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Music Performance Anxiety: Theory, Assessment and Treatment

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Dianna T Kenny

1

PART 1 ....................................................................................................................... 5

INTRODUCTION TO MUSIC PERFORMANCE ANXIETY .................................... 5

Chapter 1 .................................................................................................................... 6

Music Performance Anxiety: introduction to theory and concepts ............................ 6

What is anxiety? .................................................................................................. 6

What is music performance anxiety? ................................................................... 8

Optimizing music performance........................................................................... 11

Task complexity ................................................................................................. 13

Task mastery ..................................................................................................... 15

Performance setting ........................................................................................... 16

Reducing music performance anxiety ................................................................ 17

Goal setting, practice and performance preparation ........................................... 20

Therapy for music performance anxiety ............................................................. 23

Health and wellbeing in focus ............................................................................ 27

Summary and Conclusions ................................................................................ 33

References ............................................................................................................... 35

PART 2 ..................................................................................................................... 42

PSYCHOMETRIC AND CLINICAL ASSESSMENT OF MUSIC PERFORMANCE

ANXIETY .............................................................................................................. 42

CHAPTER 2 .......................................................................................................... 43

IDENTIFYING cut-off scores For Clinical purposes for the Kenny Music
performance anxiety inventory (K-MPAI) in a populatIon of professional orchestral
musicians .............................................................................................................. 43

CHAPTER 3 ............................................................................................................. 60

2
 Exploring the attachment narrative of a professional musician with severe
performance anxiety: A case report ....................................................................... 60

CHAPTER 4 ............................................................................................................. 81

An exploratory narrative study of attachment quality and music performance anxiety

in professional orchestral musicians ...................................................................... 81

Theoretical background ..................................................................................... 82

Attachment and musical performance ................................................................ 84

PART 3 ................................................................................................................... 125

TREATMENT OF MUSIC PERFORMANCE ANXIETY ....................................... 125

CHAPTER 5 ........................................................................................................... 126

Intensive Short-Term Dynamic Psychotherapy (ISTDP) for severe music

performance anxiety. ........................................................................................... 126

Part 1: Exposition and psychodynamic assessment of a professional musician .. 126

Intensive Short-Term Dynamic Psychotherapy (ISTDP)................................... 127

Therapy ........................................................................................................... 138

Phase of inquiry ...................................................................................................... 139

Inquiry moving into the phase of pressure............................................................... 139

Phase of pressure................................................................................................... 140

Phase of challenge ................................................................................................. 142

Head on collision .................................................................................................... 148

Discussion .............................................................................................................. 155

CHAPTER 6 ........................................................................................................... 157

Intensive Short-Term Dynamic Psychotherapy (ISTDP) for severe music

performance anxiety: ........................................................................................... 157

Part 2: The process and outcome of psychotherapy with a professional musician

............................................................................................................................ 157

References ............................................................................................................. 170

CHAPTER 7 ........................................................................................................... 175

3
Short-term psychodynamic psychotherapy (STPP) for a severely performance
anxious musician: A case report .......................................................................... 175

The nature of music performance anxiety ........................................................ 178

4
 PART 1

INTRODUCTION TO MUSIC PERFORMANCE ANXIETY

5
 CHAPTER 1
MUSIC PERFORMANCE ANXIETY: INTRODUCTION TO
THEORY AND CONCEPTS

"Whoever is educated by anxiety is educated by possibility, and only

he who is educated by possibility is educated according to his
infinitude." i

Is music performance anxiety related more to the characteristics of

the performer, the music, or the context of the performance, or does
it involve a complex interaction of all these elements? In order to
understand what music performance anxiety is and to learn effective
ways to self-manage it, it is helpful to have a basic understanding of
the concept of anxiety and its close relatives, arousal, stress and
fear, how they arise, how the body reacts to their occurrence and
how they may be applied to our understanding of music performance
anxiety. A new definition of music performance anxiety is offered,
followed by a discussion on how we can optimize music performance
and reduce performance anxiety. We then examine the complex
interaction between performer, task and performance setting and
identify factors that are performance-enhancing and performance-
impairing. Key elements that enhance music performance and
reduce music performance anxiety are explored. The paper
concludes with a discussion of recent theories of music performance
anxiety and some case studies that highlight the concepts discussed
in this paper.
What is anxiety?
"If a human being were a beast or an angel he could not be in
anxiety. Because he is a synthesis, he can be in anxiety; and the
more profoundly he is in anxiety, the greater is the man"ii

Although philosophers extol the virtue of anxiety, our subjective

experience is not so positive. Anxiety is an emotion that arises when
we feel threatened by challenges that test our ability to manage

6
them. When we feel anxious, we may also feel that we can neither
control the situation nor predict its outcome. Many people also report
a sense of dread, as if disaster is around the corner, or fear that they
will embarrass themselves. Some people are more affected
cognitively, that is, they worry excessively about the impending
performance, have catastrophic thoughts about what might go wrong
during the performance and the fear the possible consequences of
a poor performance. Others report feeling very strong bodily
sensations that are caused by the release of hormones such as
adrenaline into the blood stream. These sensations include a
churning stomach, sweaty hands, dry mouth or trembling. Others
report a combination of emotional, cognitive and physical responses.
Table 1 summarizes some of the responses to anxiety that people
report.
Table 1 Systems affected in anxiety
o Somatic [Fright-Fight-Flight Response (Generalised
Activation Syndrome)] is also called the hyper arousal or acute
stress response that produce a range of bodily sensations that
prepare the body to meet the perceived challenge.
o Emotional – anxiety, fear, panic
o Cognitive - Worry, dread, inattention and distractibility, lack of
concentration, memory loss
o Behavioural manifestations - technical errors, memory loss,
performance breaks, avoidance of performance opportunities).

Anxiety occurs on a continuum from mild to severe and has a

number of different forms that are summarized in Table 2.
Table 2 Types of anxiety
o Adaptive anxiety - the body adapts to a threatening or
challenging situation by increasing our state of arousal. This
type of anxiety may be experienced as excitement and may
enhance coping and improve performance.
o Reactive anxiety - results from actual or perceived inability to
meet the demands of the situation.

7
 o Maladaptive anxiety - anxiety impairs thinking and problem-
solving and has a negative effect on behaviour or
performance.
o Pathological anxiety – anxious arousal occurs in situations
where the individual cannot identify the cause of the anxiety.
This state is often referred to as Generalized Anxiety Disorder.

Terms such as stress, anxiety, arousal and activation tend to be

used interchangeably. However, it is best to assign to each concept
a precise definition. Stress is more properly defined as an
environmental demand that requires a coping response. Arousal
signals that the person is feeling stressed (either positively or
negatively), and anxiety is that state experienced when one believes
that the demands are excessive or unachievable. It is important to
distinguish physiological arousal from somatic anxiety. Physiological
arousal refers to the intensity of behaviour that varies on a continuum
from deep sleep to intense arousal. Arousal is initially non-directional
and may denote either a positive or negative experience. If arousal
is associated with a positive affective quality, the person will report
a feeling of excitement; if arousal occurs as a result of some
perceived threat in the environment, the person will experience
somatic anxiety. Anxiety is generally understood as a two-factor
structure, consisting of state and trait components. State anxiety is
a transitory emotional state characterized by heightened tension and
apprehension; trait anxiety refers to relatively stable individual
differences in anxiety proneness, that is, in differences between
people in their tendency to respond to situations perceived as
threatening with elevations in state anxiety. State anxiety more
closely resembles fear, while trait anxiety refers to the propensity of
the individual to feel chronically worried or apprehensive.
What is music performance anxiety?
I have recently challenged existing definitions of music performance
anxiety because many of them are not consistent with the emerging
research (see Kenny, 2011). I have proposed a new definition, as
follows:

8
 Music performance anxiety is the experience of marked and
persistent anxious apprehension related to musical
performance that has arisen through specific anxiety
conditioning experiences and which is manifested through
combinations of affective, cognitive, somatic and behavioural
symptoms. It may occur in a range of performance settings,
but is usually more severe in settings involving high ego
investment and evaluative threat. It may be focal (i.e. focused
only on music performance), or occur comorbidly with other
anxiety disorders, in particular social phobia. It affects
musicians across the lifespan and is at least partially
independent of years of training, practice and level of musical
accomplishment. It may or may not impair the quality of the
musical performance.

You will notice that the definition distinguishes performance anxiety

from social phobia. Although the two conditions share common
features, in particular, the nature of the faulty cognitions that
underpin anxious responding (e.g. likelihood and consequences of
negative evaluation), there are also significant differences between
social phobia and music performance anxiety (for a detailed
discussion, see Kenny, 2008). Several theories attempt to account
for the central theme in social phobia - the fear of negative evaluation
(Beck, Emery & Greenberg, 1985; Leary, 1983; Rapee & Heimberg,
1997; Schlenker & Leary, 1982; Strauman, 1989). These theories
propose that a discrepancy between the motivation to make a
desired impression and the perceived (in)ability to make that
impression triggers anxiety. Dysfunctional cognitive schemas,
comprising negative core beliefs and assumptions regarding oneself
and others are activated during the appraisal phase of a threatening
event. The individual then assesses their ability to cope with the
situation by following rigid rules and enacting safety behaviours,
such as avoiding or escaping the perceived threat. The result is an
anxiety response, which feeds back into the core beliefs and
assumptions in a vicious cycle. Two key differences between social
phobia and music performance anxiety are that people with music

9
performance anxiety are more likely to be concerned about their
ability to competently perform the task rather than others’
perceptions and are much more likely to remain in the threatening
(performance) situation than people with social phobia. Highly
performance anxious people demonstrate reliable differences in the
way they think about performance situations compared with low
anxious people. These are summarized in Table 3.
Table 3 Differences between high and low performance anxious
individuals:
High (vs low) performance anxious individuals show:
o stronger negative expectancies before the event
o stronger negative bias in their retrospective self-evaluations of
performance
o stronger expectation that their performance will be judged
negatively by their examiners/audience
o Stronger concerns about the consequences of a poor
performance
o heightened responsiveness to changes in reactions of judges
or audience
o failure to derive comfort from evidence that they have handled
the situation skilfully (Wallace & Alden, 1997).
_________________________________________________
Performers need a certain amount of arousal or anxiety to maximize
their performance. Increased anxiety can, under certain conditions,
facilitate performance, especially for performers with high task
mastery, and this in turn is associated with better adjudicator ratings
(Steptoe & Fidler, 1987). More experienced performers may need
more anxiety in order to achieve peak performance (Steptoe, 1989;
Wolfe, 1989). Therefore, we can distinguish between the positive
aspects of anxiety, such as arousal and intensity that enhance
performance and negative aspects such as apprehension and
nervousness that may impair performance (Mor, Day, Flett & Hewitt,
1995). These are issues that must be addressed when planning
interventions for music performance anxiety and for musicians who
wish to learn to manage their performance anxiety. Treatments for

10
music performance anxiety need to promote sufficient relaxation to
counteract the negative symptoms of excessive arousal, while
maintaining sufficient arousal and concentration needed for an
optimal musical performance (Brotons, 1994). There will be more
detailed discussion on prevention and management later. First, we
need to understand the elements that contribute to an optimal music
performance, as these elements must be included in treatments for
music performance anxiety.
Optimizing music performance
“…if excitement is merely a form of anxiety that is expressed
positively, then anxiety, under certain conditions, can be regarded
as a salutary component of living. . . .anxiety supplies essential
creative energy . . . and that, instead of running away from anxiety,
it is wisest to "move through it," achieving a measure of self-
realization in the process”iii.

Performance anxiety is a more complex phenomenon than other

anxiety disorders, because of its multi-faceted nature. Both
psychological theories and performance theories are needed to
understand this phenomenon. Performance theories are
distinguished from psychological theories of performance anxiety in
that their focus is on maximizing performance rather than alleviating
psychological distress. It is often assumed that successful
performance, once reliably achieved, will reduce psychological
distress (Kenny, 2004; Powell, 2004; Wilson, 2002). Of course, this
is not always the case, as we shall see later when we discuss some
case studies of performance anxiety.

It is important to prepare all aspects of the performance because

performers have a finite capacity to attend to relevant cues in the
performance setting and as arousal or somatic or cognitive anxiety
increases, the range of cues to which one can attend reduces
(Easterbrook, 1959). Individuals take in cues from the environment
or from their own movements that aid in performance. As arousal
increases, performers may reduce attention to the cues needed to

11
regulate performance. At some optimal level of arousal, the most
effective combination of attention to relevant cues seems to exist.
Reduction in the use of appropriate cues will result in deterioration
in performance quality. This process is called perceptual narrowing
(Kahneman, 1973). High cognitive anxiety can result in
preoccupation with extraneous stimuli (e.g. negative self-talk, focus
on audience reactions) that are irrelevant to the performance task
and which interfere with the attention needed to meet the challenges
of the task. Hence, performance preparation such as visiting the
venue and practising in the performance setting may be helpful to
anxious performers. Integrating performance setting cues into
performance preparation reduces the demands on attention on the
day of the performance. This may improve confidence, lower anxiety
and enhance performance quality.

An optimal performance is determined by a complex interaction

between person characteristics, task characteristics and
performance setting. These are summarized in Table 4 and are
discussed in more detail below.

Table 4 Optimal performance is associated with:

o awareness of and management of personal vulnerabilities
such high trait anxiety
o adequate practice and preparation
o a match between task complexity and skill level
o achievement of task mastery such that the complex motor
tasks required to perform are (over)learnt to the point of being
automatic (Oliveira & Goodman, 2004)
o familiarization with the performance venue, and
o adequate rehearsal with other performers in the case of
ensemble performance.

When all of the characteristics described above occur at an optimal

level, the performer is said to be “in the zone” (Young & Pain, 1999)
or to have achieved a state of “flow” (Marr, 2000). Another construct
to describe peak performance, borrowed from sport psychology, is

12
the “individualized zone of optimal functioning” (IZO) (Hanin, 1986),
that is, the performer has achieved the optimal level of pre-
performance anxiety that results in a peak performance. “Optimal”
pre-performance anxiety that creates excitement and enhances
mental focus and alertness predicts performance quality (Turner &
Raglin, 1991).
Task complexity
Probably the most quoted figure in the history of psychology is the
Yerkes-Dodson Inverted U curve (Yerkes & Dodson, 1908), which
was developed to explain the relationship between the amount of
physiological arousal experienced by a performer and the quality of
their performance. As Figure 1 shows, the law states that a
moderate level of arousal results in the highest level of performance.
Arousal that is too low or too high impairs performance.

High
Performance

Low High

Physiological arousal

Figure 1 Yerkes-Dodson curve

However, the relationship between arousal and performance is

more complex than this and several theories have emerged to
further contribute to our understanding. Most of these theories have
been developed in sport psychology and have yet to be tested in the
area of music performance anxiety. One of these theories, the
Multidimensional Anxiety Theory (Martens, Burton, Vealey, Bump, &

13
Smith, 1990) identified two distinct and partially independent
components to competitive sport anxiety – cognitive anxiety and
somatic anxiety. A time to event paradigm derived from this theory
demonstrated the dissociation between these two forms of anxiety.
Hence, somatic anxiety (negatively-valenced physiological arousal)
cannot be considered in isolation, but assessed in the context of the
degree and timing of cognitive anxiety. This is illustrated in Figure 2
that shows that cognitive anxiety can be high and somatic anxiety
low two days before the performance, with somatic anxiety rising
sharply shortly immediately before the performance.

Figure 2 Marten’s et al., (1990) time to event paradigm (in McNally,

2002)

A number of other important interactions have been observed

between the inverted U and task complexity. For example, optimal
performance on simple tasks will increase as arousal increases, but
will deteriorate on complex tasks after a moderate level of arousal is
exceeded (Tassi, Bonnefond, Hoeft, Eschenlauer, & Muzet, 2003)
(see Figure 3).

14
 Arousal and task complexity

Good
High complex task Low complex task
Performance

Poor

Low High
Arousal
Figure 3 The relationship between physiological arousal and task
complexity

Focused attention shows a similar relationship, increasing when

there are low to moderate levels of arousal but decreasing with very
high levels of arousal (Mather, Mitchell, Raye, Novak, Greene, &
Johnson, 2006). When arousal is high, one's attention to peripheral
cues in the situation is reduced and there is a greater focus on highly
salient central stimuli (Libkuman, Stabler, & Otani, 2004).
The location of the curves on the continuum of low to high
physiological arousal also depend on other factors, such as the
performer’s level of trait anxiety and their degree of task mastery
(Kokotsaki & Davidson, 2003); that is, different levels of arousal are
optimal for different performers (Salmon, 1990). Those high in trait
anxiety will require lower levels of arousal to achieve an optimal
performance compared with low trait anxious individuals who need
higher levels of arousal to achieve their best performance.
Task mastery
A similar relationship has also been observed between the degree
to which the task has been practised to mastery (automaticity) and
the amount of physiological arousal needed to produce an optimal
performance. As Figure 4 shows, even at ideal levels of arousal, low

15
practice will produce a suboptimal performance. A well practised
piece will be performed well at higher levels of arousal but will also
suffer if arousal exceeds a certain optimal maximum (Kokotsaki &
Davidson, 2003).
Arousal and task learning

Good High practice

Low practice
Performance

Poor

Low High
Arousal
Figure 4 The relationship between physiological arousal and task
mastery
Performance setting
It is almost a truism to say that musicians are more likely to feel
anxious under conditions of evaluation, such as competitions, jury
performances and concerts/recitals than they would under practice
conditions. Brotons (1994) examined this question to determine
whether musicians’ physiological and psychological responses and
behaviours are affected by jury compared to non-jury performances
and whether the type of jury mattered i.e. whether it was an open
jury (both performer and adjudicators were known to each other) or
double-blind (neither performer nor adjudicators are known to each
other). Results showed significant increases in heart rate and state
anxiety between jury and non-jury performances but no differences
between open and double blind jury conditions.

