Okay, so we’re covering a lot of ground here. 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. Enabling 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. Number one, realistic expectations. This means the adrenaline is going to be there in a challenge situation.
Do not waste any time hoping it will not. Number two, this is the hardest. Accepting the wave, going with it, accepting it, with the interpretation that it’s your power. Number three, going with the wave with one or two diaphragmatic breaths. Exhale, inhaling the oxygen, exhaling the tension. Let’s breathe now like we did previously. Taking a long, slow, deep breath through your nose. Now slowly exhale, four, three, two, one.
Now here’s your strategy for implementing the surfing technique. You need to first create your behavioral hierarchy of anxiety on a scale of one to ten, one the lowest and the highest. This is a totally subjective phenomenon. For one person, the board of directors meeting is a ten and Toastmasters is a two. For another, Toastmasters, which is an international support group for public speaking, is a nine. For patient number two, the Fortune 500 exec communicating with his wife around a conflict issue was a solid six. For another exec, speaking live in front of one hundred plus people was a ten, addressing the same group via Zoom was a six and small talk at a party was a four.
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 ten. Given that his business involved ventilator distribution, he’s been actively sought out during the pandemic, talking to many government officials and business leaders. Given his sustained exposure to stress and immersion in performance scenarios concurrent with the work we were doing in his own words, there was no more hierarchy. During the last year and a half of adaptation to our COVID world, hierarchies have been in flux.
Many patients are challenged with re-emersion back to the office from the world of Zoom at the time I’m putting this podcast together. Once you have created your hierarchy, you need to determine at what number do actual waves start for you. This will take some time and intention. Again, this is totally subjective and this process is complicated for most people. For example, let’s say your wave started at number three. You want to practice going inside and becoming aware of your interoception at lower levels, meaning at levels under three.
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. So your objective is to describe in as much detail as is possible the internal physical sensations of adrenaline before the adrenaline becomes a wave. 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 number do the waves start, you want to consciously with intention produce.
Now produces a key word here, produce wave opportunities at that number and progressively move up the hierarchy as your skills and confidence increases. Now here is a very important point. 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 numbers on your hierarchy as you begin the surfing 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 and surfing should start at high levels, this is an unrealistic expectation that is symptomatic of perfectionism. This thinking usually doesn’t work well. Unless you’re a superstar. Realistic expectations are a component of how you think. This is cognition. Let’s start now 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’s no such thing as a bad mind state. The issue is synergy or balance. Please go to 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. You now have a picture of what therapeutic success looks like. All too often something like this is not available. The 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. 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 judgment. Common to my patience has been the critical script of you need to be successful. Okay, 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 mind state.
The adapted child is learned behavior. You are not born with performance anxiety. You learned it. The two states together function as a reflex. Think of it as a mind tick. This is not a neurological issue, rather a deeply ingrained psychophysiological dynamic. Patient number 13 was a lawyer who was considering running for political office. He experienced hyperhidrosis. Hyperhidrosis is excessive sweating. It’s 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 hyperhidrosis 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 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 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-acknowledgment. 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 seven decades, is being in a good mood. There are numerous and complex variables that determine this phenomenon.
I recently refined my definition to include, this is a big word here, E-U-D-A-I-M-O-N-I-A Eudaimonia. Thanks to an article in the January 31, 2019 Wall Street Journal titled, Aristotle’s Pursuit of Happiness. I understand it 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 number four who developed a $500 million business.
His mother was an abusive narcissist mentally and physically as was his first wife. A more subtle example is patient number seven, the CEO of a 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 again 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-acknowledgment on an emotional as well as a cognitive or thinking level. It includes trauma resolution. It also includes brain health in addition to a multiplicity of other examples. It’s 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. Most people want to get better yesterday. I understand the pain is significant but it’s been there for a long time.
It’d be better off thinking of pacing yourself for a 10k race versus once or twice around the track. Patient number three is the head of sales for a television network. He’s responsible for hundreds of staff and billions of dollars. Upon observing one of his sales people’s anxieties with public speaking he said, why don’t you attend a Toastmasters meeting with me? This is truly different behavior. His kindness and openness were nurturing for his employee and empowering for himself. That said, most people in high positions would not be open about the challenge. Nurturing can include paradoxical intention.
This means thinking in opposite fashion. For example, this is a great story. A college student who suffered from debilitating arithrophobia which is a fear of blushing. Once said to his college class before giving a presentation and I quote, 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 China’s 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’s a best-selling author. In fact he wrote Jerry West’s biography. He taught me something that has been so critical for my high performance in my personal and professional life.
