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I’m going to start with a dramatic story. Patient #1 (not in any specific order other than for the flow of this podcast) was a well-known motivational speaker in the finance industry. He contacted me at age 53 after a three year break down driven by performance anxiety. He literally was off the grid for three years. Flash forward; he’s live-in front of 16,000 people in a sports auditorium. He asked, “anybody know what a phobia is?” Some responses were fear of spiders, fear of flying. He countered with” I may be up in front of you now, but I have suffered from public speaking anxiety and went on to describe in detail some of the symptoms that he experienced during panic that resulted in his breakdown. He added “if I’m up here in front of you now, you can be proactive with the things that you need to do”. After the speech he got a standing ovation. One person came up to him and said “did you find Jesus”? Now I don’t make up any stories! Obviously, it takes balls to say what he did! It also takes a lot of skill and high performance to get to the point that he was in front of 16,000 people.  The clinical point here is that with his dramatic behavior he took himself out of defense. By being open he took the pressure off his nervous system. It had been the accruing pressure on his nervous system that resulted in his performance anxiety and nervous breakdown.

Now let’s be clear here. I’m not suggesting that you get in front of a group and tell people you have performance anxiety. My intention is to drive home the point that you can only resolve an anxiety disorder by playing offense. There’s no way it can be resolved by playing defense, which most people who come to me for treatment are experts with. The metaphor that I use in treatment is with football. Quality healing whether facilitated by treatment or self-help requires an immersion in cross training and paradoxical approaches. With my patients I say “you’re the quarterback and I am the coach. You’re Tom Brady and I’m Bill Belichick. Of course, that’s before his trade to Tampa Bay. The quarterback may drop the ball or throw an interception, but he takes responsibility for creating motion. Motion and active learning are what is needed to resolve performance anxiety. If the football metaphor does not resonate, you need to be the pilot of your ship or plane. You need to drive the healing process with intention! “Intention” is the key word. It means the effort of focus.

One more very point to this story. Patient 1 was going to do a clinical interview with me to add to the free clinical library at www.social-anxiety.com.

I strongly suggest you listen to the one-of-a-kind interviews which features successful executives, salespeople, professionals, and entrepreneurs. If you listen carefully, you will get insight into the healing process beyond the testimonial. One day #1 didn’t show up for an appointment which was unlike him. Long story short. He was in a boating accident and later communicated to me “my personal and professional life is on hold”. I never heard from him again. The moral of the story is people make plans and God laughs! This is a segue into a super important question. Do you know what your most valuable asset is? Think for a moment. It’s not your bank account, your mortgage, or even your career. Your most asset is time. Time is not elastic. It doesn’t stretch. You can borrow money. You can’t borrow time. To resolve performance anxiety and public speaking anxiety a proactive approach needs to be integrated into your time economy.

When is the last time you left your home to go somewhere; to work to the store to a friend. Wherever you went you had a map in your brain. You knew what streets to make turns on what numbers to look for. Think of this podcast as your map for resolving your public speaking anxiety and fer of being noticeably nervous. Think of the content here as surgical cross training!

The reality is that no one contacts me for public speaking anxiety without a significant problem. The biggest mistake that individuals tend to bring into treatment is regarding how ingrained the problem has become. Make no mistake please. This content is for those who understand they have an anxiety disorder. It is based on a clinical methodology. It’s not about organizing your notes, developing content, picturing people in their underwear, or practice practice practice!

Patient #2, early 50’s is the number two person in a Fortune 500 company. Patient #3, also in his early 50’s is head of sales for a television network. Patient #4 also early 50’s (there is a pattern here) developed a brilliant software program and a business worth 500 million. Patient #5, age 45 is a genius in complex systems in Silicon Valley. Patient #6, age 42, is an expert in international accounting working for a top accounting firm. All suffered from significant public speaking anxiety and the fear of being noticeably nervous. These individuals were at pivotal, and crisis points in their careers due to performance anxiety. All obviously were blessed with a variety of skills that resulted in their career success. All were in significant pain due to their anxiety. Pain is an important word. All feared that being noticeably nervous would ruin their careers! All resolved their anxiety disorder in their treatment with me. Across the board they communicated this is the hardest thing they’ve ever done in their life, meaning treatment. What they were specifically referencing is the process of introspection or looking into oneself. The typical public speaking anxiety sufferer will do anything to avoid this process wanting to rely solely on technique.

This thinking results in a low ceiling for potential success. High performance resolution to the problem requires an integration of technique and core work.

Technique includes a variety of tools. Core work is discovering the root of the problem and resolving the relevant emotional energy.