Other situational factors influencing the occurrence and experience

of performance anxiety include the presence or absence of an

16
audience and its size, status, and perceived competence (Craske &
Craig, 1984; Fredrikson & Gunnarsson, 1992; Hamann, 1982;
LeBlanc et al., 1997; Ryan, 1998). Larger audiences whose
members are respected by the performer for their status in the field
and expert knowledge of their repertoire will elicit more performance
anxiety than audiences without these characteristics. Moreover, the
size of the ensemble influences the level of anxiety, with solo
performances eliciting the highest anxiety, followed by small
ensembles, orchestras, and teaching settings (Cox & Kenardy,
1993; Jackson & Latane, 1981). Table 5 itemizes the key features
that need to be considered when assisting a student to achieve an
optimal performance.
Reducing music performance anxiety
Music performance anxiety has a complex etiology and needs
careful management. The best treatment is always prevention,
because, like many psychological disorders, complete cure is not
always possible. Much is known about how to achieve healthy
development and this knowledge can be applied in the service of
preventing or minimizing conditions such as performance anxiety. A
four-pronged approach involving prevention, practice, pre-
performance routines and therapy is presented as a cost-effective
method of reducing the negative effects of anxiety on performance.
Prevention
Good pedagogues have a sound knowledge of their domain content,
including repertoire, instrument management, and health and safety
issues related to musical performance. In addition, they must come
to understand each of their students individually, learning to which
teaching strategies they respond best, how they react to feedback,
how anxious they feel during lessons and performances, how much
they enjoy learning their instrument and other demands they face in
their lives. Individuals differ with respect to their musical ability in
much the same way that they differ in other abilities such as
mathematical and abstract reasoning. Teachers need to be guided
by their students with respect to the pace of progress and complexity
of repertoire introduced. Students must have a sense of progress

17
and accomplishment to maintain motivation. Demands that exceed
capacity will soon result in either demotivation and despondency or
anxiety, both of which can have deleterious effects on progress. Both
cognitive and physical limitations need to be considered, the latter
with respect to young students whose fine motor skills in the hands
and fingers do not fully develop until relatively late in the early
lifespan.

Anxiety has received by far the most attention in discussions of

performance anxiety, but there are many other factors that interact
to affect the quality of performance in musicians. For example,
causal attributions, that is, the explanations given by performers
for performance outcomes predict future performance (Peterson,
2000; Seligman, 1991). Those who attribute negative outcomes to
stable (i.e., factors that cannot be changed) causes (e.g., lack of
ability) compared with unstable (factors that can be changed) causes
(e.g., inexperience, lack of practice) are more likely to feel hopeless
about improving their performance skill, while those who attribute
positive outcomes to stable causes (e.g., hard work) compared with
unstable causes (e.g. luck) are more likely to feel hopeful about
future performances. These attributions affect motivation, which in
turn affects commitment to training or practice, which in turn affects
performance.

Attentional and cognitive styles (Baghurst, Thierry & Holder,

2004), goal setting, self-monitoring, self-regulation, self-
confidence and self-efficacy are other factors that affect
performance (Behncke, 2002). While these factors have been
studied in sport psychology with reference to athletic performance,
their impact on musicians and musical performance has yet to be
determined. Although pedagogy should be based on the best
available evidence, it is reasonably safe to assume that all of these
factors will play a role in both the degree of anxiety experienced
during music performance and in the quality of the performance
achieved.

18
Perfectionism is another personality trait that has been poorly
evaluated in musicians. Mor, Day, Flett, and Hewitt (1995)
investigated this trait in 49 professional classical musicians and
found that performers with higher personal standards of perfection
(eg. “I must work to my full potential at all times”) and social
standards of perfection (eg. “The people around me expect me to
succeed at everything I do”) experienced more debilitating anxiety
than those performers who did not score highly on these items.
Another study, using the Frost Perfectionism Scale on a sample of
138 university instrumental music students reported a significant
relationship between some dimensions of perfectionism (high
concern over mistakes, high doubts about actions and low personal
standards) and performance anxiety (Sinden, 1999). In a
subsequent study, Kawamura, Hunt, Frost, and DiBartolo (2001)
found that maladaptive perfectionism was related to a social/trait
anxiety/worry factor. The effect of perfectionism on performance
quality has not been evaluated, but the vigilant teacher will be alert
to statements by their pupils in this regard and will take steps to
assist the student to make a more realistic appraisal of their abilities
and expectations for their performance based on this appraisal.
Table 5 summarizes the key principles of sound pedagogy.

Table 5 Principles of sound pedagogy

o Awareness of cognitive capacity and limitations of students
o Choosing repertoire at level of physical and musical
development
o Ability to tailor teaching to cognitive style and level of
development
o Attunement to psychological characteristics e.g., anxiety,
attributions of success and failure, perfectionism, motivation,
coping, self-concept that affect performance
o Use of ideal teaching practices that involve goal setting, sound
practice techniques and performance routines

19
Goal setting, practice and performance preparation
Effective practice is a foundational skill to both prevent and manage
performance anxiety. Regardless of the performer’s degree of skill
and confidence, without practice, that skill cannot be expressed to
its full potential and confidence will be eroded with successive
experiences of sub-optimal performances. Performance preparation
is another essential pre-cursor to successful performance so I would
like to address a few comments to a key question that concerns the
determinants of individual differences in skilled performance. There
are three overlapping factors that affect the level and quality of skill
acquisition – the innate characteristics of the learner, quality of
pedagogy/training, and nature of the task. The key task factors
are the:

(i) extent to which the task requires speed and accuracy of

motor movements;
(ii) consistency with which the performer can reproduce the
tasks on each occasion of practice; and
(iii) degree to which the task depends on expert knowledge and
abstract reasoning abilities.

Consider for example skilled performances such as driving a motor

car or word processing on a computer. The majority of individuals
are capable of acquiring these skills and consistent practice has the
greatest impact on the quality of performance. Practice develops
speed and accuracy in these tasks to the point that people are able
to drive a car while thinking about other things; that is, the
performance becomes automatic. Practice on tasks of this type
leads to a reduction in the variability in performance across
individuals. However, for more complex tasks, like learning to play a
musical instrument, some individuals attain a level of great skill,
complexity, speed and accuracy, while others do not progress
beyond the status of a novice. This is due to the fact that a greater
number of component skills are required for skilled musical
performance and the scope for individual differences is larger the
more complex the task. For musical performance, one needs

20
conceptual, analytical and musical/aesthetic skills to understand and
interpret the musical language, and high level psychomotor abilities
and perceptual speed to execute the musical task. Individuals who
eventually achieve excellence as performing artists will need to have
excellent skills in each of these components. Although practice
remains the best predictor of individual differences in skilled
performance requiring motor speed, it is not sufficiently explanatory.
Type of practice is very important – that is, whether the student
practises with purpose and motivation – is particularly important in
skill acquisition in sport and music.
Goal setting and goal type
This leads us into a discussion of the role of goal setting and goal
type as useful components in anxiety reduction. Goal setting and
goal type are associated with performance outcome and students
need to be inducted early in their training into thinking about their
goals for each performance so that it becomes an integral part of
their performance preparation (Barron & Harackiewicz, 2001; Elliot
& Church, 1997; Harackiewicz, Barron, Pintrich, Elliot, & Thrash,
2002; McGregor & Elliot, 2002). Performance goals are of three
kinds – skill-based (mastery focused), interpersonal (striving for
success or avoiding failure) or process oriented (how one manages
their performance). Mastery and performance goals facilitate optimal
performance in athletes (Jackson & Roberts, 1992; Lacaille et al.,
2005), but only when the goal is realistic and achievable. Unrealistic
goals increase cognitive anxiety and are likely to be abandoned as
the performance approaches. Performance and mastery goals also
predict educational achievement and outcomes through their effect
on how challenges are appraised, the degree to which students
engage with the task and their level of aspiration during exam
preparation (McGregor & Elliot, 2002). Performance approach (but
not performance avoidance) goals also predict long-term academic
outcomes (Harackiewicz et al., 2002). One study with tertiary music
students (Lacaille et al., 2005) showed that mastery goals and
intrinsic goals (i.e., goals focused on enjoyment rather than
achievement) were beneficial in facilitating peak performance.

21
These goals can be built into the preparation phase of a
performance, in which skill development, aesthetic features of the
music, and enjoyable aspects of the impending performance are
emphasized (Lacaille et al., 2005).
Performance routines
Performance routines are sequences of mental operations and
behavioural actions that assist in the development of an optimal
mental state for skill execution and maintenance of attentional
control during performance. These routines encourage the
performer to remain grounded in the performance moment in order
to prevent the switch of attention to consciously monitoring skills that
may interfere with automatic performance (Beilock & Carr, 2001;
Boutcher, 1990; Lavallee et al., 2004). Performance routines
comprise psychological, physiological and behavioural components
that facilitate focus on task-relevant cues, establish optimal
physiological arousal and appropriate (motor) behaviour. There are
a number of possible components in these routines that need to be
developed with practice over an extended period of time. These
include application of previously learned relaxation responses to
cues associated with stimuli that are present prior to a performance
(this is called cue-controlled relaxation); creating a mental image of
ideal skill execution, pairing this image with the necessary
kinesthetic skills needed to execute the task and then focusing
attention on the ideal performance outcome. Other strategies include
intensely focusing on an object or thought in order to block unhelpful
distractions such as negative cognitions of self-doubt and fear of
failing. The routine culminates in automatic skilled performance (that
is, performance in which conscious attention to the component parts
of the performance is suppressed), allowing the body to execute the
task as an integrated smooth movement (Singer, 2000). This state,
if achieved, is described as “flow,” a concept discussed earlier.

In situations in which the performance does not go well or as well as

expected, post-performance routines may also be useful. The
principal aim is to prevent transfer of mistakes in the performance

22
becoming cemented into subsequent performances. Performers
may need emotional release immediately after the performance but
protracted focus on the negative aspects of the performance should
be avoided. Note should be taken of the problematic passages for
the purpose of targeted intensive practice and enhanced kinesthetic
rehearsal of the correct skill.

Performance routines must be devised with careful consideration of

the characteristics of the learner and the situation. They develop with
maturation, experience and practice. Younger musicians will begin
with short and simple performance routines and gradually evolve
these into routines that are effective for their particular capacities
and needs. The content of performance routines must be tailored to
the child’s level of cognitive development and to the stage of skill
acquisition they have reached on their instrument. Young children
are not capable of abstract thought, have difficulty with future
orientation and have not yet developed meta-cognitive skills (i.e., the
capacity to think about one’s own thinking processes). The difficulty
of the task and situational pressures are also important factors to be
considered. Easy tasks performed in low pressure situations are
unlikely to need well developed performance routines compared with
difficult tasks in high pressure situations.
Therapy for music performance anxiety
Most music teachers are not trained psychologists, yet an essential
part of their role is to assist their students develop their musical
potential to the level to which each is capable. In order to do this,
teachers need to address issues that arise in the learning process.
These include students’ level of physiological arousal, cognitions,
emotions, goal setting and use of strategies to manage the many
challenges that face aspiring musicians. Most of these issues can be
adequately managed within the teacher-student relationship,
provided that the teacher is well trained and possesses a sufficient
level of empathy and insight to guide their students through the
sometimes treacherous waters to musical mastery.

23
When the teacher becomes aware that the student’s level of anxiety
is such that progress and enjoyment are being impeded, it may be
time to seek professional advice. There are many available
treatments for the anxiety disorders in general and a growing body
of research on effective treatments for music performance anxiety
(see Kenny, 2005). Good programs share common features
(Andrews et al., 2003; Conrad & Roth, 2007) and these will be briefly
discussed below:
(i) Adequate assessment

Treatment of music performance anxiety commences with an

adequate case formulation that explores causes, triggers and
maintaining factors. The problem is defined according to the
subjective statement of their experiences by the musician (examples
are given in the Experience in Focus section of this chapter). These
can reveal a great deal about the nature, severity, timing and
occurrence of the problem and are used to develop a tailored
program to address the specific issues raised. Although cognitive
and somatic anxiety are both strongly implicated in performance
anxiety, an important question concerns how they interfere with
individual performance. These include their effects on motivation
(Yoo, 2003), cognitive and attentional interference (Erickson,
Drevets, & Schulkin, 2003), distraction (Harvey & Payne, 2002) and
reduced cue utilization (Easterbrook, 1959). Dispositional self-
consciousness and trait anxiety are additional factors that have been
associated with performance impairment (Wang, 2002) and all these
factors needed to be assessed before a treatment program is
developed. In addition, the fit between the performer and music
needs to be assessed as well as more general issues of musician
health and health practices. Table 6 provides a summary of the
factors that need to be assessed in case formulation.

24
 Table 6 Factors to assess in music performance anxiety
Psychological
1. Negative attitudes and emotions
(a) Fear of failure (fear of getting worried & tense, fear of making
mistakes) wrong notes, over-focused on making mistakes
(b) Fear of success
(c) Fear of disapproval (e.g., negative past performance
experiences)
(d) Fear of losing control
(e) Fear of problems with distraction or memory problems such as
forgetting lyrics, notes or fingering
(f) Lack of confidence in ability (not feeling good enough,
believing others are better, feeling like a fraud)
2. Unrealistic or no goals
3. Negative or no mental rehearsal
4. Poor concentration, no refocus plan e.g., when there are
equipment problems or failure, conductor indicates faster
speed than rehearsals
5. Poor pre-performance routine
Musical
1. Poor technical preparation & practice methods
2. Focusing too little on emotional intention, poor emotional
connection with the music
3. Don’t enjoy performing
4. Don’t like the music
5. Insufficient performance experience
6. Insufficient performance simulations e.g., unfamiliarity with
performance venue
Physical
1. Poor health
2. Lack of sleep
3. Poor nutrition
4. Poor control over bodily tension
5. Use of alcohol, drugs or medications
6. Performance-related musculoskeletal disorders
_____________________________________________

25
(ii) Psycho-education
Psycho-education provides corrective information about the nature
and origins of anxiety and how people can engage in either adaptive
or maladaptive responses to feared stimuli. Anxiety is defined as a
universal emotion that protects us from harm and motivates us to
achieve our goals. The goal is not to eliminate anxiety, but to reduce
it to manageable levels and to use it in the service of performance
enhancement.
(iii) Cognitive therapy
Anxious people show marked differences in the way they perceive,
interpret and think about situations that involve challenge, threat and
evaluation. This component of treatment helps them to articulate
these faulty cognitions, to assess them and to replace them with
more realistic thoughts that help reduce their anxious responding.
(iv) Exposure
An automatic reaction to threat is to run away, thereby escaping or
avoiding the unpleasant experience of anxiety and its attendant
negative cognitions. However, such behaviour, while effective in the
short term, cements the fears surrounding the feared situation
because there is no opportunity to challenge it. Exposure refers to
the component of therapy whereby the person is “exposed” in a
graded manageable way to the feared situation so that they can
implement their new skills in anxiety management directly in the
feared situation. This component underpins most treatments for
anxiety and the anxiety disorders, regardless of its type.
(v) Structured problem solving
Structured problem solving teaches rule-governed behaviour that
reduces unfocussed worry. It involves precise problem identification,
uncritical brainstorming of possible solutions, selection and
implementation of the best strategy to solve the problem, and
evaluation of the outcome.
(vi) Somatic management
If somatic anxiety is severe, therapy will need to include a
component for somatic symptom management. This usually involves
some form of relaxation training, such as progressive muscle

26
relaxation, breathing techniques, and cue-controlled relaxation
strategies that can be implemented in the feared situation.
(vii) Relapse prevention
Relapse prevention involves equipping people with skills and
strategies to self-manage future challenges once the therapy has
concluded. In the early stages after termination of therapy, it is useful
to schedule “booster” sessions spaced further apart than the therapy
sessions, in which progress is monitored and strategies assessed
and updated. In these sessions, the therapist takes on the role of
coach, encouraging their client to suggest their own solutions to
impending difficult situations.
Health and wellbeing in focus
Evidence in Focus
The literature has often confused the terms “music performance
anxiety” and “stage fright” or used them interchangeably. Stage fright
should be understood as an extreme form of music performance
anxiety in which performance breakdown occurs. Such self-
presentation catastrophes, also described as “choking” or “freezing,”
usually involve a panic-like reaction and result in performance
impairment or breakdown, or the performer avoiding or leaving the
scene. These extreme forms of performance anxiety do occur,
however rarely, and need to be explained. Two models that have
received considerable attention in the sport performance literature
are the performance catastrophe model (Hardy, 1990; Hardy &
Parfitt, 1991) and the multidimensional anxiety theory (Martens et
al., 1990), discussed earlier. Neither of these theories have received
strong empirical support. Recent studies attribute positive results in
earlier studies to methodological limitations. For example, in a recent
re-analysis of several studies using seven levels (13, 25, 40, 50, 75,
89%) of maximum arousal, catastrophe theory’s predicted
precipitous drop in performance was not replicated; rather,
performance showed gradual decline when participants’ cognitive
anxiety dominated over their self-confidence (Landers & Lochbaum,
1998). Similarly, contrary to multidimensional theory, cognitive and
somatic anxiety have also been shown to co-vary rather than act

27
independently. Further, the discrepancy between goal attainment in
previous performances and goal aspiration for future performances
may heighten both anxiety and motivation, provided that the goal
discrepancy is not so great such that the probability of success is
perceived to be (or is actually) low, in which case anxiety will remain
high but motivation will show a significant decrease.

