 2005). In this set of therapy sessions, a comprehensive approach was used, with behavioural rehearsal and cognitive techniques applied through hypnotherapy to increase the effectiveness of these techniques. 1st Session Introduction First, the patient was informed of the cognitive-behavioural-physiological model of anxiety, as was discussed above. She should also be informed of hypnosis, including the risks involved in this therapy. The basics of the hypnotherapy technique were also introduced. She was then informed of the expected outcome of the session. This used the cognitive technique of the power of suggestion, that she would be relieved of her performance anxiety after the therapy. Finally, the patient was also asked about her apprehension toward the treatment, or if she had any questions at all. These were addressed accordingly. Induction Breathing and muscle relaxation exercises were used in this part of the session. After making the patient comfortable, she was asked to focus on a spot on the wall. The patient was then instructed to breathe deeply, and was asked to feel the air go into her lungs. After holding her breath for three seconds, the patient was ordered to exhale slowly. Then, the patient was asked to relax and loosening her muscles. Once the patient blinks again, she was instructed to close her eyes, and think of a peaceful and relaxing moment. The patient was reminded to follow the breathing exercise while in this phase. Deepener While in that moment, the patient was asked to move around, explore the moment she envisioned. The therapist then added that somewhere in the area, was a huge trampoline. The patient was asked to get onto the trampoline and jump as high as she could. The therapist then instructed the patient to relax further as she jumps. After which the therapist was saying, “Jump! You’re relaxing further...Jump! You’re muscles are loose...Jump! Relax, down, down, down...” After a few seconds, the therapist asked her to lie down and to close her eyes. The deepeners used in this session and the next two was under the premise of Conditioned Reflex Theory, which states that repeating relaxing words, down, sleep and relax, may tap the brain to actually feel relaxed or sleepy (Connelly). Post-hypnotic Suggestions An experiment using 81 subjects found that suggestions are an effective means of relieving anxiety (Kazdin, 1973), thus providing a vital component of hypnotherapy. After being in a deeper relaxed state, by virtue of the Placebo theory, the patient was ready to receive suggestions from the therapist (Connelly). In this hypnotherapy, hypnotic visualization was extensively used as it there was evidence to be effective against performance anxiety (Pearce, 1997). The patient was asked to open her eyes, finding herself at home. She was about to go to work. She was then ordered to look up to the building where she works, and to realize that out of all the employees the company has, it was her chosen by her bosses to deliver presentations to their clients. This exercise changes her cognition by having a positive outlook and confidence she needs to have. If she understood how important she is in her field, then, by social role theory, it would be easier for her to perform the roles expected of her (Connelly), including delivering presentations. By this time, she was asked to be open to ideas and to let her imagination set free so she can paint a perfect day for her. Awakening Then, she was informed to that this exercise can be done whenever she wants to. The patient was made to realize that she has control over her anxiety, thus adding onto her self-esteem. She was then woken up. Homework The patient was just reminded to do the breathing and muscle relaxation exercises regularly. Self-hypnosis was promoted as it decreases symptoms secondary to anxiety such as depression, confusion, fatigue, and immune deficiency (Yu, 2006). In addition, the patient was asked to prepare a presentation that she normally does for her work. She should make visual presentations just as she would if it had been for the clients of her company. The patient was also asked to rehearse for it more than usual, to the point that she memorized everything needed to be said during the interview. 2nd session Introduction First, the patient was asked how she was feeling. Ideally, the patient should have shared and recalled the idea of the positive feeling of success and confidence she was made to feel during the first session. This is important in enforcing concentrated attention onto the patient, so that the idea of confident presentation realizes itself (Nongard and Thomas, 2009). Convincer Then, the patient underwent a convincer. This would objectively assess whether or not she still believes in the process. First, the patient was instructed to straighten her arms in front of her, with her fingers clasped together and her index fingers extended as far away from each other as she can. And then, the patient should concentrate on the space, and in the process see them getting closer and closer together, despite any effort to pull them apart. The patient should not be hesitant in following the commands, and in no time should she feel that whatever you tell her is supposed to work. In the event that it did not, the therapist should still give positive feedback to the patient, commending her effort to focus or concentrate (Nongard and Thomas, 2009). No matter how awkward it may seem, the patient did it, because, as the theories of atavistic regression and reality testing suggest, the higher functioning parts of the brain takes a back seat to give way to its more primitive processes, especially when stimuli from the environment is shut away (closing eyes, focusing on internal feelings) (Connelly). Induction The patient was then instructed to do the breathing and muscle relaxing exercises she did in the last session. In the process, she was asked to narrate to the therapist how she was feeling (“The air is filling my lungs, I am breathing more slowly now, my muscles start to loosen up...”). Deepener After that, the patient was asked to imagine the perfect day for herself she envisioned last session. During this time, the fractionation method was used for the deepener. Briefly, the therapist narrated to the patient that, “You could still get more sleep, and so you hit the snooze button and roll over for a few minutes. When the alarm goes off again, you snoozed again and relaxed. There, you’re beginning to breathe deeply and you’re breathing is slowing down. Then the alarm ringed again, so you get irritated...” This was continued for about two to three more cycles of relax-awake state to make the mind tired, making the patient fall deeper into hypnosis (Nongard and Thomas, 2009). Post-hypnotic Suggestions The therapist then asked her to step into the conference room where the meetings are