Patient #7, the owner, and CEO of a twenty-five million a year business in the Midwest and a former catcher for a division 1 University said “there has been no one has held me accountable” for his anxiety/mental health issues. Indeed, many anxiety sufferers at the top of business systems can delegate challenging situations to their subordinates, hence avoidance. When avoidance of the challenge occurs, anxiety has evolved into a phobia.

The fear of being noticeably nervous is driven by uncontrolled adrenaline. It can manifest in a variety of ways. For example, fear of blushing, fear of sweating, fear of stammering, fear of verbal freeze, and disassociation, as well as full blown panic attacks. This fear can bring the most successful businesspeople to their knees; humbled and overwhelmed with thinking that goes something like “if they can see I’m nervous they can see who I really am”. “If they can see I’m nervous I’m not good enough”. As one exec said, “If I go on CNBC and have a panic attack the stock of the company will go down”.

At age 42, patient #8 was making $2,000,000 a year as an investment banker. He wanted to be a team leader. That said it took him two years to work up the courage to go to toastmasters. Once, at a holiday party, everyone put their business cards in a fishbowl. For the card that was picked the winner would win 1,000,000 American Express points. He was praying that he wouldn’t win. Why you might ask. Because if he did, he would have to be in front of the group and say thank you. This would risk exposing his nervousness.

It’s important to consider the diagnostics of public speaking anxiety. There are layers to this. I’m going to keep it as simple as possible. Basically, to measure the degree of the problem there are three primary variables to consider. #1 is the degree of avoidance of the anxiety situation. Number# 2 is the degree of internal mind-body or psychophysiological discomfort during the performance challenge. #3 is the degree of obsessive rumination pre- and post-performance. As we move forward in this discussion consider these variables as interchangeable with the term “pain”.

Consider the following. “Carol” was an ovarian cancer survivor who said, and I quote “I would rather be back in chemotherapy than speak in front of a group”. She explained “with cancer there’s no judgement!” Her interview titled “I’d Rather Be Back in chemotherapy Than Speak in Front of a Group”

Is at the website.

Take a deep breath now……what # 1-10 would you rate your pain?

Let’s get back to diagnostics. This can get complicated. For example, patient #9, age 46, is an entrepreneur in commercial real estate. He made a lot of money and was very philanthropic. He had eight children. His wife would complain that he did not give enough attention to the family as he was always busy. They had participated in marriage therapy for with no success. Given that #9 was always busy and distractible it was easy for his wife to come to the conclusion that he suffered from  ADD; attention deficit disorder. In fact, he did have ADD characteristics. That said, the priority clinical issue for him was his compulsion to detach or disconnect from emotions. Any behavior that did not feed his compulsion he had no interest in. He needed to be always busy, always on. Compulsion is a key word and diagnostic. The way that he did this, which is common to many of my patients, is efficiency at creating external stimuli. Not only did he build a successful business, but his charitable investments were also a huge component of his time economy. There was no time to go inside. And when, he attempted it was an anxiety provoking experience!

Understanding OCPD. That’s not OCD although it’s very intertwined, is essential for healing. The primary component of Obsessive-Compulsive Personality Disorder is perfectionism which is a symptom of insecurity.

For more of an in-depth discussion, you may want to read “Toward a clinical Understanding of Obsessive-Compulsive Disorder as Etiology of Social and Performance Anxiety”. You can access this article at socialanxiety.com tip of the month club March 21, 2016.

https://www.social-anxiety.com/long-articles/article-perfection-20151230.html

Another relatively common diagnostic impacting public speaking anxiety sufferers is dysthymia. The specific DSM criteria is a “depressed mood for most of the day, for more days than not, as indicated by subjective account or observation of others for at least two years”. To dumb this down think of it as an ongoing state of not being happy enough”, which can be significantly influenced by performance anxiety. For example, if you had an important presentation on Monday would you be able to enjoy your weekend?

Patient # 9 was the go-to guy for public speaking for his hedge fund. Six months before his yearly presentation to the board of directors his obsessive worry was a significant source of agitation. Only his wife and I knew of his condition. Many of the salespeople with whom I have worked have experienced an obsessive worry driven burnout on a quarterly cycling basis. For example, patient #10, the head of a sales team projected 28 million for the quarter. When the reality of 22 million kicked in he suffered from panic which mimicked a heart attack and a suicidal ideation. The degree of obsessive worry is an important diagnostic.

Patient #11 in his early 50’s was offered 120 million for his business. That said he experienced selective mutism in business meetings rendering him dependent on his partner to do the talking. The more his anxiety accrued the more he became depressed. The many years of a buildup of performance anxiety concurrent with his adaptation to the Covid world resulted in paralyzing depression. He said” no matter how much anxiety I ever had I was always excited to make money, watch my stocks grow, play tennis with my friends, take my kids on vacation, have sex, go to my summer home, enjoy my pool, buy new clothes, drive my Porsche, have a few drinks. Now I don’t” If this sounds over the top remember the title of this podcast. “Empowerment for high performers”!