In the past few years, new theories have been proposed that add to
our knowledge and understanding of performance impairment under
pressure, commonly known as choking. The most prominent are
distraction theory and self-focus or explicit-monitoring theories.
Choking occurs under conditions of high pressure to perform well.
Although we all wish to perform well under pressure, some
performers experience performance pressure as an excessively
anxious desire to excel at their performance and as a consequence
some will perform more poorly than expected given their level of skill
and preparation. Although there are still some unresolved issues
regarding theories of choking, most researchers agree that it is
fundamentally a problem of (in)attention. There are two key
explanations for choking.

Distraction theory: Distraction theories propose that pressure

creates a dual-task situation in which skill execution and anxiety
about the performance compete for the attentional and working
memory capacities needed for the performance (Beilock & Carr,
2005). However, pressure does not result in a uniform loss of
performance capacity but is dependent on the nature of the task
being performed. Tasks that rely heavily on working memory are
more likely to be affected by performance anxiety or pressure to
perform than tasks that are performed more intuitively or
automatically (Maddox & Ashby, 2004). Distraction theory accounts
best for complex cognitive tasks (such as mathematical problems)
not based on an automated or proceduralized skill representation
(such as playing a concerto from memory). For the latter type of task,
a decrement in working memory capacity may actually improve
performance by forcing reliance on the automatic (i.e., over-learned)

28
processes used to achieve skill mastery. Choking is a relatively
infrequent occurrence and is more likely to occur for only the most
difficult problems that make large demands on working memory and
that have not been highly practiced or automated.

Self-focus or explicit monitoring theories of choking suggest

that pressure-induced performance decrements result from the
explicit monitoring and control of proceduralized knowledge that is
best performed as an uninterrupted and unanalyzed whole. This type
of performance does not rely on conscious execution of the
component skills and tasks that make up the total performance of
skilled physical actions such as golf putting and tennis strokes.
Maximum consistency of performance occurs using motor loops that
allow the performer to operate at a subconscious (non-cognitive)
level; that is, automatically, integrating all of the components of the
task into a single smooth action based on sensory and motor
feedback. When this process works optimally, the performer is
described as operating ‘in the zone’ or experiencing ‘flow.’ This
account of choking is akin to the automatic execution model
(Baumeister, 1984), the basic premise of which is that choking
occurs as a result of the inhibition of well-learned or automatic skills.
Performance anxiety may disrupt the normal functioning of feedback
loops by making previously automatic actions conscious, thereby
interfering with the smooth, integrated performance of the action.
Thus, if, during the performance of an expert task such a playing a
piano sonata from memory, the pianist switches to explicit-
monitoring of the performance, such as thinking, for example, “I hope
I remember the key change in the recapitulation,” this may hinder the
processes underlying its automatic production, thus leading to
performance impairment or breakdown.
Evidence to date supports the assertion that distraction theories of
choking are more applicable to challenging cognitive tasks (such as
mathematical problem solving), while explicit monitoring and
automatic execution theories of choking apply more to tasks based
on sensorimotor skills, such as sport performance. Music
performance is a complex mix of both of these types of tasks.

29
Learning a difficult musical piece involves a range of cognitive skills
but ultimately is dependent on mastery of the automatic motor tasks
required for executing the performance. Both theories of
performance impairment may prove appropriate to music
performance, perhaps at different stages of learning, and future
research can usefully explore these theories applied to music
performance.
Experience in focus
Below are some first person accounts of musicians’ experience of
music performance anxiety. They are presented with a view to giving
teachers and students some useful ideas about how to address the
presenting symptoms of this condition and to highlight the diversity
of possible responses to this condition. We will start with an account
from one of the greatest romantic pianists of his age, Claudio Arrau.
In response to a question about how he felt when something went
wrong during a performance, Claudio Arrau answered:

“I used to think it was the end of the world. It sometimes took months
for me to recover. I wanted to be perfect, divine-beyond any flaw or
memory mistake. But that always produces the opposite effect. Now
I don't get so upset. . . You know what would happen in my very early
years if something went wrong? I gave up. I kept playing but I gave
up. As if the rest didn't count.”iv

Music performance anxiety affects both experienced and

inexperienced performers, and those who have reached the dizzying
heights of international fame are not immune to its effects. In this
short excerpt of this interview with Claudio Arrau, we can detect a
number of features that would need to be targeted in a performance
anxiety management program. Firstly, this account is dominated by
cognitive anxiety and faulty cognitions, so the focus in therapy for a
performer giving such an account would be focused on the cognitive
aspects, as opposed to the somatic aspects of performance anxiety.
Most of the features of cognitive anxiety are present in this short
description – catastrophic thinking, perfectionism, unrealistic goal
setting, post-performance rumination and inability to take pleasure

30
or comfort in the positive aspects of the performance. The first
statement is an example of catastrophic thinking – if one wrong note
is played during a performance; it is perceived as “the end of the
world.” What could be more catastrophic than the end of the world?
When musicians make such statements, we need to understand the
precise thoughts and ideas behind the words, which are really a
metaphor for the intensity of the anguish felt. Does the musician
believe that one wrong note will end his performance career? Result
in loss of status and respect within the musical community? Lead to
a reduction in engagements? Produce feelings of intense
disappointment and self-criticism? Careful questioning will reveal the
actual meaning of this expression, which can then be examined and
reframed into a more realistic statement. The second statement
gives the clue to the intended meaning: “I wanted to be perfect,
divine-beyond any flaw or memory mistake.” The wish to be perfect,
divine and flawless is an unattainable goal, even for the most
consummate artist. Striving to achieve unattainable goals results in
frequent experiences of (perceived) failure, which eventually evolve
into a vicious cycle of sub-perfect performance, followed by
disappointment and hopelessness. A third element completes the
vicious cycle - post-performance rumination. This situation is most
unhelpful and needs to be managed. The psychological energy
expended in ruminating about each performance error for months is
likely to leave the performer depleted and self-doubting, a situation
that exacerbates the sense of defeat, hopelessness and
helplessness. This is in fact what Arrau reports – “I kept playing but
I gave up. As if the rest didn't count.” Note that he cannot take
comfort in the “rest” - by which I presume he means the other 99%
of the performance that went well. As his career progressed, Arrau
reports that he did not get as upset as he did as a young performer.
Nonetheless, one can imagine that public performances could
potentially still take a great toll on Arrau’s subjective well-being.

Below is an account of a young oboist describing how somatic

anxiety affects him during performance:

31
“On the day of a performance, I’ll start getting quite nervous, just
feeling a bit agitated. When I step out to perform, I look quite
confident; I know how to look confident and people comment that I
look calm and fine. But as soon as I raise the instrument to play, my
hands start to shake and my mouth gets very dry. It is really annoying
to have a dry mouth because it never happens in your practice at all.
When I practice, I am usually drying out my instrument.”

Unlike the previous account, in which the focus was on cognitive

anxiety, this performer reports primarily somatic anxiety, a kind of
wordless (“agitated”) state that is characterized by physiological
arousal that is experienced as performance impairing. Individuals
vary in the degree to which they experience somatic arousal and the
body systems affected. From the range of possibilities, this young
oboist reports shaking hands and dry mouth. It is not uncommon for
people who experience somatic anxiety to learn to cover it, as this
young man does – he “knows how to look confident…calm and fine.”
Note how proximal to the commencement of his performance his
symptoms occur. As the above account indicates, it is common for
somatic anxiety to be minimal in the days before a performance and
then to rise rapidly as the concert approaches. This can be very
disconcerting, because it leads to a sense of loss of control which,
in vulnerable individuals, may progress to panic and possible
performance breakdown if the work is not (over)learned to the point
of automatic execution. The focus on anxiety management for this
musician will be learning how to reduce the physiological effects of
his anxiety through performance-cue controlled relaxation training
and simple measures like having a bottle of water in the wings (in
addition to making certain that all the precursors to an optimal
performance have been addressed).

Here is another vivid account of the subjective experience of

performance anxiety.

“Once the fear of embarrassing myself grabbed me, I couldn’t get

loose. It was as if a big bizarre and terrifying unreality had replaced

32
everything that was familiar and safe. In the grip of my wildest fears,
I was paralyzed, certain that if I made one wrong move, I would
literally die. The harder I tried to remember the words, the more
elusive they became. The best I could do was not to black out, and
I got through the show, barely, telling myself repeatedly, ‘Stay
conscious, stay conscious’.” v

This description comes from Donny Osmond, who enjoyed an

international career as a pop singer for over 20 years. His account
contains reference to an extreme combination of cognitive/emotional
(“fear of embarrassing myself” and “making one wrong move”) and
somatic anxiety (paralysis and fear of blacking out) that resembles
descriptions given by people who suffer from panic disorder. Note
the language used – the fear that grips him is like a “big bizarre and
terrifying unreality” in which he feels “paralyzed” and afraid that
would literally “die” if he made a mistake. His fear of blacking out
may have been related to hyperventilation, a common symptom of
panic. (For a detailed treatment of panic in performance, see Kenny,
2008). Such extreme responses to performance may have their
origins in early childhood experiences, in which the child may have
been exposed too early to the scrutiny of public opinion by adults
who had high expectations but who did not provide sufficient support
or opportunities to experience mastery over their environment
(Barlow, 2002). When there are other significant psychological
issues involved that complicate the experience of music
performance anxiety, a combination of psychotherapy and symptom
focused treatments may be the best approach.
Summary and Conclusions
o Music performance anxiety is a complex condition that may
affect the musicians’ overall wellbeing, their enjoyment of
performing and the quality of their performances. In extreme
cases, it may end their music career.
o Performance quality is determined by a complex interaction
between person characteristics, task characteristics, and
performance setting.

33
 o Person characteristics include trait anxiety, perfectionism,
cognitive and musical ability and attributions of success and
failure.
o Task characteristics include task complexity and task mastery.
o Situational characteristics include the size and composition of
the audience, whether the performance is competitive or
involves evaluation, the importance placed on the performance
by the performer and the perceived consequences of a poor
performance.
o Prevention of music performance anxiety through the
integration of pedagogy, practice and performance preparation
in the music learning experience is preferable to treating the
condition once it has arisen.
o Essential elements in the treatment of music performance
anxiety include adequate assessment, education, cognitive
restructuring, exposure, problem-solving, management of the
somatic symptoms and techniques to support relapse
prevention.
o Music performance anxiety should be distinguished from other
anxiety disorders, in particular, social phobia or social anxiety,
and from stage fright.
o Some theoretical explanations for stage fright, the most severe
form of music performance anxiety, include distraction theory
and self-focus or explicit monitoring theories of choking.
o The chapter concluded with three case studies that
demonstrate the very different phenomenological experiences
of the condition and how detailed subjective reporting forms
the basis for effective intervention.
Further information and reading
Ackermann, B.J., Kenny, D.T., O’Brien, I., Driscoll, T.R. (2014).
Sound Practice: Improving occupational health and safety for
professional orchestral musicians in Australia. Frontiers in
Psychology, 5, 1-11.
Kenny, D.T. (2005). A systematic review of treatment for music
performance anxiety. Anxiety, Stress and Coping, 18(3),183-
208.

34
Kenny, D.T. (2008). Negative emotions in music making:
Performance anxiety. In P. Juslin, & J. Sloboda (Eds).
Handbook of Music and Emotion: Theory, Research,
Applications. Oxford, UK: Oxford University Press.
Kenny, D.T. (2011). The psychology of music performance anxiety.
Oxford, UK: Oxford University Press.
Kenny, D.T. and Ackermann, B. (2008). Optimizing physical and
mental health in performing musicians. In Susan Hallam, Ian
Cross, Michael Thaut (eds.). Oxford Handbook of Music
Psychology. Oxford, UK: Oxford University Press.
Kenny, D.T., & Ackermann, B. (2015). Performance-related
musculoskeletal pain, depression and music performance
anxiety in professional orchestral musicians: A population
study. Psychology of Music, 43(1), 43-60.
Kenny, D.T., Driscoll, T., & Ackermann, B. (2014). Psychological
well-being in professional orchestral musicians in Australia: A
descriptive population study. Psychology of Music, 42(2), 210-
232.
Kenny, D.T., Fortune, J. & Ackermann, B. (2013). Predictors of
music performance anxiety in skilled tertiary level flute players.
Psychology of Music, 41(3), 304 - 326
Kenny, D.T. & Osborne, M. S. (2006). Music performance anxiety:
New insights from young musicians. In Thompson, W. F. (Ed).
Advances in Cognitive Psychology
http://www.ac-psych.org/?id=2&rok=2006&issue=2#article_13
Osborne, M. S., & Kenny, D.T. (2008). The role of sensitizing
experiences in music performance anxiety in adolescent
musicians. Psychology of Music, 36, 4, 447-462.

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41
 PART 2

PSYCHOMETRIC AND CLINICAL ASSESSMENT OF

MUSIC PERFORMANCE ANXIETY

42
 CHAPTER 2

IDENTIFYING CUT-OFF SCORES FOR CLINICAL

PURPOSES FOR THE KENNY MUSIC PERFORMANCE
ANXIETY INVENTORY (K-MPAI) IN A POPULATION OF
PROFESSIONAL ORCHESTRAL MUSICIANS

By virtue of its reliability and convergent validity with clinical tests of

anxiety and depression, the K-MPAI (Kenny Music Performance
Anxiety Inventory) has the potential to identify performers who have
a clinically significant level of music performance anxiety who may
benefit from clinical intervention. In order to identify these musicians,
clinical cut-off scores are required for K-MPAI. The aim of this paper
was to assess K-MPAI against tests validated in clinical populations
in order to develop indicative preliminary cut-off scores for use with
musician populations. Receiver Operating Characteristic (ROC)
Curves were generated for established clinical screening tests
(STAI-T, ADD, PRIME-MD, SPIN) using different scores to
dichotomise these instruments with K-MPAI as the scale measure.
The cut-point for K-MPAI using Youden’s Index for STAI-T•65 (1.5
SD above mean) was 105.3; using the cut point for STAI-T•60 (1 SD
above mean), Youden’s Index for K-MPAI was 104.5. For musicians
answering yes to both depression questions on the PRIME-MD, the
K-MPAI cut-point was 118.5; for one of two questions, K-MPAI cut-
point was 110. For ADD, for those answering at least one question
affirmatively, K-MPAI cut-point was 84.5, for those answering at
least three questions affirmatively, K-MPAI cut-point was 89.5. As
previously identified, K-MPAI and SPIN were unrelated.

The K-MPAI is in wide use internationally and has been translated

into several languages. It has been described in detail in previous
studies; see, for example, Kenny (2011); Kenny, Ackermann, &
Driscoll (2013); Kenny & Ackermann (2014); Ackermann, Kenny,
O’Brien, Driscoll (2014). By virtue of its reliability and convergent
validity with clinical tests of anxiety and depression, the K-MPAI has

43
the potential to identify performers who have a clinically significant
level of music performance anxiety. However, relevant cut-off points
have not yet been identified. In order to determine the diagnostic
accuracy of the K-MPAI, its sensitivity and specificity need to be
calculated. Sensitivity refers to the “true positive” rate i.e., the
probability that a test accurately detects a condition that is present.
Specificity refers to a “true negative” rate i.e., the probability that a
test accurately detects that a condition is not present. A “false
positive” is the detection of a condition when the condition is not
present (sometimes called a “false alarm”); a “false negative” is the
failure to detect a condition when it is, in fact, present. These rates
can be represented in a 2x2 matrix as shown in Table 1.

Table 1 Matrix for representing and calculating probability of

conditions

Condition

Test Present Absent

result

Positive True positive (TP) False positive (FP)

Negative False negative (FN) True negative (TN)

All with condition (TP All without condition

+FN) (TN + FP)

Sensitivity = TP/TP +FN = TP/All with condition

Specificity = TN/TN+FP = TN/All without condition

Tests with both higher sensitivity and specificity are more

appropriate for use in clinical settings. The decision regarding choice
of test is more difficult when a test has higher sensitivity but lower
specificity than a competitor (Biggerstaff, 2000). For any given
diagnostic test, the ratio of the true-positive to false-positive rates is
described as the likelihood ratio of a positive test. Larger values of

44
this ratio indicate better discriminative ability and are the preferred
test. Similarly, higher likelihood ratios of a negative test are also to
be preferred.

Measures such as Youden’s Index [Sensitivity – (1-Specificity)]

which provide the area under the receiver operator characteristic
(ROC) curve have been identified as robust methods for determining
a test’s diagnostic or discriminative ability (Fletcher, Fletch, &
Wagner, 1996). The area under the ROC curve (AUC) provides a
prediction ability score (akin to a percent correct prediction score),
that is, the ability of the continuous measure to determine correct
binary membership. This score ranges from between 0.5, which
indicates a level of prediction no better than chance, to 1.0, which
indicates perfect prediction or discriminability, that is, 100% true
positive rate (Swets, Dawes & Monahan, 2000). An AUC value
equal to or in excess of 0.8 can be interpreted as a test with good
predictive power (Meijer, Grobbee & Heederik, 2002). The cut-off
score is the point of inflection of the ROC curve which maximizes
true positives and minimises false positives.