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, learning a new skill. 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 has to be perfect now. Next is your adult. This is your internal computer. It’s objectivity and logic, not contaminated by emotion. 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 seven days. We’re looking for an objective scientific answer. For example, consider the Texas football fan who describes power drinking. I had a couple of beers, he said.
How many exactly? Over a dozen. Let’s move on to the natural child. Think of this as the truth of desire. It’s 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. You have to be in your natural child to experiment, to learn skills. It’s also your primitive self. Identify something that you desire to do but stop because of anxiety. This could be expressing yourself, learning something, taking a good risk. Many with whom I have worked 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 in the media, I was booked on the Opie and Anthony show. I didn’t know who they were but discovered they were two complete 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 asked, Doc, how do I get my girlfriend to bend over?
What do you mean I responded? To have anal sex, he said, I responded, guess you should teach her to relax. Not a bad answer, right? And it went 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 quite 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. Work Reader pitched for the San Francisco Giants. He won the most games for the team as a left-hander. The readers 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 six zip in the first inning to the Rockies with no ounce. I asked, how do you deal with that? He responded, I have to pitch every fifth day so what I think about is what do I have to do to be better the next time out.
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? Two excessive and 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 something called tension, myositis syndrome. This brings us to core work and the brilliant methodology of the late John Sarno MD.
Dr. Sarno created the term tension, myositis syndrome from his groundbreaking work with back pain. Now, remember, I previously introduced the concept of 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 bloodstream, creating physical 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 literally 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 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. 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’s no such thing as time in the unconscious mind. No calendar, no 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 perfect and 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, OCPD perfectionism.
The third part is the pressures of life. Common life pressures, 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. Most people tend to philosophize them away. The unconscious is not philosophical. It is enraged by the idea. Part 4 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 over.
Core work involves bringing issues in one’s reservoir vertical into one’s consciousness and crossing the bridge from the intellectual or conceptual mind to one’s emotional self. The emotional energy that lurks in one’s reservoir needs to be processed to ensure control of that energy in real time. If this does not 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, 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 does not drive them in negative waves, but instead encourages them to reveal the best of themselves. A good picture of emotional agility is the resolve performance graph that you looked at under the performance anxiety area of concern. Let’s take this a step further. The Latin derivative for the word emotion, emo-ter, e-m-o-t-e-r-e literally means energy and motion. Think of it. Is that not profound? Energy and motion equals emotional agility if you are in control of the energy.
This requires introspection and channeling. If you detach, if you disconnect from the emotions, the energy will control you. Patient number five, the genius and complex system said at the beginning of treatment, feelings are a nuisance. Another patient, a Wall Street analyst said, and I quote, feelings are a luxury. His reservoir includes growing up with immigrant parents who worked all the time. There was no downtime. I suggested that he take ten minutes a day to meditate. At first, he could only go twenty seconds before becoming impatient and distractable.
This behavior and emotional state is the result of the conditioning to be always on its complex trauma. Another patient was a scientist. When journaling for her treatment sessions, she would put a number one to ten after each emotion that she experienced. For example, when you last experienced anger, pride, or frustration, what was the intensity of your emo-ter? 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, that’s N-E-U-R-A-L, 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-egograph given your current anxiety baseline. Often, due to the significantly ingrained psychophysiological 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 psychopharmacologist. 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, selective serotonin reuptake inhibitor. In 90% 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 e-gograph. 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 a 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 beta blockers because the energy is too blocked. 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 the website 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 that’s natural child stuff 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 doctor they have an anxiety problem and are prescribed anti-anxiety medicine known as benzodiazepines. I’ve worked with over 30 psychiatrists who have consulted in my practice over the years. The present one I’ve collaborated with for over a decade and we’ve been doing very productive work together. In a recent conversation, I asked him if he had 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 end quote. The bottom line with pharmaceuticals is that productive diagnostics are needed first. They should be integrated only with the philosophy that their purpose, again, this is for performance public speaking anxiety, is to facilitate the neuroplasticity needed for resolution of the anxiety challenge. This may not apply to comorbid issues.
Be careful about the diagnostic of quote, 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 a 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 was 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 hyperhidrosis 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 in 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 doctor now for an SSRI without appropriate therapeutic work, 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 mindset at the time was to get people off medicine. I learned many skills during this clinical process. Decades of experience later merging these skills with productive pharmacology has resulted in profoundly positive clinical results. Now, I’ve covered a lot of ground here.
You now have a map or blueprint for your surgical mindwork based on the most successful clinical experience anywhere with public speaking anxiety disorder. There’s plenty of valuable content at socialanxiety.com including treatment information and self-help resources. Stay tuned for continuing podcasts. I wish you high performance. Thank you.