Staying with diagnostics for another moment; selective mutism is important to consider here. In essence selective mutism is a speaking phobia. More specifically it’s a complex variation of obsessive-compulsive disorder. Most of the information online and clinically is regarding children. But believe me; the children grow into adolescents and into adults. I’ve worked with many. There’s a ton of content on this subject at www.social-anxiety.com area of concern “selective mutism”.

The fact that texting has replaced talking as the most common form of communication may not resonate with you but for me it’s a mind-blowing fact! Society’s adaptation to technology has created a challenge for many regarding the accessing of neural pathways required for verbal communication!

A common scenario is an individual experiences panic during a business or group meeting. This can be traumatic! The experience of loss of control becomes embedded in the individual’s psyche. From this point on hyper vigilance and obsessive worry that the panic can occur again can become overwhelming which leads to the strain of hypervigilance.

Hypervigilance is a state of increased alertness. It’s the state of being highly or abnormally alert to potential danger. Hypervigilance is when your internal radar is working overtime. Hypervigilance can be a bitch! Hypervigilance is the result of trauma; whether acute, chronic, or complex. I experience hypervigilance.

A few years ago, on Memorial Day I lost my internet connection in my East Hampton home. Without any observable trigger it went off. And it went on. And it went off. On and off. On and off. Neither optimum’s techs nor my personal techs could figure it out. No one could figure it out and I was at the mercy of the universe. I was anxious, angry, frustrated, and on edge. I’d be at a beautiful beach during the day and my mind would go to internet anxiety. Afterall; I have a lot going on online. My wife was getting crazed. I was getting crazed. After 3 months of living with this on and off anxiety the problem was apparently fixed having something to do with IP addresses that no one was able to previously figure out.

This was trauma for me. My sense of control and security were threatened! This episode left me with something I call click anxiety. Anytime I click on a technical device and there is a glitch or delay my mind reflexively goes to a negative place. Ok; so, I put an internet satellite on my roof for a back-up strategy. I’ve learned to compensate effectively. But the worry never completely goes away.

On a more ingrained level. After experiencing a kidney stone which required surgery a couple of years ago which rocked my world, I’ve become extremely sensitized to any internal sensations that remind me of that trauma.

These are examples of conscious trauma. When a patient has detached from traumatic content its crucial to develop empowering strategies to go inside to bring relevant content vertical to a conscious level. Detachment is a defense mechanism. It’s disconnecting from troubling emotions, thoughts, and memories. The belief goes something like “if I don’t think about unpleasant and troubling content, I will be ok”. The problem is this unresolved repressed emotional energy is recycling right beneath the surface ready to be triggered at any moment.

Without the process or bring relevant content to a conscious level anyone suffering from performance and social anxiety will be limited in their attempt to create the high-performance mind! In other words, without identifying relevant emotional energy in one’s reservoir this energy can be triggered when you don’t want it to be! It can render one helpless!

The longer hyper-vigilant driven obsessive worry is present the more ingrained it becomes. It accrues and worsens with time. For example, let’s go back to patient #4.

#4 developed brilliant software as the core of his $500 million business. When he first contacted me for treatment, he experienced a 24-hour episode where he lost his memory. Fearing a stroke his wife brought him to the hospital at which point the physician said and I quote “this is a once in a lifetime situation where you lost your memory because of a buildup of stress”. Dealing with the many challenges inherent in his business and personal life with the added component of public speaking anxiety he imploded.

Patient #12 in his early 50s was in commercial real estate. He was 6’6” and had played semi pro baseball. He said to me at the beginning of treatment “your book was great but don’t insult me by saying something about my past is related to my current problem”. We were totally incompatible!

Listen to breathing instructions please. Take a deep breath..inhale the oxygen slowly through your nose and pace your exhale to my counting from 4 down to 1 slowly through your mouth. Now let’s do it. Inhale and slowly exhale. 4..3..2..1..

When was the last time you experienced  performance anxiety? I’m sure you remember where you were and what you were doing. Do you know what was going on internally? Many people answer this question with “it’s fight or flight”. That is correct. Let’s be more specific. Your internal radar sensed danger and the threat of judgement. Once the adrenaline was activated your internal critical script went something like “oh no” “holy shit; excuse my language, “this is bad”. This script activated the adrenaline and made it worse! Does this make sense?

This is not the end of the story, however. The triggers in the environment that activated fight or flight also activated unresolved emotional content from your reservoir which is your conscious and unconscious past. This is energy that has been repressed and recycling. It has been overflowing in the form of your anxiety.