A possible limitation of the use of ROC curves is that only binary

diagnostic tests (i.e., positive/negative; true/false) can be used;
these may ignore the underlying continuous nature of a diagnostic
test. This limitation would certainly apply to psychological conditions;
in such cases, it is rare for categorical diagnostics with a specific cut
point to be meaningful. However, there are several advantages of
ROC curves. These include the production of a simple graphic that
allows immediate comparison of a number of diagnostic tests,
particularly in tests that may demonstrate that a decrease in
specificity may be compensated by an increase in sensitivity. For
every test, there is a trade-off between sensitivity and specificity;
achieving higher true positive rates usually means an increase in
false positive rates. The aim of a cut-off score is to maximize
sensitivity without excessively increasing the false positive rate.

45
The aim of this paper was to assess the K-MPAI against tests
validated in clinical populations in order to develop indicative
preliminary cut-off scores for use with musician populations.

METHODS
Participants

Ethical approval for the study was obtained from The University of
Sydney Human Ethics Committee. All musician members of the
orchestras were invited to participate. Those who agreed to
participate (n=377) completed a self-report survey at the
commencement of the study. Response rate varied from between
50% and 98% between the eight orchestras. A comparison of the
age, sex and instrument group of participants and non-participants
was undertaken in order to ascertain the possible presence of
systematic bias in the sample. Independent t-tests indicated that
there were no differences between responders and non-responders
on age, sex or instrument group.

Measures

A number of standardized tests and tests and rating scales

constructed for this study were used to assess the psychological
health of the orchestral musicians. The psychological tests were
selected to address particular questions about psychological
functioning in this population. Firstly, we were interested in exploring
the question of the possible comorbid occurrence of the anxiety
disorders and of anxiety and depression in professional musicians
because the highest rates for comorbidity in clinical populations
occur between the different anxiety disorders and between anxiety
and depression (Andrews, Henderson & Hall, 2001). Patients with
more pervasive anxiety disorders such as generalized anxiety
disorder frequently receive additional anxiety diagnoses of social
phobia and/or simple phobia (Sanderson, DiNardo, Rapee & Barlow,
1990). To date, there have been no studies undertaken to assess
the co-occurrence of different types of anxiety and of anxiety and
depression in professional musicians. The psychological tests were

46
selected to address these issues. In addition, there was some
redundancy built into the protocol in order to examine convergent
validity of the screening measures for anxiety and depression.

The measures used were as follows:

1. Kenny Music Performance Anxiety Inventory (revised) (K-MPAI)

(Kenny, 2009)
This 40-item inventory was developed to assess the emotion-
based theory of anxiety proposed by Barlow (2000) as it applies
to anxiety in the context of music performance. The 40-item K-
MPAI (Kenny, 2009) is a revised, expanded version of the original
24-item inventory (Kenny, Davis, & Oates, 2004). Items were
either specially constructed or selected from other scales to
address each of Barlow’s theoretical components, including
evocation of anxious propositions (e.g. uncontrollability,
unpredictability, negative affect, situational cues); attentional shift
(e.g. task or self-evaluative focus, fear of negative evaluation);
physiological arousal and memory. Questions are answered on a
7-point Likert scale [0=Strongly disagree to 6=Strongly agree].
Higher scores indicate greater anxiety and psychological distress.
This scale demonstrated excellent internal reliability (Cronbach’s
alpha = 0.94) (Kenny, 2009). Exploratory factor analysis with
varimax rotation using the professional orchestral musicians from
this study revealed six factors (Cronbach alpha) – proximal
somatic anxiety and worry about performance (.91); worry/dread
(negative cognitions/ruminations) focused on self/other scrutiny
(.86); depression/hopelessness (psychological vulnerability)(.85);
parental empathy (.75); concerns with memory (.92); generational
transmission of anxiety (.72); an additional weaker factor –
anxious apprehension (.59); and one item for biological
vulnerability. Factor analysis of the inventory with 159 tertiary
level music students showed a similar factor structure
(depression/hopelessness – psychological vulnerability; parental
empathy; concerns with memory; generational transmission of
anxiety) but with two separate factors for each of proximal

47
 somatic anxiety and worry/dread (negative cognitions) (Kenny,
2011).

2. Trait questionnaire of the State-Trait Anxiety Inventory (STAI-T)

(Spielberger, 1983) is a 20-item scale used to measure state (20
items) and trait (20 items) anxiety. Good to excellent internal
consistency has been reported for both scales (Cronbach’s
alphas between 0.86 and 0.95) across adult, college, high school,
and military recruit samples (Spielberger et al., 1983). Adequate
30-day test-retest reliability with high school students [r = 0.71
(State); r = 0.75 (Trait)], and 20-day test-retest reliability with
college students has been reported [r = 0.76 (State); r = 0.86
(Trait)] (Spielberger, 1983). Convergent validity of the STAI-T and
other trait measures of anxiety are evident among community
samples and samples with an anxiety disorder. Internal
consistency of the state (alpha= 0.90) and trait scales (alpha =
0.82) in a sample of tertiary level flute players was also
acceptable (Kenny, Fortune, & Ackermann, 2011). Only the trait
questionnaire, which assesses a propensity to worry and feel
anxious was administered in this study. Raw scores (range 20-
80) were converted into T scores with mean=50; SD=10. High
scores indicate higher levels of trait anxiety. In this population
sample the mean STAI-T score was 54.1 (SD=11.37).
The STAI-T was dichotomized at two cut points – the first at 60
which represents scores 1SD above the mean, the second at 65
which captured those musicians whose trait anxiety was at least
1.5 SD above comparable population norms. These cut-offs were
chosen because they indicate in population studies the precise
percentage of individuals who score above these scores – 16%
at 1 SD above the mean and 2.3% at 2 SD above the mean.

3. Social Phobia Inventory (SPIN) (Connor et al., 2000). This 17-

item self-report inventory reports on the full spectrum of
symptoms of social phobia including fear, avoidance and
physiological components. Items are scored on a five-point scale

48
 (0=not at all; 4=extremely) and scores range from 0 to 68. The
SPIN was developed and normed on a sample of 353 participants
comprising healthy volunteers and psychiatric patients without
social phobia as well as three groups of patients with a diagnosis
of social phobia. Test-retest reliability (0.78) and internal
consistency (0.87- 0.94) for the various groups were acceptable.
A cut off score of 19 reliably distinguished correct diagnoses of
social phobia from controls, with sensitivity of 0.73 and specificity
of 0.84. A SPIN score of 19 was used as the cut-off score in this
study.

4. PRIME-MD Patient Health Questionnaire (2-item questionnaire to

screen for depression). Musicians were asked these two
questions: During the past month, have you often been bothered
by feeling down, depressed, or hopeless? 2. During the past
month, have you often been bothered by little interest or pleasure
in doing things? These questions are taken from the Primary Care
Evaluation of Mental Disorders Patient Health Questionnaire
(PRIME-MD PHQ) (Kroenke, Spitzer, & Williams, 2003). If the
response to both questions is "no", the screen is negative. If the
response is "yes" to either or both question(s), further screening
for depression is advised. Whooley, Avins, Miranda, & Browner
(1997) compared the 2-question screen to the Quick Diagnostic
Interview Schedule (QDIS-III) and reported a sensitivity and
specificity of 96% and 57% respectively. Four receiver operating
characteristic (ROC) curves were generated as follows: one for
each of the two questions separately, each of which was
answered “yes” or “no”; one for those who answered one or two
questions affirmatively compared with those who answered both
negatively, and finally, those who answered both questions
affirmatively against those who answered both questions
negatively. The three possible outcomes of the two questions
combined – no to both questions=0; one to either question=1; and
yes to both questions=2 – were dichotomized in to a binary
variable where 0=no depression and 1=screen for depression
(answered yes to either question).

49
5. Anxiety and Depression Detector (Means-Christensen, 2006).
This is a brief screening instrument (five items) used in primary
care to screen patients for panic disorder, posttraumatic stress
disorder (PTSD), social phobia, generalized anxiety disorder
(GAD) and major depression. Respondents answer “yes” or “no”
to five items; they answer a supplementary item (5a) if they
answered yes to Q5, which is a question probing for PTSD. It was
trialled on 801 primary care patients. Follow up clinical interviews
with patients answering “yes” to any of the screening questions
showed sensitivity (0.92 to 0.96) and specificity (0.57 to 0.82)
values that demonstrate its utility as a screening device for
anxiety and depression. There were no differences in accuracy of
specificity or sensitivity by gender, age or ethnicity. Two analyses
were undertaken: those who answered no to all questions (0=no
to all questions) against those who answered at least one
question affirmatively (1=yes to at least one question); and those
who answered three or more questions affirmatively.

Statistical Analysis

Non-parametric signal detection analysis, defined as the area under

the Receiver Operating Characteristic (ROC) curve (McNicol, 1972),
was used to obtain preliminary indicators for a cut-off score that
might reliably identify those musicians with clinically relevant levels
of MPA. ROC curves were used to plot the probability of correctly
placing musicians from their K-MPAI scores into dichotomous
groups who scored in the clinically relevant ranges of other
standardized tests of trait anxiety, social anxiety, depression and
psychological distress (unsafe alcohol use) from those who did not.
ROC curve were generated by plotting the true-positive rate
(sensitivity) and false-positive rate (1-specificity) along the vertical
and horizontal axes for each of the predictor measures. The area
under the ROC curve is the most useful comparative measure of the
performance of screening tests (Park, Griffin, Sargeant, & Wareham,
2002). Areas under the ROC curve were calculated using SPSS 21.0
for Windows, and comparisons between variables and calculations

50
of cut-off scores were performed using Youden’s Index (Biggerstaff,
1999).

RESULTS

The sample comprised 184 males (49%) and 192 females (51%).
The mean age of the musicians was 42.1 years (SD=10.3;
Range=18-68 years). There were no gender differences in age
group distribution [ȋ2=4.9; p=0.18]. One hundred and two musicians,
27% of the sample, scored at or above the standard score of 60 on
the STAI-T, compared with 16% of the general population; 64
musicians (17%) scored at or above 65 on the STAI-T, compared
with 2.3% of the general population. These figures represent much
higher prevalence rates than the general population. The sample
means and standard deviations for the five tests used to develop cut-
off scores are presented in Table 2.

Table 2 Means (SD), Range, Min and Max for K-MPAI, STAI-T, SPIN
and ADD

Tests N Mean SD Range Minimum Maximum

K-MPAI 373 83.73 40.72 204 6 210
STAI-T 376 54.08 11.37 62 34 96
SPIN 359 15.09 10.81 58 0 58
ADD 365 2.09 1.35 5 0 5

ROC curve analyses

The first analysis examined the sensitivity and specificity of K-MPAI

(and SPIN) when two cut points for the STAI-T •65 and STAI-T •60
were used as the dichotomous tests. Table 3 shows the means for
K-MPAI and STAI-T for the cut-point groups for the STAI-T •65 and
STAI-T•60.

51
Table 3 Means (Standard Deviations) for K-MPAI and STAI-T for the
cut-point groups for STAI-T •65 and STAI-T•60.

STAI- STAI-T STAI-

STAI-T •65 T<65 •60 T<60
n=63 n=307 n=101 n=269
73.4 121.1 69.4
K-MPAI 132.7(32.4) (34.5) (35.7) (32.9)
12.8 24.1 11.8
SPIN 26.7 (12.6) (8.8) (12.3) (8.1)

Table 4 presents the area under the curve for the STAI-T•60, and
STAI-T•65.

Table 4 Area under the ROC curve (Area), standard error (SE),
asymptotic significance (p) and 95% confidence interval (CI) for
STAI-T•60, and STAI-T•65

Variable Area SE p 95%CI

STAI-
T•60 0.86 0.02 <0.001 0.82-0.90
STAI-
T•65 0.89 0.02 <0.001 0.85-0.93

52
Figure 1 ROC curve showing sensitivity and 1-Specificity for STAI-T
• 65

The cut point for the K-MPAI using Youden’s Index for STAI-T•65
was 105.3; 29% (n=109) musicians scored in this range. Using the
cut point for STAI-T•60, Youden’s Index for K-MPAI was 104.5;
29.5% (n=111) of musicians scored above this cut-point. This
process was repeated for the other four tests. For example, the cut
point for the PRIME-ED (“yes” to both questions) was 118.5; 90
(24%) musicians scored at or above this score on the K-MPAI. One
hundred (100; 27%) musicians answered yes to one question. Table
5 shows the descriptives for the cut-point groups against their means
for K-MPAI, STAI-T and SPIN.

53
 Table 5 Means (SD) for K-MPAI, STAI-T and SPIN for different
categories of the PRIME-MD, SPIN and ADD
PRIME-MD (Depression) SPIN ADD
Yes to 2Q Yes to 1 or 2 No to 2 Q SPIN•19 SPIN<19 ADD=3-5 ADD=1-5 ADD=0
Q
n=64 n=118 n=249 n=126 n=249 n=148 n=305 n=58
K- 119.5 105.5 73.9 111.6 69.3 106.3 90.6 49.1
MPAI (42.7) (40.8) (36.7) (35.9) (34.7) (40.4) (40.1) (25.0)
STAI-T 66.5 62.0 51.4 53.9 54.1 59.8 55.7 45.7
(13.2) (12.4) (9.0) (10.4) (11.8) (12.4) (11.5) (6.8)
SPIN 22.5 19.3 13.0 27.1 8.7 19.4 16.0 10.7
(13.4) (12.3) (9.3) (8.1) (5.1) (12.2) (11.1) (8.3)

Table 6 presents the findings for ROC curve analyses.

Table 6 Area under the ROC curve (Area), standard error (SE),
asymptotic significance (p) and 95% confidence interval (CI) and
Sensitivity (S), 1-Specificity (1-Sp) and Youden’s Index (YI) associated
with cut points for K-MPAI (CP) for different categories of the ADD,
PRIME-MD (D1, D2) and SPIN.

1-
Variable AUC SE p 95%CI Sens Sp YI CP
Yes to D1 0.71- 0.61 0.15 0.46 118.5
0.77 0.03 <0.001
and D2 0.84
Yes to D1 or 0.66- 0.48 0.18 0.30 110.0
0.72 0.03 <0.001
D2 0.77
0.75-
ADD=1-5 0.81 0.03 <0.001 0.86 0.52 0.07 0.45 84.50
0.83-
ADD=3-5 0.88 0.02 <0.001 0.92 0.66 0.05 0.61 89.50
0.46- - - - N/A
SPIN•19 0.56 0.03 0.44 0.59

DISCUSSION
The diagnostic capacity of the K-MPAI was evaluated against a
number of clinically established tests of anxiety and depression in
order to identify preliminary cut points that may indicate a clinically
significant condition requiring clinical intervention. Like most tests of

54
this kind, it is relatively straightforward to interpret scores at the
extreme ends of the range of possible scores; that is, very low scores
could confidently be interpreted to indicate that a clinically relevant
level of music performance anxiety is not present. Similarly, very
high scores would point to the presence of a high level of music
performance anxiety that may benefit from treatment. The scores in
the mid-range create greater uncertainty for interpretation as to
whether the condition is present or not. Normally, in medical testing,
a population is examined at Time 1 and scores on a particular test
are recorded. After a period of time, the population is re-tested to
identify all those who subsequently developed the condition of
interest. The original tests are then re-examined to identify the cut-
point score, which also maximizes the overall quality of the
prediction, over which most people went on to develop the condition
of interest. From these data, it is also possible to develop each
person’s probability or risk of contracting the condition based on his
score and the outcomes for all the people who received the same
score at Time 1. Medical examples include the use of the PSA
(Prostate-Specific Antigen) score for predicting prostate cancer.
Higher scores are more strongly associated with the condition,
prostate cancer, but the test has a high false positive rate because
there are reasons other than prostate cancer for elevated PSA
levels, and because some men with high PSA do not have prostate
cancer. Tests like these, with unacceptably high false positive or
false negative rates, may be discontinued because the risks of the
test outweigh its benefits (National Cancer Institute, 2013a). A much
more reliable test – for predicting breast and ovarian cancer in
women - is the presence of a mutation to the BRCA1 or BRACA2
genes (National Cancer Institute, 2013b).

In the case of MPA, the “condition” is more difficult to identify.

Catastrophic breakdowns during performance or the inability to go
on stage at all are possible equivalents in the psychological domain
of a disease state in the medical domain. However, these
“conditions”, even among very anxious musicians, are rare among
professional musicians and any test applied would almost certainly

55
report high false negative rates (i.e., the failure to detect MPA when
it is present). It is important to test this assertion empirically by
conducting some psychological screening at Time 1 and evaluating
scores of those who breakdown, avoid performance, develop
significant psychopathology as a result of their MPA, or leave the
music profession in the future. This will be a task for future research.

In this study, the “conditions” against which the K-MPAI was

assessed were scores on other psychological tests that have
established reliability and validity in general or clinical populations
for trait anxiety, depression, and social anxiety. In the first ROC
curve analysis, two cut-offs for the STAI-T were assessed – scores
that identified musicians at 1 SD and 1.5 SD above the mean of a
general population sample. Using Youden’s Index, musicians who
scored 104-105 on the K-MPAI were more likely to score 60 or higher
on the STAI-T and conversely, those scoring below this value were
more likely to score below 60 on the STAI-T, indicating this score as
a potential cut point for identifying highly anxious musicians. The cut
point was more stringent for depression, with K-MPAI score of 118.5
for musicians answering both depression questions in the
affirmative, and 110 for those who answered one of the two
depression questions in the affirmative. The percentages of
musicians scoring in the higher ranges of these tests were far greater
than those in the general population, confirming that professional
musicians are highly vulnerable to the experience of anxiety and
depression. There was a much lower cut point for the K-MPAI on the
ADD, with scores of 84-90 identifying those musicians who
responded in the affirmative to at least one or at least three questions
on the ADD. As observed previously, the SPIN does not appear to
be a predictor of MPA because of its focus on the avoidance
behaviours of people with social anxiety, a behaviour that is
infrequently observed in professional musicians (Kenny, Driscoll &
Ackermann, 2012).