held. She was asked to deliver the presentation she prepared for this session. As the patient began to speak, the therapist followed the presentation using a laptop, and reminded the patient about the slides in cases she forgotten. During the presentation, the therapist also gave encouraging words such as, “That’s very informative”, “That’s right”, or “Mm-hmm” (as if nodding in agreement). In moments of tension, the patient was asked to pause, and to do the breathing and muscle relaxation exercises, to integrate the behavioural exercises into the lifestyle of the patient. As she finished, the therapist played a recording of the presentation. This was used to debunk the patient’s wrong beliefs on her capacity to deliver presentations. Hopefully, behavioural and physical changes follow. Awakening She was then asked to become aware of the surroundings, the fan, the clock, and the therapist’s voice. The patient was again to breathe in deeply and slowly while relaxing her muscles. After a few cycles of deep breathing, the therapist told the patient that he/she would count to three, and on three she should open her eyes slowly and feel the sense of peace. Homework For the last session, the patient was asked to prepare for another presentation. The therapist then told her that her clients would be there to listen. When seen that this has aroused fear, the therapist handed the recording of the previous presentation to her. The patient was told that whenever she felt fear, she should practice her breathing and muscle relaxation exercises. She was also advised to go to her peaceful place if needed. It was also suggested that the patient listen to the recordings so that, in case she forgot, she would remember how great she is in delivering presentations. In addition to that, the patient was asked to bring her closest friends over. She was told there would be a small celebration for her finding the complete control in making everyday her perfect day. All she got to do was to tell herself to breathe deeply and slowly, while relaxing those muscles. 3rd session The third and final session was dedicated to sharpening the relaxation skills the patient had already learned. As well, her confidence was given further boost during this consult. These were done by actually letting the patient conduct the hypnotherapy on her peers. This mental rehearsal had been seen to improve stress management among medical students preparing for their examinations (Yu, 2006). Introduction The therapist welcomed the patient and her peers warmly. The patient was asked of how she sees her progress thus far, and the peers were asked as well if they noticed anything different on the patient. After building rapport, the therapist then asked if there were any worries or questions the peers had for what would happen in the session. As some of the peers began to speak up, the therapist asked the patient to answer some of the questions based on her experience. Because it cannot be helped that some might be doubtful, the therapist asked the patient if she could lead her peers to the convincer she underwent last session. Induction The therapist then led the patient and her peers through the breathing and muscle relaxation exercises. Deepener For the deepener, the patient and her peers were asked to imagine they were at a middle of a wide stairway together, joined hands. Fractionation method of deepener was then conducted. Briefly, the therapist said, “As I count from ten to one, you are going to become more and more relaxed. With each number, you’ll go up or down the stairs, and double your relaxation. Ten...becoming more relaxed, Nine...go down as you further go down into relaxation, Ten...down the stairs, inhale, exhale, loosen your muscles, Nine...a step lower, Eight...go up as you further go down into relaxation...” Post-hypnotic Suggestions Then, the therapist asked the patient and her peers to go to the door at the foot of the staircase. And then, when they opened, it revealed the conference room of the patient. The therapist told her, “Remember, you make this your perfect day. Breathe slowly and relax those muscles.” As the patient was delivering her speech during hypnosis, the therapist also recorded the presentation. Awakening After a few cycles of breathing, the therapist made them aware of the clinic, such as the fan and the ticking clock. And after the count of three, the patient and her peers were asked to gently open their eyes and to feel the sense of peace. Homework The patient was reminded yet again that she is in control of making everyday her perfect day. She was told to always do the breathing and muscle relaxation exercises, especially when feeling tensed. These breathing and muscle relaxation exercises should be the behavioural changes she needed. When practiced, physiological symptoms felt during stressful situations should wane. Most importantly, she was advised to come back after two months for assessment of progress. References Barlow, H. (2000). Unravelling the mysteries of anxiety and its disorders from the perspective of emotion theory. American Psychologist, November, 1247-1263 Burns D. D. (1980) Feeling Good: The New Mood Therapy. New York: William Morrow. Connelly, T. Hypothesis of Hypnosis. [online]. Available at: Cukor, J. Olden, M., Lee, F., and Difede, J. (2010) Evidence-based Treatments for PTSD, New Directions and Special Challenges. Ann. N. Y. Acad. Sci., 1208, 82-89. Gruzelier, J. (2000) Unwanted Effects of Hypnosis: A Review of the Evidence and its Implications. Contemp. Hypnosis, 17(4), 163-193 Kazdin, A. E. (1973) The Effect of Suggestion and Pre-testing on Avoidance Reduction in Fearful Subjects. Journal of Behavior Therapy and Experimental Psychiatry, 4(3), 213-221 Kenny, D. T. (2005) A Systematic Review of Treatments for Music Performance Anxiety. Anxiety, Stress & Coping: An International Journal, 18(3), 183-208 Nongard, R. K. and Thomas, N. (2009) Keys to the Mind: Learn How to Hypnotize Anyone. Oklahoma: PeachTree Professional Education, Inc. Palmer S, Dryden W (1995) Counselling for Stress Problems. London: Sage. Pearce, M. (1999) A Case Study in the Use of Hypnosis to Assist with Exam Preparation and Anxiety. Australian Journal of Clinical Hypnotherapy and Hypnosis, 18(1), 33-38 Schmidt, N. B., Woolaway-Bickel, K., Trakowski, J., Santiago, H., Storey, J., Koselka, M., and Cook, J. (2000) Dismantling Cognitive Behavioral Treatment for Panic Disorder: Questioning the Utility of Breathing Retraining. Journal of Consulting and Clinical Psychology, 68(3), 417-424 The Hypnotherapy Association. What Can Hypnotherapy Treat? [online]. Available at: Wagstaff, G. F. (2000) Can Hypnosis Cause Madness? Contemp. Hypnosis, 17(3), 97-111 Yu, C. K. (2006) Cognitive-Behavioural Hypnotic Treatment for Managing Examination Anxiety and Facilitating Performance. Contemp. Hypnosis, 23(2), 72-82 Read More