As one Harvard professor said in a seminar I attended “when the trauma is resolved there are no more triggers”. Well said! Until relevant emotional issues are processed at a conscious level the emotional energy will remain repressed. It will recycle and drive the disorder until it is processed!

If you are building a house, it’s important to have a solid foundation. If you want to resolve an anxiety disorder it crucial to understand the domains that that will make the therapeutic foundation solid and secure.

Therefore, think of the anacronym FATE. F stands for function and physiology. A is action or behavior. T is thinking or cognition. E is for emotion.

Now you may have heard of the therapy called CBT or cognitive behavioral therapy. It’s quite common and well publicized. If the goal of therapeutic intervention is anxiety control, obviously, the domains of cognition and behavior are needed. That said, leaving emotion and physiology out of the therapeutic architecture is going to be extremely limiting. The claims made by the CBT community and its research regarding social anxiety as “the golden standard of treatment” have been as egregious as Trump lying about the coronavirus. It sets the consumer up for unrealistic therapeutic expectations.

I got so fed up with CBT’s claims that I decided to research its research which is so flawed!

“Researching the research on CBT and Social Anxiety” can be found at the tip of the month club dated January 31 2020. https://www.social-anxiety.com/fear-of-public-speaking/researching-the-research-on-cognitive-behavioral-therapy-and-social-anxiety

I’m going to cover the basics of FATE algorithm. First let’s discuss physiology. Interoception is defined as the sense of the internal state of the body. Internal awareness is a prerequisite for learning self-regulation skills. The challenge is that most anxiety sufferers find it difficult to go inside.

I’ve never started a speech or presentation without my hands being cold. I’m not nervous. It’s good stress. The Greek word is Eustress. It’s an awakening of energy. This is my physiology of performance. Cold hands mean vasoconstriction. Warm hands are a manifestation of vaso-dilation. This is peripheral blood flow.

A few years ago, as I was an hour before a 2-hr. presentation to a group of 600 people my hands were very cold and damp. My adrenaline was flowing big time. I was not nervous. I wanted to be on the stage but the buildup-up of energy was uncomfortable while waiting for a release. Focusing on my cold hand temperature I said to myself “this is exactly the energy which when my patients don’t accept and channel, they have a panic attack”.

The skill of identifying hand skin temperature (that’s not body temperature) and its relation to cognition and emotion can be an important technique for self-regulation and interoceptive awareness. A tool to help accomplish this is the bio-card which shows different colors as related to changes in skin temperature. You can get this card at the website for a dollar plus postage.

If you get it the instructions are:

There is no such thing as good or bad with this card. One woman asked, “does it really work?” Yes, it really works as an awareness tool. It doesn’t do anything to you. However, you may want to consider that the biofeedback technique of hand warming as little as a few degrees can abort a panic attack or stop a migraine. I once published an article titled Hemorrhagic Diabetic Retinopathy and Temperature training based on a discovery that a patient was able to control his hemorrhaging with this biofeedback technique. This requires training beyond basic awareness.

Let’s start to merge physiology with behavior. The physiological mechanism that needs to be regulated for performance anxiety is adrenaline. Adrenaline is energy and power. While core work involves identifying how the negative association to adrenaline was learned, controlling this energy in real time requires skills acquisition. The skill that needs to be learned and implemented is surfing. When I’m doing beach time, I like to watch the surfers. The surfer goes with the wave. He or she accepts the energy that’s coming and goes with the power. This is a metaphor. Adrenaline is the wave. You want to surf it. Surfing is your priority technique because it’s your most direct natural method for controlling adrenaline which is a requirement for not being noticeably nervous!

Here are the basic steps for surfing:

Let’s breathe now like we did previously. Take in a long slow deep breath through your nose drawing the oxygen into your diaphragm and slowly pace your exhale  4..3..2..1..

Now here is your strategy for implementing this technique. You need to first create your behavioral hierarchy of anxiety on a scale of (1 lowest-10 highest). This is a totally subjective phenomenon. For one person the board of directors meeting is a 10 and toastmasters is a 2. For another toastmasters, which is an international support group for public speaking, is a 9. For patient #2 the fortune 500 exec communicating with his wife around a conflict issue was a solid #6. For another exec speaking live in front of 100 plus individuals was a 10, addressing the same group via zoom was a 6 and small talk at a party was a 4. As you create this hierarchy think expansively; meaning not just work scenarios. For one entrepreneur the board of directors meeting of the business he created was at one time his 10. Given that his business involved ventilator distribution he was actively sought after during the pandemic, talking to many government officials and business leaders. Given the sustained exposure to stress and immersion in performance scenarios concurrent with the implementation of his treatment strategy “there was no more hierarchy” in his words.