This study represents a first step towards the identification of

potential cut points for the K-MPAI that will reliably predict conditions

56
that require treatment. The cut points against each criterion test
varied, suggesting that the cut point on the K-MPAI is dependent on
issues of clinical interest with each patient. The K-MPAI is a multi-
construct instrument that incorporates anxiety, depression, and
assessment of deeper psychopathology, such as an attachment
disorder or a disorder of the self (Kenny, 2011). In this way, it differs
from most screening tests that tend to be solely symptom-focussed.
This difference between the K-MPAI and these other screening tests
may account for differences in cut points against each of the tests
used in this study.

Limitations
In a standard situation, there is an expensive and/or time consuming,
state of the art measurement, called a ‘gold standard’, and a cheaper
measurement, which is used for screening the presence of a
condition; if the screener detects high risk of pathology, the gold
standard is applied (Kraemer, 1992). In this study, a “condition”
variable was constructed using cut-offs on an alternative measure
(STAI). Consequently, the predictive utility for the K-MPAI could not
be assessed. Rather, this study examined concurrent validity. In
other circumstances, a correlation coefficient would be sufficient to
determine concurrent validity. However, the aim of this study was to
identify a clinically useful cut point for the K-MPAI in a unique
population of professional musicians that could be calibrated against
similar measures, such as the STAI-T, in a general population on
which these tests were normed.

Finally, the Youden index has been criticized by some authors

because it combines sensitivity and specificity in a way that depends
on prevalence (e.g., Smits, 2010). For a genuine decision analytic
approach costs of false negatives and false positives, or their ratio,
should be made explicit (e.g., Smits, Smit, Cuijpers, & De Graaf,
2007). However, others (e.g., Michils, Louis, Peche, Baldassarre &
Muylem, undated; Schisterman, Perkins, Liu, & Bondell, 2004) argue
that a strength of the Youden Index is its independence from
prevalence, by virtue of the independence of sensitivity and

57
specificity measures. Since Youden's index (J) is the difference
between the true positive and the false positive rate, maximizing this
index allows the identification, from the ROC curve, of an optimal
cut-off point independently from prevalence.

References

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Kenny, D.T. (2011). The Psychology of Music Performance Anxiety.
Oxford, UK: Oxford University Press.
Kenny, D.T., & Ackermann, B. (2013). Performance related
musculoskeletal pain and depression in professional orchestral
musicians. Psychology of Music, published online 2 September,
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Kenny, D.T. & Ackermann, B. (2014). Optimising physical and
psychological health in performing musicians. In Susan Hallam,
Ian Cross, Michael Thaut (eds.)(2nd ed.). Oxford Handbook of
Music Psychology. Oxford: Oxford University Press.
Kenny, D.T., Driscoll, T. & Ackermann, B. (2012). Psychological
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 CHAPTER 3

EXPLORING THE ATTACHMENT NARRATIVE OF A

PROFESSIONAL MUSICIAN WITH SEVERE
PERFORMANCE ANXIETY: A CASE REPORT

The aim of this chapter is to contribute to the further development of

a coherent theory of music performance anxiety (MPA). Kenny
(2011) proposed three forms of MPA – focal, MPA with social
anxiety, and MPA with panic and depression. An attachment
disorder was proposed as the underlying psychopathology for this
third type of MPA. Accordingly, an open-ended in-depth assessment
interview of a professional musician presenting with severe music
performance anxiety that included panic attacks and depressed
mood was analysed from an attachment theory perspective. We
hypothesized that the musical performance setting re-triggers
unprocessed feelings related to early attachment trauma, and that
performance anxiety can be a manifestation of the emergence into
consciousness of these powerful early feelings. As hypothesised,
this musician suffered both early and current relational trauma that
was expressed through particular symptomatology in his music
performance anxiety. Failure to identify and treat underlying
attachment disorders in severely anxious musicians may render
other forms of treatment ineffective or short-lived.

INTRODUCTION
Until recently, music performance anxiety (MPA) has been
understood as a uni-dimensional construct occurring on a continuum
of severity from career stress at the low end, to stage fright at the
high end (Brodsky, 1996). Kenny (2011) has argued that MPA is
better understood as a typology comprising three subtypes to
account for qualitative differences in presentation as well as
variations in severity. The three subtypes are: (i) MPA as a focal
anxiety, where there is no generalized social anxiety, depression or
panic; (ii) MPA with other social anxieties; and (iii) MPA with panic
and depression. There are different levels of severity within each

60
subtype. The theoretical model underpinning this typology is that
MPA represents an intersection between an individual’s
developmental history, which may be more or less disturbed – mildly,
or not at all, in the case of focal anxiety and more severely in the
third subtype - and the specific psychosocial conditions of
musicianship - talent, achievement of technical mastery,
preparedness, performance demands, exposure, competitiveness,
and so on. Accordingly, MPA will have some of the general
characteristics of other psychological disorders, in particular, anxiety
disorders, which are shared by non-musicians, and some that are
specific to MPA and other performing artists such as dancers, actors,
and athletes. This conceptualization of performance anxiety awaits
further empirical examination. The aim of this paper is to contribute
to a better representation and understanding of the third proposed
subtype of MPA.

Attachment theory (Ainsworth, 1963; Bowlby, 1973) offers a

heuristic, evidence-based framework from which to explore severe
performance anxiety in professional musicians. Attachment is
defined as a biologically based motivational-behavioural system
whose primary goal is to ensure survival of the helpless infant. This
system is characterized by three features: (i) maintenance of the
infant’s physical proximity to its caregiver through crying, clinging,
crawling, searching and reaching for the attachment figure to attain
physical closeness; (ii) using the attachment figure as a “secure
base” (Ainsworth, 1963) from which to explore the environment; and
(iii) returning to the primary attachment figure (usually the mother)
as a “safe haven” when in danger or alarmed (Kenny, 2011, 2013).
Bowlby (Bowlby, 1988) later expanded his view of the role of
attachment to include reassurance of the ongoing (emotional)
availability of the caregiver, experienced as “felt security” (defined as
a subjective or internal experience of comfort and safety (Holmes,
2010; Sroufe & Waters, 1977) recently redefined as ‘epistemic trust’
(Fonagy, 2015).

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Four main patterns of attachment have been identified (Ainsworth,
1963; Main, 1995). First, securely attached infants, with attuned and
responsive caregivers develop felt security. Insecure infant-parent
dyads fall into three types: (i) In avoidant or ‘deactivating’ attachment
(Mikulincer & Shaver, 2011), infants appear calm and independent
and more interested in exploring the environment than
communicating with their caregiver. Despite the apparent lack of
manifest distress, these infants have elevated heart rates and levels
of circulating cortisol (stress hormone) (Letourneau, Watson, Duffett-
Leger, Hegadoren, & Tryphonopoulos, 2011). These babies learn
that attempts to seek comfort and care from their mothers are likely
to be met with rebuff, and therefore develop self-sufficiency; (ii) In
ambivalent or ‘hyper-activating’ attachment, infants exposed to
inconsistent and intermittent care are too concerned about their
mothers’ whereabouts to feel free to explore their environment.
They respond with intense distress when left, and appear
inconsolable when reunited (Mikulincer & Shaver, 2011); (iii) In
disorganized attachment, that presages later psychopathology,
infants have experienced ‘frightened and/or frightening’ caregivers
(Lyons-Ruth, 2015) and are thus subject to an ‘approach-avoidance
dilemma’ in which the source of comfort is also a potential threat,
either through neglect or active physical or sexual harm from
parents who are mentally ill, substance affected or chronically
depressed or anxious (Main, Hesse, & Kaplan, 2005). Following
reunion after separation, disorganized infants may manifest this
conflict through seemingly inexplicable and bizarre behaviours,
which may have a ‘perverse’ self-soothing component, that include
‘freezing’, collapsing to the floor, and appearing dazed and
confused.

The development of these varying attachment patterns – which also

have a severity as well as a categorical dimension (Maunder,
Lancee, Nolan, Hunter, & Tannenbaum, 2006) - is an interpersonal
process that emerges in the context of the parents’ caregiving style.
Parental states of mind are typically assessed using the Adult
Attachment Interview (AAI) (Hesse, 2008). Secure mothers tend to

62
have secure infants who grow to be secure adults. Parents of
avoidant infants tend towards dismissing states of mind: they
minimize or devalue the influence of their own attachment
experiences, and ignore or suppress their infants’ attachment needs,
who in turn, learn to minimize their own needs, becoming
compulsively self-reliant, and reluctant to feel or express emotions.
Such parents, however, tend to display excessive physiological
arousal, as do their avoidant infants (Spangler & Grossmann, 1993).
Parents of ambivalent infants have ‘preoccupied’ states of mind
(Main et al., 2005), so called because past unsatisfactory attachment
experiences intrude upon their present life and relationships. The
emotional life of such parents is governed by feelings of
helplessness and fears of abandonment, disapproval or rejection;
hence, they are often discouraging of their child’s growing autonomy.
In contrast to avoidant infants, ambivalent infants use hyper-
activating strategies that amplify their affect in an attempt to secure
the attention of their unreliably available parents. Finally, parents of
disorganized/unresolved infants have often suffered repeated
trauma in their own developmental histories, and are classified as
‘unresolved’ on the AAI. Responses to unresolved trauma include
fear, emotional withdrawal, and dissociation.

A number of brain structures are involved in regulating the brain’s

danger response system, including the amygdala, mature at birth,
which is involved in the fight/flight response, and where, it is
hypothesized, unconscious emotional memories are encoded; and
the later maturing hippocampus, which moderates the reactions of
the amygdala and interacts with the cortex to store explicit,
linguistically retrievable memories (Le Doux, 1996). In children who
have suffered severe emotional or relational trauma, the
development of these brain structures may be compromised, with
the result that the unchecked reactivity of the amygdala will produce
extremely intense autonomic reactions in response to relatively
minor internal or external triggers (Wallin, 2007). The extreme
reactions of intense music performance anxiety in some musicians
can perhaps be understood in this context. Kenny (2011) has

63
hypothesized that severely performance anxious individuals, by
virtue of faulty attachment experiences in early life, do not develop a
sense of felt security on which to draw when endangered on stage.

The attachment system remains active during adulthood and

continues to exert a significant influence on psychological and social
functioning. Adults respond to perceived threats with activation of the
mental representations of attachment figures laid down in infancy
and childhood, as a means of coping and regulating emotions (Ein-
Dor, Mikulincer, Doron, & Shaver, 2010). When these attachment
systems are insecure, especially if disorganized, their activation at
times of stress and crisis is likely to result in emotional dysregulation.
This provides a plausible model for the type of emotional difficulties
experienced by musicians whose music performance anxiety feels
unmanageable. Individuals with developmental histories leading to
patterns of severe insecure attachment cannot readily mitigate
distress or attain felt security. Instead, in the face of intense distress,
alternative, secondary attachment strategies involving either hyper-
activation or deactivation of the attachment system are triggered
(Main et al., 2005). By contrast, those who are securely attached
demonstrate both a strong sense that they can manage the threat
and, if need be, seek support from others to aid their own coping
efforts (Cassidy & Shaver, 2008).

In light of the above discussion, we examined an account of severe

music performance anxiety from a professional musician who
participated in a phenomenologically-oriented, open-ended, in-depth
interview. The account given below elaborates the narrative that
emerged in the course of the interview.

Participant
Callum, aged 26, a pop musician and his band’s lead singer and
song-writer, comes from a somewhat conservative, professional
family. His father is an ear, nose and throat (ENT) specialist, his
mother is an academic; he has two older brothers in the legal
profession. Callum is the youngest, and definitely the “black sheep.”

64
He stated that he always felt “like a misfit” in his “academic” family
and like “an antipathy” in his private school. He described his family
as “streamlined” by which he meant that they had all trodden the
familiar path of school, university, profession, partner, marriage, and
children. He said that he “went through a process of separating
myself from all that life.”

He presented in bohemian/Indian dress with dreadlocks, head-

scarves, and numerous body piercings. He lives an alternative
lifestyle in the “arty” side of town because he does not “feel so much
like an alien” there, although he struggles to manage on his insecure
income and casual work (“I don’t exist within that social framework
of 9 to 5, Monday to Friday”). To supplement his income from “gigs”,
he works part-time as a barista to pay the rent. Callum experienced
some learning difficulties at school and did not complete any formal
secondary qualification, preferring to pursue his desire to become a
professional musician and songwriter. At 15 years of age, he
“decided not to take any more money from my parents because in
order for me to feel valid in this world I need to make my own way.”

Callum was encouraged to participate by his father, who was worried

about Callum’s concerns with his voice, for which no physical cause
could be identified, his increasingly withdrawn demeanour, and his
dishevelled appearance.

Interview format and analysis

Psychoanalytic psychotherapy reconstructs the stories an individual

tells about him- or herself through a process of narrativization of an
experience, or ‘keeping a particular narrative going’ (McAdams,
1997) that would otherwise ‘linger as a traumatic lapse of meaning’
(Spence, 1986, p. 62); that is, it offers a ‘home’ for meaning, which
is a precondition for psychological well-being. In attachment terms,
the interviewer aims to develop a relationship of sufficient security
and ‘epistemic trust’ for the interviewee to feel free to explore the
emotional truths of his or her life-story. Hence, a qualitative life story

65
method supporting a holistic, contextualized, chronological telling
was used in this study, a method akin to history-taking methods in
psychotherapy (Winnicott, 1965).

There are a number of significant precedents for the use of narrative

data in studies that explore the role of psychological factors in health
outcomes. One such example is a 35-year longitudinal study of male
physicians that revealed the impact of a pessimistic explanatory
style, assessed via narratives of participants’ life experiences, in
increasing the likelihood of negative medical outcomes (Peterson,
Seligman, & Vaillant, 1988). Conversely, a 60-year longitudinal study
of nuns found the expression of positive affect in unstructured
narratives in early adulthood to be a predictor of longevity, with those
with positive affect surviving those with negative affect by an
average of 10.5 years (Danner, Snowdon, & Friesen, 2001).
Cousineau and Shedler (2006) argued that narratives “tap implicit
psychological processes not accessible via self-report
questionnaires” (p. 428) because participants lack conscious
awareness of such processes (hence their implicitness), or may be
unable or unwilling to disclose such processes directly, even if they
are aware of them. Many individuals defensively deny, avoid or
downplay emotional distress and musicians are no exception.
Shedler, Mayman & Manis (1993) called this defensive denial of
distress, aroused via early memory narratives, “illusionary mental
health” (p. 1117) and found strong associations between denial and
physiological reactivity. Levitt (2015) has noted the expanding and
increasingly accepted use of qualitative methods in psychotherapy
research, because it “provides a vivid, dense and full description in
the natural language of the phenomenon under study” (Hill,
Thompson, & Williams, 1997, p. 518).

For the purposes of this presentation, the transcript commences at

the point where Callum is asked: “Can you tell me what it is that has
been concerning you about your musical performance?” Callum
needed very little encouragement to speak. Accordingly, subsequent
interviewer participation was minimal and comprised simple

66
encouragers (Mmmm, ah-huh etc), clarifying comments (“It sounds
like…”; “Can you say more about that?”) and an occasional question
that assisted the interviewee to further explore his understanding of
his relationship with himself and his music (e.g., “What are the worst
manifestations of your music performance anxiety?”). The questions,
comments and interpretations (hypothesis-testing) arose organically
from the interaction between interviewer and interviewee for the
purpose of clarification, confirmation of understanding, or to explore
hypotheses that arose in the course of the interview (e.g., “Do you
have trouble having faith in yourself in other endeavours or is it
mainly focused on your musical performance?”).

Textual and thematic analyses of this phenomenologically-oriented

narrative were undertaken, based on the text and the independently
derived commentaries of the two clinician assessors. The research
process was informed by McLeod’s (2003) five stages of qualitative
data analysis – immersion, categorization, phenomenological
reduction, triangulation and interpretation. The analysis of the
transcript was guided by the methods of consensual qualitative
research (CQR) (see Hill et al., 1997, for a detailed exposition). The
commentary on the narrative represents the triangulation and
consensus interpretation of the two reviewers.

The narrative
Below is the verbatim narrative derived from the section of the
interview related to Callum’s music performance anxiety, with some
narrative smoothing and omissions of words or phrases at points
marked […] that were considered unimportant or repetitive.

Recently, I’ve started having panic attacks... in the time leading up

to a gig, I start to feel very separated and vague; my body is just
reacting and I’m not quite there. It’s a really bizarre feeling and
difficult to put into words … When I’m under pressure I feel really
vague. I start to question…everything surrounding me and I … get
into this philosophical downward spiral…Then I get a brain fog.
When I know I’ve reached this point where I’m severely anxious, I

67
get these cold flushes through my hands… For the past two years I
get extremely anxious for a few weeks, and it’s like a constant state
of anxiety for those few weeks, and then it passes… Relating to
music, specifically last year, I was in a band that was doing a lot of
really good gigs and I was at the centre of it. I was writing the music;
I was organising it all. It was a seven-piece band with some really
good musicians. I’d been overseas for four years travelling, and I got
back at the beginning of last year - and suddenly I was confronted
with having to be in some sort of musical framework and structure
from week to week being at rehearsals and voice being in good
condition and I just went into overload. Writing (songs) and having
all the stresses that you would have, trying to lead a normal life,
waking up early, being concerned about the amount of sleep I was
getting.
And on top of it all, my voice just shat itself. It began to freak
out. That was the way that my anxiety decided to express itself,
through my voice because I was the most acutely aware of it on a
day to day basis. I entered this spiral about it. My voice hasn’t
always sounded husky like this. It is not as bad as this when I sing.
…There shouldn’t be a difference between your speaking voice and
your singing voice; it is the same thing. But my singing voice isn’t like
this. I manage to slip into a bit of a groove when I sing, and it’s
different to my speaking voice. So that was all of last year - I had all
the checks on more than one occasion. I’ve been to a variety of
voice and ENT specialists and had laryngoscopies a bunch of times.
The first doctor that I went to said, “Yep, you’ve got polyps, we’ve
got to get them removed.” Then my dad, who is an ENT specialist,
said “Let’s just go for a second opinion.” So I went to a different ENT
doctor. He said, “No, there’s nothing there.” Since then, stories have
surfaced about the first ENT. A couple of singers have told us they
are bringing a case against him because he’s prescribing surgery for
people who don’t need it - people in serious situations, such as
professional vocalists...