During the last year and a half of adaptation to our covid world hierarchies have been in flux. Many patients are challenged with re-immersion back to the office from the world of zoom.

Once you have created your hierarchy you need to determine at what # do actual waves start. This will take some time and intention. Again, this is totally subjective. For example, let’s say your waves start at a #3. You want to practice going inside and becoming aware of your interoception at lower levels. This is cross training and paradoxical to what you are accustomed to. You need to start making the acquaintance of your adrenaline before you can make friends with it. You need to embrace the awakening energy. Your objective is to describe the internal physical sensations of adrenaline before the adrenaline becomes a wave. Use specific words.

Integrating bio-card awareness into your daily life can go a long way in helping you develop your interoceptive skills.

Once you have determined at what # the waves start you want to consciously, with intention, produce wave opportunities at that number and progressively and developmentally move up the hierarchy as your skills and confidence increases.

If you wait for these opportunities to come to you understand you are in the process of playing defense and this will significantly and negatively impact your learning curve!

Now I understand that it’s a good bet that you will be faced with higher #s on your hierarchy as you begin this process. That said, you will be forced to practice your skills at this level. But not practicing at a lower level will be unproductive. If you believe that quality skills acquisition/surfing should start at high levels, this is an unrealistic expectation that is symptomatic of perfectionism.  This thinking usually doesn’t work well.

Realistic expectations are a component of how you think. This is cognition. Let’s start to integrate cognition with your introduction to physiology and behavior. Borrowing from the psychology of transactional analysis is the concept of mind states. This is a powerful tool if you give it intention! There are five mind states that make up one’s personality. There is no such thing as a bad mind state. The issue is synergy or balance. Please go the area of concern “performance Anxiety” at the website and scroll down until you reach the graphs titled “Performance Anxiety “Unresolved” and “Performance Anxiety Resolved”.

https://www.social-anxiety.com/area-of-concerns/performance-anxiety

Your goal is to learn what each state is. This is the first step for developing what I reference as a high-performance mind. I define this as a proactive state of achieving health and happiness. Obviously, performance anxiety can be a major deterrent to this process!

Think of mind state work as a tool to add to your technique arsenal along with surfing. That said, transactional analysis is a psychotherapy unto itself.

First, it’s important to understand that your performance anxiety is pictured by what looks like the twin towers on the top graph. The left-hand tower, your internal critical script is the energy of values and judgement. Common to my patients has been the critical script of “you need to be successful”. Ok this certainly makes sense. The problem is that not controlling this injunction in its excess causes the strain and pain located in your adapted child. In other words, the excessive critical script drives the problem of performance anxiety which is in the adapted child state. The adapted child is learned behavior. You were not born with performance anxiety. You learned it.

The two states together function as a reflex. Think of it as a mind tic. This is not a neurological issue. Rather a deeply ingrained psycho-physiological dynamic.

Patient #13 was a lawyer who was considering running for political office. He experienced hyper-hidrosis. Hyper-hidrosis is excessive sweating. It is a physiological condition driven by stress.  Once in a business meeting he started sweating and I quote “controlled his critical script and the sweating stopped a minute later. This does take some work. His interview titled “Performance Anxiety and Hyper-hidrosis Resolved without Medication-Successful Lawyer” is at the website.

An important note here. One of the reasons that alcohol is the drug of choice for performance and social anxiety is that it lowers the twin towers. The problem is that it depresses the energy across the board with all the mind states! There are several interviews at www.socialanxiety.com that can enlighten you to the issue of alcohol and performance anxiety.

The therapeutic objective of mind state work is to grow the nurturing parent, adult, and natural child. When this occurs synergistically the critical parent and the adapted child will decrease.

Across the board all my patients enter treatment with a nurturing deficit. Nurturing is a multi-dimensional phenomenon. It means provide support promote growth. A huge component is self-acknowledgement.

Given the ongoing strain of your success driven critical script it’s super important to create a functional definition of success as a foundation to your nurturing self. If you are still listening to this podcast, it’s a good bet that your definition is career and financially driven. Indeed, these are important variables. My definition of success crafted over 7 decades is being in a good mood. There are numerous and complex variables that determine this phenomenon I have recently refined my definition of success to include Eudaimonia thanks to an article in the January 31, 2019, Wall Street Journal titled “Aristotle’s Pursuit of Happiness”. I understand Eudaimonia to mean discovering your passion and being the best version of yourself. Sounds perfect. Right? Performance anxiety can certainly get in the way of this!

The nurturing deficit runs the spectrum from obvious and overt to subtle and complex. The nurturing deficit can be considered a variation of trauma.