Anyway, so this was just an absolute roller coaster, as you can

imagine. I’m trying to front more than one band. I was in three bands

68
at the time as well…On top of it all I was coming back from India as
well; I’d been overseas for a few years and I was thinking this was
all intertwined and at the root of it all, everybody is telling me there
is nothing wrong with my voice. And I’m going, “Well, what do I do
here?” Sometimes I find it difficult to talk when I’m anxious, and it’s
not like a thinking thing. I actually have trouble getting the words out.
Late last year I lost one of my closest friends; she died suddenly and
it was around that time that I entered a really severe depression.
There were a lot of heavy things happening and I was feeling an
immense pressure on my shoulders about this musical thing. I had
this amazing band… everyone in the band was saying to me,
“You’ve got talent, everything is great. You’re a great songwriter.
You’re a great front man. Everything is great.” But I just was
systematically undoing it in my head. I just really lost faith in it all.
And then this happened… my friend was travelling on a bus through
[…] and her body just decided that’s it, and she just died. We’d met
in India and travelled together for a couple of years. I’d lived with her
in […] and there was a romance… the timing was never right but one
day we said we would revisit it. Then she died… that’s the bizarre
thing about travel relationships - you develop these intense
relationships that nobody else in the world knows about…

Then I entered… the most severe depression I’ve ever entered in

my life. I woke up in the morning, found no reason to get out of
bed…and …considered suicide … I never actually – I was never
there, never thinking to myself, “Okay, I’m going to commit suicide”
but …just considering the whole meaning of it all… I never felt like I
was actually going to go through with it – it was more realising that
all the things that I loved in my life were coming down around me
and if I can’t sing and I can’t write music then what have I got to live
for? …I had all these things that were coming up on a personal level;
singing, being in a band, boiling over and then my friend died and
that toppled me over the edge. All the water overflowed out of the
pot.

69
Since then, the really serious band that I was in came apart and we
unofficially broke up at the end of last year… I place the responsibility
solely on myself - I brought my personal issues into the band, and I
would turn up to rehearsal and not physically be able to sing, like not
be able to get notes out of my mouth… and it became infectious,
because nobody wanted to be in that environment, where there was
no creativity and there was a really bad vibe around.

In the last six months… I’ve done a full circle. I took a solid few
months off gigging. I was writing music. I tried to get the band back
together once or twice but it just never happened…There’s a couple
of guys in that band who are professional musicians, and that always
really intimidated me because they would always put me in a
situation where I didn’t feel like I belonged there. I didn’t feel like I
was legitimate – I didn’t feel like I had earned my right to be there. I
was saying to myself, ‘Why do these really great musicians want to
play with me?’ They believed in me but I just butchered it… I’m not
good enough. Why are these guys wanting me… they were getting
us really good gigs … but I just didn’t believe in it. I thought, ‘As if
these guys want to play music with me.’ I had really no faith in myself.

Commentary
Callum described an array of distressing symptoms [feeling
“separated and vague;” (dissociation); “my body is just reacting and
I’m not quite there” (depersonalization/ disembodiment), “brain fog”
(cognitive perceptual disruption); “cold flushes through my hands”
(motor conversion)] which we may conclude are symptoms of panic
attacks/dissociative episodes. He talks of going into “overload” and
describes how he tries to cope with feeling overwhelmed and
uncontained by “trying to lead a normal life…getting enough sleep.”
Callum also reports “…find[ing] it difficult to talk… to get the words
out” (somatization), and feeling “immense pressure on my shoulders
(striated muscle tension).” …In short, he was on an “absolute roller-
coaster.”

70
This symptom complex suggests the presence of extreme anxiety in
someone who does not have a reliable secure base. Callum’s
anxiety, generated by repressed emotion, manifested in all four ways
described by Abbass, Town, and Driessen (2012) and Davanloo
(2005): (i) tension in the striated muscles of the body; (ii) smooth
muscle anxiety that manifests as somatising illnesses; (iii) cognitive
perceptual disruption (CPD) that manifests as confusion, blanking
out, tunnel vision, blurred vision, ringing or buzzing in the ears, and
dizziness and fainting; and (iv) motor conversion, which manifests in
unexplained weakness or other physiologically inexplicable
symptoms in the limb, psychogenic voice disorders, among others
(Axelman, 2012).

Callum described multiple losses and betrayals of important

attachment figures – perhaps his mother, who was conspicuous by
her absence in his narrative, his father who appeared concerned but
avoidant in his attachment style, the ENT specialist who was
prepared to exploit him, his band, which he experienced as a
secondary secure base that “came apart”, and his lost lover whose
death “…toppled [him] over the edge. All the water overflowed out of
the pot… All the things that I loved in my life were coming down
around me.” Callum is here describing the absence of a secure base
or felt security within – the whole edifice of his fragile internal objects
was imploding. Profound internal emotional conflicts rendered him
speechless and voiceless. He could not speak and he could not sing
–“…and if I can’t sing and I can’t write music then what have I got to
live for?” He reported suicidal ideation. He felt trapped in a silent
nightmare. Anxiety was the iceberg tip beneath which lay repressed
rage, guilt and grief about early attachment ruptures that were re-
triggered in his current life by the losses of his voice, his creative
drive, his band, and his “travel lover”.

Most of his concerns were, however, centred on his voice. “I’d wake
up in the morning and the first thought was, how is my voice feeling
today?” Despite the care he exercised, his “voice just shat itself. It
began to freak out. That was the way that my anxiety decided to

71
express itself, through my voice because I was the most acutely
aware of it on a day to day basis.” Callum’s state of disorganized
attachment was embodied in his voice, which was both the
nurturer/giver and the tormenter/withholder.

Callum’s preoccupation with his voice and his throat could also be
seen to represent a bid for his father’s attention. His father
responded to Callum’s distress in an ‘organised insecurity’ (typically
avoidant) fashion (Holmes, 2010), i.e., he was to an extent ‘there’,
taking his son to an ENT surgeon, but perhaps in an emotionally
distant and somatising way. He was unable to respond to his son’s
emotional distress. The very part of himself that Callum wanted his
father to love and validate was also the part that both manifested his
vulnerability, and perhaps too, like the inconsolably crying infant,
wanted to attack and debase and baffle his father in protest at his
father’s emotional unresponsiveness.

Callum’s talent and creativity, as often found in creative artists, were

both a manifestation of, and an attempt to transcend core
psychological themes. By writing and performing, he attracted the
attention of ‘The Other’, but was then beset by doubts as to whether
he had sufficient talent, whether other professional musicians
wanted to work with him, and whether he would be accepted with all
his vulnerabilities. Callum’s internal disorganised despair sabotaged
him – despite some “really great musicians want[ing] to play with
[him], Callum did not feel “…legitimate… I didn’t feel like had earned
my right to be there… I was systematically undoing it in my
head…they really believed in me but I just butchered it…I really had
no faith in myself.” Here is another brutal image through which
Callum described how he destroyed any good feeling or belief in his
talent; he infused their “good” words with his badness, which
became “infectious… there was really a bad vibe around…I place
the responsibility solely on myself” (persecutory self-object). [Note:
In disorganised attachment the child has no-one to ‘metabolise’ his
vulnerability and helplessness, so ‘bad’ feelings cannot be detoxified
and remain within the ambit of the self].

72
The fear of being an impostor, a fraud or a sham is very common in
anxious musicians and this is certainly a sentiment expressed by
Callum. Children of highly critical/accomplished parents may come
to believe that regardless of their achievements, they will never meet
the standard expected. The pervasive message is that one is either
never good enough or is only good enough if meeting parental
expectations, rather than one’s own. Callum was perhaps a poor fit
in his family of conservative, high achievers. Being the youngest, he
may have concluded early that he could never measure up to his
older brothers or his parents, so he attempted to carve out a very
different path for himself. Sadly, the feeling of being a fraud followed
him - he could never be good enough, no matter what he did (Kenny,
2011).

At this point in his life, Callum was unable to contain his anxiety and
hopelessness, or the rage and grief that were threatening to break
through (suggested in his savage imagery and choice of words such
as “shat itself” “I butchered it”); these “bad” feelings started to
overflow and spill out in all directions – his music, his personal
relationships, his position in his band, and his relationship with
himself, his creativity and his voice. This narrative provides evidence
for the presence of a significant depressive illness, with anxiety as
one of its manifestations; others include sleep disturbance, identity
disturbance, negative thoughts and ruminations, difficulty getting out
of bed, and suicidality.

DISCUSSION
The use of stories or narratives and case histories as “evidence” in
psychotherapy are criticised on the grounds that using the case
history as ‘data’ involves an unconscious and preconscious narrative
smoothing on the part of both teller (patient) and listener (therapist)
Smith, Harré, & van Langenhove, 1995). Analyses of text may be
biased in the direction of the theoretical frame under which the
narrator/therapist operates. However, these are not insurmountable
hurdles. Safeguards include recording and verbatim transcription so
that there is a complete record of the interview, the use of

73
independent assessors of the narratives, and the development of
case formulations from different perspectives. These safeguards
were to an extent applied in this study, in that the independent
assessors reached their formulations independently – and, as it
happens, transcontinentally! They were only cross-checked and
discussed post-formulation.

The psychological equivalent of the physical response to life

threatening situations - tonic immobility or “playing dead” - is
dissociation. Emotions are, in the first instance, bodily experiences.
Through the sensitively attuned attachment relationship emotions
are modulated, regulated, and understood. When such a
relationship is absent or impaired, so too is the capacity for emotional
regulation, including the capacity to accurately identify, name and
understand emotional experience - a phenomenon theorized by
Fonagy and colleagues (Fonagy, Gergely, Jurist, & Target, 2004)
under the rubric of ‘mentalization’. To the extent that mentalizing is
de-activated or undeveloped, emotions are manifest as somatic
sensations or physical symptoms that are never fully
comprehensible to the person experiencing these states. Emotional
experiences that are too painful or traumatic, or are judged to be
unacceptable to the primary attachment figure, will be split off in this
way, remaining dissociated, undeveloped and stored somatically
(Schore & Schore, 2008; Wallin, 2007).

Individuals whose early attachment experiences were unsatisfactory

tend to experience rapid shifts of feeling from manageable to
overwhelming states of mind. Suboptimal attachment relationships
can undermine the development of cortical structures that are
associated with both affect regulation and mentalization. This may
result in chronic hyper-arousal, such as that seen in severe anxiety,
including severe music performance anxiety, which cannot be
modulated by mentalizing or seeking comfort from an attachment
figure (Schore, 2003). Such hyper-arousal is experienced as outside
one’s control: disturbed attachment experiences result in the lack of
a stable sense of self (internal secure base) with the capacity for

74
symbolic representation of one’s own mental states, especially
negative ones. These include, for musicians, physical pain or
disability, rivalry and a sense of failure, disappointment, and lack of
adulatory audience response, among others. Hence, affect remains
intense, confusing, poorly labelled or understood and above all,
unregulated.

Many of these elements were evident in Callum’s narrative. By all

accounts, Callum was musically gifted. Musical talent is good for
one’s self-esteem, but if the totality of one’s self-esteem is bound up
with being a ‘good’ performer it can become persecutory – to play or
sing badly is to be a ‘bad’ person. Callum felt globally ‘bad’ – this
was the essence of his depressive anxiety. He accepted the
responsibility not only for his voice “shitting” itself, but for the
dissolution of the band, into which he believed he had injected “bad
vibes.” At times of intense anxiety, he described chronic hyper-
arousal comprising physical, sensory and dissociative symptoms
that were poorly mentalized. He tended to turn the blame exclusively
onto himself, perhaps to protect his attachment figures – his father,
his band mates – from his developmentally-derived rage and
censure.

Self-monitoring (i.e., observing oneself, learning from and correcting

mistakes) is a necessary component for skill-acquisition, and is
essential in the performing arts. However, this self-monitoring
process can also become persecutory. Internal relational models
from childhood will colour current conflicts, for example, the critical
parent/transgressing child dyad or the ‘bad’ parent (maybe
representing a projection of the child’s anger)/victimised child dyad.
Callum’s self-experience was both transgressing and victimised – on
the one hand, his woes were his fault; one the other, he implied that
he had no control over his symptoms. It was his (disembodied) voice
that “shat itself”; he did not do the shitting; his voice did it.

75
CONCLUSION
The aim of this chapter was to illustrate the complex and multi-
faceted psychodynamics and therapeutic needs of musicians with
insecure attachment and its possible relationship with how they
express their music performance anxiety (Kenny, Arthey, & Abbass,
2014). One of the key aspects from the musical point of view is the
occurrence of physiological hyper-arousal in insecure attachment.
To the extent that emotional energy is directed into “holding” oneself
during a performance, the communicative process becomes
impaired. Excessive self-awareness detracts from emotional
expressiveness, resulting in less favourable audience response to
the performance, which may arouse or exacerbate anxiety, creating
an escalating vicious circle. In the event that musicians do not seek
psychological assistance, they may resort to alcohol or drugs,
prescribed or otherwise, sexual escape or leaving the profession,
either temporarily, as in Callum’s case, or permanently.

An awareness and understanding of the role and function of

attachment theory in understanding the severely performance
anxious musician has been demonstrated through this case study
report. Additional published cases will further clarify the
psychodynamics of severe music performance anxiety, identify
suitable treatments, and hopefully relieve the intense suffering of this
group of musicians.

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 CHAPTER 4

AN EXPLORATORY NARRATIVE STUDY OF

ATTACHMENT QUALITY AND MUSIC PERFORMANCE
ANXIETY IN PROFESSIONAL ORCHESTRAL
MUSICIANS1

This chapter investigates attachment themes in the life history

narratives of professional orchestral musicians and their relationship
with music performance anxiety (MPA). Narrative accounts derived
from open-ended in-depth interviews of ten professional musicians
were analysed from an attachment perspective using content and
thematic analysis. We hypothesized that the performance setting re-
triggers unprocessed feelings related to early attachment
experiences, especially when traumatic, and that defensive
manoeuvres against their re-emergence into consciousness are
activated. The interviews identified early relational trauma as a
relevant etiological factor in the MPA-symptomatic of the musicians
studied. A case is made for the addition of an attachment-informed
life-course model rather than a purely symptomatic approach to
understanding and treating severe MPA and other intra-personal
psychodynamics of performing musicians.

Introduction
This paper explores attachment themes in the life history narratives
of professional musicians. Previous work has explored the
relationship between attachment status and the experience of
severe music performance anxiety (MPA) (Kenny, 2011; Kenny,
Arthey, & Abbass, 2014; Kenny & Holmes, 2015). Here we broaden
the investigation to consider developmental links between
attachment quality and musicians’ perceptions of their musical lives.
Specifically, we investigated musicians’ early life experiences and
attachment relationships with their primary caregivers in order to

1 With Jeremy Holmes

81
understand the impact of attachment style on musicians’ approach
to and experience of their profession in general and their musical
performance anxiety in particular.

Theoretical background
Freud’s psychoanalytic theory and subsequently John Bowlby’s
attachment theory (Bowlby, 1940, 1960, 1973, 1988) maintained a
developmental perspective founded on the principle that problematic
early experiences, particularly within the mother-infant dyad, while
not immutable, and interacting with genetic endowment and
contingent events, set the scene for later psychopathology. This
view has been reinforced by observational studies of infants
(Ainsworth, 1963; Ainsworth & Bell, 1970; Beebe & Jaffe, 2008;
Beebe, Jaffe, & Lachmann, 2005; Beebe et al., 2010) and
longitudinal studies of the outcome of early relational trauma
(Cassidy & Shaver, 2008). As Fonagy and colleagues (Fonagy,
Target, Gergely, Allen, & Bateman, 2003) stated:

The experience of security is the goal of the attachment

system, which…is the foremost regulator of emotional
experience. In this sense, it lies at the heart of many forms of
mental disorder and the entire psychotherapeutic enterprise
(p. 37).

The attachment system is not pre-formed at birth; it evolves from the

continuous transactions between the infant and the people in his
world. From these experiences, in Bowlby’s terminology, the child
develops internal working models (IWM) that also become more
complex and integrated as the child matures. These IWM operate
outside of conscious awareness and are resistant to change, but
nonetheless guide thought and behaviour in new situations
(Goodman, 2005). Faced with severely adverse/traumatic
developmental experiences – e.g., physical or sexual exploitation,
overt hostility, and/or neglect -- children may develop highly
defensive, confused or self-defeating IWMs of self, other and self-
other relationships (Schimmenti & Caretti, 2016). These confusions
typically become defensively dissociated in order to avoid the

82
unbearably painful affect associated with the extreme vulnerability
accruing to the realisation that one’s caregiver is inaccessible or
hostile (Bigelow & Walden, 2009; Blass, Lumeng, & Patil, 2007;
Bretherton, 1994).