An example of obvious trauma is patient #4 who developed a $500 million business based on his brilliant software. His mother was an abusive narcissist, mentally and physically, as was his first wife. A more subtle example is patient #7 the CEO of highly successful small business and D1 catcher. He loved and respected his father dearly. It was this love and compulsion to please and take care of which caused his pathological strain. Compulsion is a key word here. Complex trauma includes the process by which emotions were learned to be repressed. Think for a moment. What was the emotional culture in your family? Was emotional expression encouraged?

Nurturing includes developing the process of introspection and the learning and implementation of technique. It includes self-acknowledgement on an emotional as well as cognitive level. It includes trauma resolution. It also includes brain health in addition to a multiplicity of other examples. It is the most important mind state to develop.

Another critical component of nurturing is the implementation of realistic expectations regarding one’s learning curve for anxiety resolution.

Patient #3 is the head of sales for a television network. He is responsible for hundreds of staff and billions of dollars. Upon observing one of his salespeople anxieties with public speaking he said, “why don’t you attend a Toastmasters meeting with me?” His kindness and openness were nurturing for his employee and empowering for himself. Most people in high positions would not be open about the challenge.

Nurturing can include paradoxical intention. A college student who suffered from debilitating erythrophobia which is fear of blushing once said to his college class before giving a presentation “In a minute you will see a magic trick. My face is going to change color”. He then did not blush in what would have been a sure fire scenario for doing so.

I met the writer of my book Beyond Shyness in 1990. She was the girlfriend of a fellow basketball player with whom I played in Springs East Hampton. His name is Jonathan Coleman. He is a best-selling author. In fact, he wrote Jerry West’s biography. He taught me something that has been critical for my high performance. He said, “writing is all about layers”. I’ve run with the layering concept as it applies to just about everything; clinical work, working out, gardening, packing for a vacation. This podcast is the result of many layers of work.It’s a profound strategy which is totally paradoxical to the OCPD-perfectionist thinking of everything as to be perfect..NOW!

Next is your Adult which is your internal computer. It’s objectivity and logic. Now please note this does not mean intelligence. I already know you are intelligent if you are listening to this podcast. One patient was leading a PTA meeting when an individual from the back of the room shouted, “I can’t hear you”. This triggered a panic reaction. When she was in my office I said, “put yourself in your adult what did he mean when he said I can’t hear you”. She replied, “he couldn’t hear me”. That said, the question triggered unresolved emotional content from her adapted child mind state.

A question I often ask patients is “put yourself in your adult mind state and answer: “how many units of alcohol have you had in the last 7 days?” We’re looking for an objective answer. For example, consider the Texas football fan who describes power drinking “I had a couple of beers he said”. How many exactly? “About a dozen”.

Let’s move on to the natural child. Think of this as the truth of desire. It what you want, not what someone tells you you should do. It’s also genuine emotion, exploration, discovery, the development of ideas, creativity, and sexuality. It’s your primitive self.

Identify something that you desired to do but stopped because of anxiety. This could be expressing yourself, learning something, taking a good risk. Many with whom I have worked with have stopped progressing in their careers due to performance anxiety. Other than experiencing relief for not facing anxiety in the moment Do you know what the deeper result of this is? I’ll tell you in a moment.

First a story of mind state management. This is an x-rated story. Many years ago, when I was working the media, I was booked on the Opie and Anthony Radio show. I didn’t know who they were but discovered they were two assholes who made Howard Stern look tame. Little did I know that I was booked on “bad guest” day where the objective was to ambush and embarrass the guest. It was a total setup.

After my two-minute introduction the first caller asks “doc; how do I get my girlfriend to bend over”? What do you mean I responded? “To have anal sex he said”. I responded, “I guess you should teach her to relax” and it when on from there. The whole story is in my book “Work Makes Me Nervous”.

The bottom line here is that these idiots, who had a huge audience, were good at orchestrating potential embarrassment. That said I was not embarrassed I was angry. There are two clinical points here. First, embarrassment is an internal decision. A person can trigger embarrassment but not create it. Secondly, I was proud of the way I answered the questions. This was the result of mind state management and desensitization to performance adrenaline. I had done hundreds of shows before this.

Confidentiality is a key component in treatment. That said, in the following story the patients gave permission to use their name. Kirk Rueter pitched for Th San Francisco Giants. He won the most games for the team as a left hander. The Reuters worked with me to resolve their daughter’s selective mutism. The interview Selective Mutism and Professional Baseball player can be found at the website.

I once joked with Kirk asking, “did you ever have a bad game?” He responded I was losing 6-0 in the first inning to The Rockies with no outs”. I asked how you deal with that. He responded, “I have to pitch every 5th day so what I think about is what do I have to do to do better next time”. Now, isn’t that the perfect winning psychology; also known as “next play”. It’s important to consider what gets in the way of this thinking. The answer: too excessive an internal critical script and challenged self-esteem.