The interplay of infant-seeking and parental provision results in

different patterns of infant-caregiver attachment, depending on the
emotional fit between infant behaviours and parental
responsiveness. Secure attachments arise out of maternal
sensitivity and responsiveness, or ‘attunement’ (Stern 1985) to her
infant’s needs. This sensitive attunement encompasses qualities
such as acceptance, psychological availability and cooperativeness.
Recent studies suggest that a crucial factor in this pattern is parental
capacity for ‘mentalizing’ – the ability to see the child as a separate
sentient being with thoughts, feelings and needs of her own, distinct
from those of the parent (Altman, 2003; Bodin, 1996; Cortina & Liotti,
2010).

Suboptimal parent-child relationships lead to different patterns of

insecure attachment. These are seen as adaptive and appropriate
responses to the child’s primary relationships. Ainsworth, Blehar,
Waters, & Wall (1978) differentiated insecure attachment into
avoidant (parents are dismissing of attachment needs, leading to de-
activation of the attachment system in their children) and ambivalent
(parents are preoccupied, leading to hyper-activation of the
attachment system in their children) subtypes. These ‘organized’
patterns of insecure attachment are distinguished from a fourth type
– disorganized attachment – in which infants’ parents are
simultaneously experienced as a safe haven which they seek out
when threatened, and the source of danger from which they need
protection (Main, Hesse, & Kaplan, 2005).

However, these early attachment experiences need not necessarily

be a life sentence. Positive life events in childhood – e.g., a stressed
single mother forming a healthy new relationship – can impact on
their children’s attachment status, moving them from insecure to
secure (Bifulco, 2008). Psychotherapists hope that therapy can help

83
subjects move from insecure to secure attachments. Hesse (2008)
describes how the combination of a fluid-autonomous discourse
style with low ratings on parental lovingness led, in the development
of the Adult Attachment Interview, to the concept of ‘earned security’.
This refers to people whose childhood experience was bleak, but
who nevertheless manage to achieve the multilayered and fluid
detachment and objectivity corresponding with secure attachment.
The construct of ‘earned security,’ (Roisman, Fortuna, & Holland,
2006), defined as “coherent and secure adult attachment
representation despite untoward attachment experiences in
childhood” (van IJzendoorn & Bakermans-Kranenburg, 2014, p. 158)
is highly relevant to MPA.

In this paper, we test our hypothesis that unrepaired attachment

ruptures are associated with the more severe forms of music
performance anxiety in professional musicians. Given that this is the
first study internationally to examine the association between
attachment and music performance anxiety, we are primarily
concerned with the distinction between secure and insecure
attachment and the implications of these for musical performance,
and do not attempt to identify sub-classifications of insecure
attachment. A later paper will attempt a more nuanced examination
of the different subtypes of insecure attachment in performance
anxious musicians.

Attachment and musical performance

What, if any, might be the connection between attachment quality
and musical performance? An artistic performance may be thought
of as a jointly produced, co-created phenomenon involving
audience, performer, and the music itself. This is reminiscent of
mother and infant engaged jointly in the free, collaborative, mutually
enjoyable play typical of secure attachment. From an attachment
perspective play may be compromised in a number of ways: the
mother may seem 'bored' and look away (avoidant), preoccupied
with her own traumatic or depressed thoughts (ambivalent), or over-
identified with the child as a narcissistic projection of her own needs
(disorganised) (Hesse & Main, 2000). Transposing these suboptimal

84
prototypes into the musical arena, being called upon to perform can
result in anxiety or depression because the fertile, creative and
hedonic meeting point between the musician’s ‘play’ and the
containing responsiveness of the audience is inherently and perhaps
necessarily fragile and regressive. Thus the psycho-physical activity
of music-making activates a range of emotions and dispositions
reaching backwards into childhood, as well as forward into future
aspirations (Kenny, 2011). From this perspective, MPA may be seen
as arising out of IWMs of maternal/audience inattention, or a
persecutory or narcissistic focus on the child/performer him/herself
rather than the music.

Another theme that has influenced our thinking about MPA is that of
narcissism (e.g., Kernberg, 2008; Kohut, 1966, 1972). In ‘healthy
narcissism’, people legitimately value their uniqueness and
specialness and develop healthy self-esteem on the basis of
parental acceptance and pride. This healthy narcissism is a
component of the unconditional acceptance and provision of
‘narcissistic supplies’ (Powell, Cooper, Hoffman, & Marvin, 2013)
characteristic of secure attachment. A musical performance vis-à-vis
the audience has its analogue in the parent-child interchange in
which parents take pleasure in the quotidian achievements of their
children – first steps, nascent language, stick-like drawings etc. If the
delight inherent in this process has been suboptimal in childhood,
performance may be freighted with the desire to please and to be
applauded beyond the parameters of the task itself, and anxiety
about this may manifest as MPA. In secondary or pathological
narcissism – often a feature of disorganised attachment - the child,
in the absence of appropriate mentalized, pride-ful attention, may
resort to excessive self-evaluation. For musicians, this constellation
can underpin MPA (and maladaptive perfectionism), since beneath
secondary narcissism typically lurk feelings of emptiness - an
existential void that threatens to overwhelm when things go ‘wrong’–
as in a flawed performance (Kenny, 2011).

85
Another component in the evolution of MPA that emerged from our
previous research with gifted adolescent musicians is the experience
of a catastrophic performance breakdown, during which the young
musician felt ridiculed and humiliated. Associated with these
‘sensitizing experiences’ (see Osborne & Kenny, 2008), there is
often a history of attachment trauma, anxiety in the family, and
generational transmission of anxiety from parents, which renders
such individuals vulnerable to the development of anxiety disorders.
Many adolescents experience shame over perceived or actual
failures, but most would not carry the traumatic memory with them
through life. It is highly probable that those who do retain these
traumatic memories did not have an empathic attuned adult who
could assist the young person to metabolize and neutralize these
disturbing affects (Kenny, 2011).

Behavioural inhibition is an additional risk factor (i.e., a form of

psychological vulnerability) for the incidence, severity and longevity
of anxiety disorders in later life (Biederman et al., 1993). Behavioural
inhibition refers to a temperament characterized by a tendency to be
shy, timid, and constrained in novel situations, that is, unwilling to
take risks or to explore the unfamiliar. Behavioural inhibition that
persists beyond infancy into childhood confers a higher risk of
developing anxiety disorders. Longitudinal studies show that
inhibited temperament predicts later diagnosis of social anxiety in
adolescents (Schwartz, Snidman, & Kagan, 1999). Parents of
behaviourally inhibited children have higher rates of anxiety disorder
(Hirshfeld et al., 1992). Attachment security moderates the
relationship between behavioural inhibition and stress reactivity
measured by circulating cortisol in toddlers. Unlike insecurely
attached inhibited toddlers, inhibited toddlers with secure
attachments to their mothers did not react with increased circulating
cortisol to novel situations (Nachmias, Gunnar, Mangelsdorf, Parritz,
& Buss, 1996).

Because there is so little literature to guide our theorizing on the

relationship between attachment quality and MPA, the approach was

86
exploratory, guided by five research questions: (1) How do
musicians remember their early lives and relationships? (2) How do
musicians remember their early musical experiences? (3) How do
these early memories and experiences affect musicians’ current
attitudes to and perceptions of their musical performance? (4) What
inferences can be drawn about the quality of musicians’ attachment
styles, both the quality of their attachment to early primary caregivers
and their current adult state of mind with respect to attachment? (5)
What is the association between early relational trauma and their
experience of MPA?
We used a descriptive qualitative study design based on
phenomenologically-oriented, open-ended, in-depth interviews
(Wertz, 2005) to explore musicians’ understanding of their early life
experiences, both musical and relational, and how these affected
their experiences and perceptions of their current musical lives.

Participants

The sample comprised 10 professional orchestral musicians who

volunteered to participate in an in-depth interview study “to explore
their early and current life and musical experiences”. They were
drawn from the eight premier state orchestras in Australia. This study
was part of a larger research project that investigated the physical
and mental health of professional orchestral musicians in Australia
(see, for example, Ackermann, Kenny, O'Brien, & Driscoll, 2014;
Kenny & Ackermann, 2015; Kenny, Driscoll, & Ackermann, 2014).

Ethics approval

The study was approved by the University of Sydney Human

Research Ethics Committee. All interviewees signed a consent form
to allow their interviews to be audio- or video-recorded and for their
de-identified transcripts to be used for research purposes, including
journal publication.

Procedure

Notices and information statements were distributed via orchestral

liaison officers and orchestra rehearsal notice boards to eligible

87
orchestral musicians, with the first author’s contact details. Those
who wished to participate contacted the first author via email or
phone. All interviews were conducted by the first author either face-
to-face or by audio- or video-conferencing. The interview durations
ranged between 90 and 150 minutes. Interviews were fully
transcribed and copies of the interview transcripts were sent to the
second author, a psychiatrist and psychoanalytically trained
psychotherapist. Both first and second authors independently
annotated the transcripts for themes and content, as well as for the
presence of exemplars of the theoretical constructs under
investigation (e.g., parental attunement, quality of attachment
experience in early life; current state of mind with respect to
attachment; presence of internal secure base; behavioural inhibition,
sense of self) for each of the participants. Despite differing
geographical and professional backgrounds, there was surprisingly
close agreement between the two reviewers with respect to their
conclusions regarding musicians’ attachment experiences and adult
state of mind with respect to attachment; differences were resolved
by discussion and consensus.

Interview format

The interview used a qualitative life story method that supported a

holistic, contextualized, chronological recounting of participants’ life
experiences that resulted in a coherent narrative. The method is akin
to intake assessment and history-taking in psychotherapy. There are
several empirical precedents for the usefulness of narrative data in
studies that explore the role of psychological factors in health
outcomes (see, for example, Cousineau & Shedler, 2006; Danner,
Snowdon, & Friesen, 2001; Peterson, Seligman, & Vaillant, 1988).
Further, this approach avoids the constraints of closed questions
and self-report measures and the possible bias that emerges from
open questions specifically related to the topic of interest. Some
researchers argue that “…indirect methods to assess psychological
growth, such as open-ended personal accounts of trauma, can
allow…reports to emerge freely by eliciting the individual’s memory
of the trauma, as it is organized subjectively” (Dekel, Hankin, Pratt,

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Hackler, & Lanman, 2015, p. 2). We chose a narrative rather than a
psychometric approach (using, for example, the Adult Attachment
Interview), firstly, in order to allow the critical concepts to emerge
spontaneously, in the manner akin to grounded theory, rather than
introducing theoretical preconceptions inherent in formal
psychological testing. Second, we were interested in the relationship
between psychological constructs that had not previously been
examined together – psychological vulnerability (e.g., behavioural
inhibition), attachment trauma, sensitizing experiences in music
performance, and music performance anxiety. The effective use of
narrative transcripts to identify attachment quality has been reported
previously (e.g., Schimmenti et al., 2014).

The in-depth nature of the interviews provided detailed

phenomenology of MPA as it arises in the life course. Critics of the
use of stories or narratives and case histories as “evidence” in
psychotherapy argue that the case history genre is fiction because it
involves unconscious and preconscious narrative smoothing on the
part of the teller (patient) and listener (therapist). What is recorded
in the interview/session may be biased in the direction of the
theoretical frame under which the narrator/therapist operates (Smith,
R. Harré, & van Langenhove, 1995). These are not insurmountable
hurdles, as there are safeguards against such biases. In this study
these included: recording and verbatim transcription so that there
was a complete record of the interview, two independent assessors
of the narratives, and the free development of case formulations
from different perspectives.

We commenced every interview with a musical question to establish

rapport and interest prior to tackling wider issues. “Can you tell me
about your musical life, from the time you started to learn music?”
Please speak freely about any thoughts or feelings that arise.”
Thereafter, the majority of interviewer interchanges arose
organically from the interview discourse and dialogue, so, typically
for exploratory qualitative research, varying comments and
questions were applied with different musician participants. Textual
and thematic analyses of these phenomenologically-oriented life

89
history narratives were undertaken based on the text and the
commentaries of the two clinician assessors.

Analysis

The narrative texts were explored to identify themes related to the

subheadings contained in Table 1. Following this process, each
author independently coded the transcript as showing either secure
or insecure attachment – that is, the presence of (unresolved)
attachment trauma. There was complete consensus between the
coders regarding the quality of attachment displayed in the
narratives of the 10 musicians.

RESULTS
Four of the 10 musicians reported lifelong MPA of considerable
severity. Five musicians had previously suffered significant MPA but
had either recovered or learnt to manage it satisfactorily. One
musician reported never having experienced MPA during her
musical career. Eight of the 10 reported that they had not
experienced parental attunement (i.e., secure attachment) during
their formative years. Walter was the only musician who clearly
stated that he had experienced parental empathy and attunement.
We could not determine parental attunement for one musician –
Jenna. Nine of the 10 musicians had not developed an internal
secure base (again, Jenna’s interview was not clear). Behavioural
inhibition (psychological vulnerability) was identified in seven of the
musicians. Seven musicians reported sensitizing experiences during
adolescence; six reported a similar experience as adult musicians.
Table 1 provides a summary of the key issues in the life stories of
each of these musicians. We selected five musicians to explore in
detail, two each from those suffering lifelong or limited MPA and the
one musician, Leila, who had never experienced MPA.

--------------------------------------------

Table 1 Assessment of psychological vulnerability, parental

attunement, development of a secure base, sensitizing experiences,

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current musical experience, attachment trauma, and current
experience of music performance.

-------------------------------------------------

91
Name Psychological Parental Attachment– Current musical Attachment
vulnerability (PV) attunement internal secure experience trauma and
(behavioural base? experiences with
inhibition) and/or music
sensitizing performance
experience (SE)
Anna Yes (PV) No No “It’s been a lifelong
47 years Always anxious; “My parents, who Enmeshed family - “At work I am struggle for me… I
Violin too affected by are also professional all six members - often unable to couldn’t have been
“nerves” to play musicians, didn’t parents and four continue playing a musician without
Lifelong solo; panic attacks; understand it [severe children - are because my the pharmaceutical
MPA cannot perform MPA] at all, because violinists who heart races so industry.”
without beta they’ve never had “didn’t get any much, I can’t
blockers and anything like that choice”; children think.” “I’ve often felt
valium. “Two of my and they can’t see were pressured suicidal, to do with
sisters also have what the problem is. into international music… especially
the same problems They would say, “If competitions at around
as me – anxiety, you’re a good young ages; Anna competitions and
depression, violinist, then there was depressed auditions which are
panic…” shouldn’t be any and suicidal as a just too much for
Yes (SE) problem, so pull teenager. “I me to cope with.”
yourself together.”
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 “I won some really cannot imagine a “I want my life to be
big competitions as worse mother.” over.”
an adolescent and
after that …I fell
apart; I started
having panic
attacks all the time.
It was too much for
me to cope with.”