Let’s go back to the question do you know what happens when your critical script prevents your natural child from activating? The answer: a lot of repressed emotion which becomes an investment in Tension Myositis Syndrome.

This brings us to core work and the brilliant methodology of the late John Sarno M.D. Sarno created the term “Tension Myositis Syndrome” from his groundbreaking work with back pain. Now remember, I previously introduced the concept that “pain” as it refers to the mind-body aspects of public speaking anxiety.

TMS is based on the dynamic that repressed emotion is so powerful it impacts the flow of oxygen into the blood stream creating symptoms. In a nutshell TMS is the cause of all physical symptoms that do not have an organic etiology. In other words, your public speaking anxiety disorder and your physical symptoms that can make you noticeably nervous are a manifestation of TMS.

Now I understand that this is a huge statement and probably a totally new concept for you. My suggestion is that you embrace it as crucial for the growth of your nurturing mind state. I can assure you that in my clinical experience which includes hundreds of thousands of clinical hours with thousands of patients of all ages with social anxiety I can verify that it’s true!

Building on the Sarno model, high-performance healing requires going “vertical” which means bringing relevant content to a conscious level. This is what most people find difficult and want to avoid.

Concurrent to vertical work it’s necessary to cross the bridge to one’s emotional self. This means attaching to the emotional energy that lurks in one’s reservoir. This is the energy that needs to be channeled in real time

The brilliance of Sarno’s work is how he organizes the content in one’s reservoir. In your reservoir is a buildup of emotional pain, rage, sadness, fear, and feelings of unworthiness in the unconscious mind. Contributions to the reservoir come from four different aspects of our emotional lives. It’s important to look at your life and see how much each one contributes to your reservoir. I’m just going to cruise briefly through the basics here.

The first is childhood. Anger, hurt, emotional pain, fear, and sadness that we may have experienced as children were not felt consciously but stay with us all of our lives because there is no such thing as time in the unconscious mind, no calenderer or clock. Everything we feel any time in our lives is permanent.

The second part is self- imposed pressures based on personality traits. Sarno refers to the “the perfect and the good”. These personality characteristics appear to be universal in people with TMS and certainly with the high performing individuals with whom I have worked. This often manifests as Obsessive Compulsive Personality Disorder Perfectionism.

The third part is The Pressures of Life. The commonest life pressures are work, family, money, etc. These are pressures that most people are aware of, but they have a great influence because of the way we relate to them unconsciously as well as consciously! For example, everyone hates the idea of aging and mortality, but most people tend to philosophize them away. The unconscious is not philosophical. It is enraged by the idea!

Part four is about other emotions including guilt, fear, shame, and loss of control.

When you experience anxiety and the fear of being noticeably nervous, as well as any physical symptoms that do not have a biologically organic cause your reservoir is overflowing!

Core work involves bringing Issues in one’s reservoir vertical into one’s consciousness and crossing the bridge from the intellectual/conceptual mind to one’s emotional self. The emotional energy that lurks in ones’ reservoir needs to be processed to ensure control of that energy in real time! If this doesn’t happen the reservoir will overflow, and physical symptoms will occur.

In the November 2013 Harvard Business Review Susan David and Christina Congleton discuss the importance of labeling emotions as transient sources of data and important for success in business. This labeling process creates emotional agility which is defined as “an individual’s ability to experience their thoughts and emotions and events in a way that doesn’t drive them in negative ways, but instead encourages them to reveal the best of themselves”.

Let’s take this a step further. The Latin derivative for the word emotion, “emotere” literally means energy in motion.  Energy in motion equals emotional agility if you are in control of the energy. This requires introspection and channeling. If you detach from the emotions the energy will control you.

Patient # 5 the genius in complex systems said at the beginning of treatment “feelings are a nuisance”. Another patient, a Wall Steet analyst said, “feelings are a luxury”. His reservoir includes growing up with immigrant parents who worked all the time. There was no down time! I suggested that he take 10 minutes a day to meditate. At first he could only go 20 seconds before becoming impatient and distractable. This behavior and emotional state is the result of the conditioning to be always on; it’s complex trauma.

Another patient was a scientist. When journaling for her treatment sessions, she would put a number 1-10 after each emotion that she experienced. For example, when you last experienced anger, pride, or frustration what was the intensity of your emotere? Developing agility requires identifying the specific emotion and its relative intensity. This process is critical for nurturing mind state growth.

Neuroplasticity is defined by Wikipedia as the ability of neural networks in the brain to change through growth and reorganization. According to Medicine.net neuroplasticity is the brain’s ability to reorganize itself by forming new neural connections throughout life. Neuroplasticity is also called brain plasticity or brain malleability. The objective of the technique and core work discussed in this podcast is to create neuroplasticity. A vision of neuroplasticity is your “after” ego-graph given your current anxiety baseline.

Often due to the significantly ingrained psycho-physiological reflex at play with public speaking performance anxiety a pharmaceutical strategy can be employed to facilitate neuroplasticity. This is especially true when the obsessive worry and rumination dominate.

I’m going to give you the very basics here. Prescribing ideally should be in the hands of a competent psycho-pharmacologist. This is because it’s important for the prescriber to be aware of co-morbid conditions, overall variables of chemistry, and titration levels. But often a general practitioner can do the job.

The medicine of choice is an SSRI or selective serotonin uptake inhibitor. In 90%ish of the over 1000 individuals with public speaking performance anxiety that I have treated and used medicine it does what it’s supposed to do, which is to lower the twin towers on the beginning ego-graph. It diminishes obsessive worry while creating neuroplasticity. It creates an evenness in mood which allows for surfing skills acquisition. This dynamic enhances therapeutic learning. The other 10 % includes individuals where there was no efficacy or side effects that required different medicine.

Here’s a common example of how medicine can be used incorrectly albeit with the best of intention. A patient goes to the MD and says I need medicine for my public speaking anxiety or performance anxiety. The typical response is to prescribe a beta blocker. These usually are effective at blocking the spike of adrenaline and decreasing heart palpitations. The problem is it’s impossible to learn surfing skills with them as the energy is too blocked. And they often breed psychological dependence. Many of my patients have carried them in their pocket in case of a spontaneous challenge. There’s an interview at socialanxiety.com entitled “High Performance Use of Beta Blockers”. The high performance for this patient was using the beta blocker for only high levels of challenge on his hierarchy. Taking a beta blocker before a toastmasters meeting is an example, in my opinion, of over-dependence as toastmasters would be the place to experiment with the skill of surfing! Typically, patients who come to me who are already on beta blockers have no concept of a therapeutic strategy. Their behavior is based on desperation!

Even more potentially negative are the patients who tell their MD they have an anxiety problem and are prescribed anti-anxiety medicine known as benzodiazepines. I’ve worked with over 30 psychiatrists who have consulted with my practice over the years. The present one I have collaborated with for over a decade. In a recent conversation I asked him if he has observed therapeutic productivity with benzos and social and performance anxiety. Here is his answer. I quote “On a rare occasion I have found benzos helpful in very low doses during the first few weeks of treatment while waiting for an SSRI to take effect. I have also found tiny doses of a benzo to be helpful when used for the first public speaking opportunity after treatment is initiated. Aside from these two exceptions I find benzos to enable avoidance and prevent someone from getting comfortable with discomfort and overall counterproductive”.

The bottom line with pharmaceuticals is that productive diagnostics are needed first. They should be integrated only with the philosophy that their purpose is to facilitate the neuroplasticity needed for resolution of the anxiety challenge. This may not apply to co-morbid issues. Be careful about the diagnostic of “chemical imbalance”. The typical patient who comes to me for treatment who has been on benzos for a time is usually in a helpless and defensive state.

Now there’s a right and wrong way to use this medicine. Remember the entrepreneur I referenced who distributed ventilators during the pandemic who “had no more hierarchy”. When I suggested an SSRI he went to his MD who said “I know a lot about SSRIs. I’ve been on one for 10 years”. This is not the right way to use this medicine in my opinion. My patient went on the medicine, the purpose of which is to facilitate his therapeutic work and went off the medicine approximately nine months later.

Another patient, a 46 year old CEO of an international medical supply company who had suffered from hyper-hidrosis since he was an adolescent said when I first suggested medicine. “Take it off the table I never want to discuss it”. That said, with the combination of his therapeutic work and medicine he became a rock star with public speaking and his career grew exponentially. The problem: he did not want to get off the medicine.

So, here’s the moral of the story. Medicine can be highly effective if used the right way. All too often it’s not. My suggestion to patients who go on an SSRI is to think of it as a metaphorical pregnancy. Invest in the belief that you are using it for approximately nine months to facilitate your therapeutic work. If you are thinking of running to a dr for an ssri now without appropriate therapeutic you are falling into a trap!

The irony here is that I started my clinical practice in 1978 using biofeedback to treat stress related disorders. My mind set at the time was get people off medicine. I learned many skills during this clinical process. Decades of experience later the merging of these skills with productive pharmacology has resulted in profoundly positive clinical results.

I’ve covered a lot of ground here. You now have a map or blueprint for your surgical mind work based on the most successful clinical experience anywhere with public speaking anxiety disorder.

There’s plenty of valuable content at www.socialanxiety.com including treatment information and self-help resources. Stay tuned for continuing podcasts.

I wish you high performance!