Greg Yes (PV) No No “Deep down I’ve “Music is my life; I

49 years Described “Dad is a jazz pianist “I didn’t get got a lack of self- don’t do anything
Percussion symptoms of social but he is highly practical or esteem…I am a else.”
anxiety disorder as strung, very nervous, emotional support good musician
Lifelong well as severe paranoid, never from my parents.” but I can’t make “Being nervous
MPA MPA. stuck at anything. I He also received myself believe it.” about what I do has
worried that I would little support from almost completely
Yes (SE) end up like him.” his wife: “My wife
“Nervousness… ruined my
Had a profound ruins my ability to enjoyment of music.
is aware of it concentrate and It’s a monster so
sensitizing Mother not [MPA] but we
experience at age mentioned in the don’t talk about it.
… paralyses my big…I just can’t
12, when he interview. Sometimes she
mind to deal with fight it…it’s bigger

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discovered that gets mad at me the problem at than me. I have
“other students and says, “Don’t the time.” lived with it for 30
were as good as be silly.” “I am completely years…when I
me; that ruined by this botch a
permanently upset monster and I performance, the
my self- don’t know what shame is
confidence… I to do.” immeasurable.”
started to feel like “I fear that other
a sham from Had a
devastating musicians will see
primary school me for the sham
onwards. That experience of
being ridiculed by that I am.”
feeling has never
left me.” a conductor, from
which he has
Also, had a never recovered.
devastating
experience of
being ridiculed by
a conductor, from
which he has
never recovered.
“It’s bad enough
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 having this
monster on my
back of my own
making without
somebody like that
making it worse.”
Richard Yes (PV) No No Anxious his A bad performance
56 years Mentally ill mother;
Shy, social anxiety, Grew up “in the whole life; leaves him with a
Timpani started musical changeable shadows”; intensity of MPA “sense of
career late (18). unreliable, and became rebellious has not changed disappointment, of
Lifelong unavailable; gives up and left home at over 30 years. despair”; “Outside
MPA Yes (SE) easily; Richard 17 to escape the He was in a forces sabotage
MPA from outset – always “in the shadow; little “living hell” with a any chance of
“I panic, and shadow” of a gifted contact with family conductor who achieving
hyperventilate and older brother and a over the course of disliked him. He perfection”.
feel paralysed”; blind sister. Mother his adult life. “felt shell-
shows maladaptive overwhelmed with shocked” and
perfectionism. grief. “never forgot that
experience”.
Matthew Yes (PV) No No “I’ve had lots of “Techniques don’t
40 years Describes himself Mother suffered Mother was only worse work for me
Oboe as introverted and panic attacks. She intermittently experiences than because panic

95
 “nervy.” “I felt was aware that he available, so that one at 12, comes on so
Lifelong lacking in self- was suffering but Matthew’s anxiety but that was the quickly and
MPA confidence in “left me to my own levels needed to first one that I absolutely
childhood.” devices to manage be high in order to remember and it overtakes
it.” activate her care- is with me me…Shame is the
Yes (SE) giving. always.” strongest feeling I
Had highly “She would come to have…
sensitizing some of my “I have panic I find the panic so
experiences of concerts, but never attacks all the debilitating when it
MPA at 12 and 20 had any words of time now. I have does come up on
years of age. Panic support or comfort been taking me, that I just can’t
experienced as a for me.” Inderal (a beta do anything, I still
“shock” – that blocker) regularly feel really,
memory “has for the past 25 absolutely, without
always stayed with years to stop the any control at all.”
me. I felt ashamed, panic slamming “Humiliation is a
wanted to run into me; quite a common
away, had a otherwise, I experience in this
memory lapse and wouldn’t be doing business.”
just froze.” This the job.”
experience was “Shame is one the
repeated in his 20s strongest feelings I
96
 when a maestro have about
humiliated him in a performing.”
master class.
Rebecca No (PV) No No Has found her Found playing in a
33 years but described Scientist father and I get incredibly niche in a large orchestra
Violin ambivalence about brother have frustrated with my national chamber “sterile”, “like being
exposure – Asperger’s father; I’ve learnt music group in a straight-jacket”
MPA, but formulated as Syndrome, both not to argue with and “terrifying”,
manages wanted to sit up brilliant but social him because I get can’t connect with
satisfactorily front to have the misfits; from a family so worked up, and self or the music.
gaze of the of scientists and we’ve had some Rachel feels that if
missing mother but doctors, so never felt massive family she’s not noticed
feared failure and part of the crowd fights…Mum is she doesn’t exist.
loss of the gaze. (family). Mother had fiercely loyal to Being part of a
panic attacks and Dad even though crowd i.e.,
No (SE) depression, he drives her family/orchestra is
attributed to lack of bonkers. Mum has “terrifying.”
emotionally attuned a touch of
partner in life. Asperger’s also –
Rebecca became a cross her and she
parentified child (i.e., writes you off
a child who acts as a completely. I was

97
 parent to her always… scared
parents). of her and I still
am…She finds ...
physical closeness
with us kids quite
difficult… as does
Dad.
Walter No (PV) Yes Yes “That feeling of “Sibling rivalry”
39 years Described an My parents were sitting in the continues to be a
Viola Yes (SE) attuned mother who very supportive of corner with a feature of his
Had a significant discerned when he everything that we dunce’s hat on musical experience,
MPA, but sensitizing was distressed. undertook…My has stayed with particularly in
manages experience during Parents were brother is an me all these relation to desk
satisfactorily adolescence. supportive and Olympic gold years. I get the partners in the
Played for ‘fun’ accepting of Walter’s medallist. [They] feeling again if I orchestra. However,
until selected into a choices. were quite happy am under- he is generally able
music school, to drive us to prepared for a to balance human
where he felt “like Did not set music lessons performance.” fallibility and striving
the dunce in the unrealistically high etc… to play flawlessly,
class” because he achievement Secure despite residual
was not as expectations attachment evidence of a
allowing Walter to enables Walter to “harsh superego”.
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 advanced as the develop intrinsic benefit from help
other students. motivation. e.g., When
stressed, he
“…actively seeks
out advice from
teachers…”
Lucas No (PV) No No “In my student To cope with
27 years “My parents are both Due to his parents’ years, I found parents who could
Violin Yes (SE) professional severe MPA, they performance not contain their
Had a significant musicians who could not be anxiety a much own anxiety, and
MPA, but sensitizing struggle with MPA emotionally bigger problem therefore were
manages experience during and who use beta available or than I do now… unable to help their
satisfactorily adolescence. blockers.” responsive to the On the night of a son, Lucas
Memory lapses emotional needs concert, I get out foreclosed his
were the “big grim “When you're little, of their children; of my receded career and played it
reapers” of you think your hence, the need self-obsessed safe. He “never
performance. parents are for compensatory state and try to aspired to be a solo
Lapses were completely infallible manoeuvres like relax and artist… maybe I
associated with and pillars of playing it safe. communicate should have been
feelings of shame strength, but we saw with the less realistic” – and
and humiliation. them really audience… I no he has given up
struggling.”

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 longer play from playing from
memory.” memory.

Jenna Yes (PV) Don’t know Don’t Know “When I was “It’s what your mind
57 years “I’m a very shy No clear evidence, No clear evidence, young, I said, does with any
Harp person so for me but… but… “I’m a harpist.” situation that
performing wasn’t “My family thought I “My father died After 20 years, matters …I’m still
MPA, but easy…You see the was having a ball suddenly soon “No, I’m not a an extreme worrier.
manages outgoing people, performing on stage after I was marriedharpist, I’m a I get tied up in
satisfactorily the natural and it was a dream. and that was musician who knots, because I’m
performers, once They didn’t know shocking as I did plays the harp” on my own now and
they get on stage how tied up in knots not even know but now, that’s I’m just beginning to
they take over the I really was.” that he was sick.” not who I am, I’m resent that...I’ve still
world; it was never [This suggests actually a got lots of problems
natural for me… “My daughter had emotional distance person. My job but I’m using music
even as a young severe anxiety from parents]. no longer defines as a haven from all
person, I was very problems but she hid “My husband was me... of that so that it’s
scared when I it – it only came out a manic- I am a human not the problem that
played.” when she had a depressive and an being and this it was. Life came
breakdown.” alcoholic… he allows me to along and said,
Yes (SE) took his life…” make mistakes ‘Hello, there’s a lot
more important
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 “I used to sit and Lack of emotional “I’m fed up with and be things than whether
tremble, my hands connectedness? not having creative… you make a few
would shake someone to talk “I saw people mistakes or not’”.
because the things through being
conductor’s looking with… destroyed…by a
at me.” conductor
because he’d
pick on them,
never
compliment
them; they
shrivelled up
inside and
couldn’t play;
they had to walk
away from their
careers.”

Wendell Yes (PV) No No “My Christian “There is a certain

45 years “My parents were Avoidant/dismissin faith has given self-respect that I
Violin Struggled socially. not interested in my g/de-activating me perspective now have for me as
school work ever or attachment with about the a player… I feel

101
MPA, but “Maybe there is a what I was doing. I parents but importance of confident about
manages stigma that I am didn’t feel they were earned security what I do. It what I’m doing and
satisfactorily carrying. I want to interested in through helps to separate maybe it stems
be accepted; I feel anything that I did compensatory self-respect from from the fact that I
that I have never and I felt alienated attachments (God, conceit.” had to be in order to
been socially from them.” teacher and music feel okay about my
accepted - that’s “They were distant colleagues). However, “Even own playing
probably some and aloof…There “By the time I was now, I’m certainly because my
childish was no effort for in tertiary level I not beyond parents weren’t
hangover… (a emotional didn’t need feeling there to tell me it
form of social connection. I had parental input. I humiliated.” was good or going
anxiety?) moments of anguish had a great well.”
as a teenager teacher, and I was
No (SE) because they in a string quartet
No specific SE weren’t interested in …that lasted for
reported me… I grew up three years…. that
understanding that really fed me
my parents never emotionally with
wanted to see me self-respect and
play and they never gave me a lot of
did.” confidence.”
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Leila Yes (PV) No No “I have never Music helped me to
45 years “There was no However, music had MPA. Even have an identity….
Bassoon Lonely, isolated, pressure from my became akin to when I have [but] it was
struggled with parents – I was free “earned security” - been anxious, I intensely important
Never sexuality; father to do whatever I “Playing the know I can still to be the absolute
experienced had panic attacks. wanted, but they bassoon is like play well…I love best…If I messed
MPA There was no were not sensitive to breathing… playing solos; I’m up, if I wasn’t
“parental gaze”. my intellectual and Loneliness made such a show successful as a
emotional needs. My being a musician off…I have an bassoonist, I would
No (SE) mother was attractive… in my extreme be in trouble.”
“I settled on the disengaged and was teens and 20s I determination to
bassoon because I off having affairs; socialised with play musically
wanted to do dad was anxious, all other musicians as and beautifully
something that over the place my main no matter what.
would make me emotionally – he had friends…”
stand out…” panic attacks. My
parents didn’t notice
that I was alone, not
doing things with
friends.”

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 (i) Lifelong MPA
There were four key themes in the life histories of musicians who had
experienced lifelong music performance anxiety – (i) psychological
vulnerability/behavioural inhibition; (ii) early attachment trauma; (iii) a
humiliating sensitizing experience during adolescence related to
music performance; and (iv) impaired enjoyment of the process of
music-making, especially in the context of performance. We observed
a strong relationship between attachment trauma and the failure to
develop a reliable internal secure base, which resulted in a lack of
self-confidence and an impaired sense of self as adults. Richard is an
example.

Richard

Richard has spent 33 of his 56 years as a timpanist in an orchestra.

He was the neglected sibling of an academically gifted older brother,
and a sister who was born blind. Their mother suffered from clinical
depression and was frequently hospitalized. His father was not
mentioned in his narrative.
My parents never delighted in my achievements. I was always
in the shadow of my older brother. He was two years older than
me and he was smart, motivated, conformist, always did well. I
could never measure up. I was rebellious. I left home at 17
years to escape the shadow, but there is always a shadow
hanging over me.

His mother was overwhelmed with grief and the burden of caring for
a disabled child, but also appeared dispositionally anxious,
depressed and fragile.
I have a sister who is blind so my mother had anxieties that go
with that. She is a very nervous person. She gets flustered very
easily and gives up if she doesn’t get things right the first time.
She had a bad mental breakdown when we were young and
spent time in a mental hospital… I am not close to my family …I
only see them once every four years or so… I have always been
a shy person, and anxiety has affected me in other areas of my
life, especially in musical performance and public speaking.
Richard’s perception was that his mother had no energy for him; he
was left to fend for himself, (Wendell reported a similar experience)
culminating in his early exit from home at 17 years. It is likely that
there was some generational transmission of anxiety from his mother
together with a possible biological vulnerability to anxiety (shyness);
several other members of his family also suffer anxiety, including his
19-year-old daughter. He describes his experience with MPA thus:

I have suffered from MPA my whole professional life. The

anxiety for performance has stayed the same over the course
of my long career as a professional musician. I sometimes feel
paralysed; I hyperventilate, I have a feeling of intense
nervousness and tightening in my body; my technique is not
relaxed. I am always anxious that the stick will fly out of my
hand. It has flown out of my hand on occasion, and those are
moments of intense panic…I have never played without
MPA…it does not decrease when I have easier repertoire to
play, because it still depends on a lot of other elements, such
as whether the concert is low key or a very serious major
concert with an international conductor. I always try to make
sure that I am well prepared technically. Then, when I go on
stage, I meditate and breathe deeply to help with my MPA. Most
of the time, I still can’t enjoy the performance. My strategies
allow me to remain professional and get the job done... I am a
professional musician. I know how to give a professional
performance. I would like it to be an enjoyable experience but
MPA prevents this.

His oppressively fatalistic account reveals a man who has been

disappointed by life. A bad performance leaves him with a “sense of
disappointment, of despair”; “Outside forces sabotage any chance of
achieving perfection”.

Music is the same as anything in life. I was passionate about it

at the start but it is hard to retain the passion. It becomes a job,
but I am grateful that I still have my health and my technique.

105
 Often, when the music is not uplifting or inspiring, I just go
through the motions; Music is not a glamorous profession…

There is no joy in his life – a feeling that mirrors his early experiences
with his parents, who “never delighted in his achievements.”

Matthew
Matthew is an oboist and part-time conductor, now in his 40s, whose
MPA began in early adolescence when he ‘froze’ (i.e., experienced a
catastrophic breakdown in performance) during a solo performance
in a school concert. The feelings from this early experience of panic,
humiliation and shame were later reinforced when attending a master-
class during his tertiary studies, at which time his playing and a
memory-lapse were ridiculed (as he experienced it) by the maestro.
Undeterred, he has made a successful career in music, partly by
working as a conductor in which role he is MPA-free, and partly with
the help of Inderal (a beta blocker) during stressful performances.
Nevertheless, the MPA remains as a lurking threat in his life:

There is within this thing that hits me…I find it so debilitating

when it does come up on me, that I just can’t do anything, I still
feel absolutely without any control at all. I’d love to wake up
tomorrow and think I’m never going to suffer from performance
anxiety ever again…but …I enjoy performing so much, it’s a
very strange conundrum.

For Matthew, MPA is problematic but not crippling. He spoke of his

anxiety-ridden mother with whom he felt unable to share his own
feelings of panic:

My mother’s very much prone to panic attacks and my two

nephews suffer very badly from panic attacks too. So I find it
almost like a genetic thing to a certain extent.

Matthew described his attachment to the orchestra itself and the

sense of belonging that it provided.

Umm, sometimes, it’s a bit of a funny job the orchestra, because

we’re like one big family in a way, it’s a bit like a sports

106
 team…Last year I had an offer of a music teaching job in a
school which paid twice as much as my job in the orchestra. ..I
think I would miss the job so much, the performance side of it
and the enjoyment of working with great musicians; I would miss
that a lot.

However, his MPA is constantly triggered in the orchestral context

since he is acutely aware of how he compares with other members of
the orchestra. This led to an exploration of sibling feelings:

They [his brothers] don’t work in a situation where panic or

anxiety affects them. I always remember doing a driving test
years and years ago. It was a crash driving course… we did a
whole week staying in a motel and we had to do the test at the
end of it. I remember noticing how everyone on the course with
me got completely chewed up with nerves at test time, and I’m
thinking, “Oh well, this is what I go through every week” [laughs].

(ii) MPA resolved or managed satisfactorily

There are many permutations and pathways in one’s life experience
that can repair early attachment trauma. One of the most frequently
encountered is the development of reparative or compensatory
attachments. The other is to foreclose on one’s aspirations and ‘play
it safe’, thereby avoiding dangerous, triggering scenarios. We present
two vignettes, each representing one of these ‘solutions’ to early
problematic attachment experiences.

Compensatory attachment

The quality of attachment is determined not only by the quality of

parenting, but to the availability of resources, both material and
personal, such as intelligence, talent, or temperamental flexibility that
help people moderate their affective states, and by the presence and
quality of compensatory attachment relationships that provide an
opportunity to develop ‘earned security’ (Roisman et al., 2002). All of
these factors together form the basis for the development of the
individual’s coping repertoire (Kenny, 2013). Wendell is an example.

Wendell

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Wendell is a violinist from a large (seven children), musical family; he
has two siblings in the string section of the same orchestra. He
describes himself as unambitious and seemingly rather disconnected
and aimless in his personal life. His mother taught him the violin, but,
in his perception, there his parents’ interest in him and his siblings
ended. He describes parents who were emotionally cut-off, lacking in
empathy, and disinterested in their children. He felt alienated from
them and anguished by their lack of acknowledgement.

They tended to read and sit in a chair and smoke. They left us
all to our own devices. I tried a couple of times to express this
anguish to them but I didn’t get a result because they couldn’t
communicate on that level.

As an adult, Wendell reflected on the impact of his past on his current

self-perception and coping strategies, and discusses the
compensatory attachments that he found in his teacher and peers.

I had an emotionally isolated childhood, but there is a certain

self-respect that I now have for me as a player. I feel confident
about what I’m doing and maybe it stems from the fact that I had
to be in order to feel okay about my own playing because my
parents weren’t there to tell me it was good or going well. By the
time I was in tertiary level I didn’t need parental input. I had a
great teacher, and I was in a string quartet when I was a student
that lasted for three years and we were really trying to be
successful. I think that that really fed me emotionally with self-
respect. That gave me a lot of confidence that was a valuable
thing for me.

As a teenager he ‘found’ religion, and it seems that this, in addition to

the self-reliance mentioned above, has given Wendell the emotional
support lacking in his childhood. An interesting comment implies the
modulating effect of the holding Other, in this case God, in which the
inevitable narcissism associated with musical talent is transmuted into
healthy self-esteem:

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 You know, trying to separate self-respect from conceit. I think
my faith has helped me with that.

Wendell exemplifies the importance of the teacher as a key

psychological as well as purely musical figure in the development of
a musician, and how this quasi-parental relationship can, to an extent,
compensate for what was lacking in childhood. Fostered in this way,
musical talent is an inherently resilience-promoting factor. In
Wendell’s case this has also been helped by his religious faith which
provided the validation which he lacked in childhood.

The barrenness of his inner life may have meant that he craved praise
and applause from his teachers, peers and audience, and their
attention was compensatory, but his suppressed rage about his
perceived lack of parental involvement left him with a feeling of inner
emptiness. His existential disconnection in his life is evident. Wendell
illustrates well the efficacy of the avoidant defence – he can keep
MPA at bay so long as he does not push himself forward; but
avoidance entails psychic work in keeping negative affect at bay. He
cannot plan ahead or think about what he wants to do with his life –
all his efforts are directed into keeping his psychic ship afloat.

Career is not something that’s ever really concerned me, as you

can probably tell from my sketching my childhood. I never really
had much ambition… I’m not somebody who had a vision. I
can’t understand why.

‘Playing it safe’

For some people, the experience of persistent anxiety and self-doubt

become so intolerable that they resolve the emotional crisis by
foreclosing on their adolescent dreams and goals and ‘play it safe’.
This is what Lucas did.

Lucas

Lucas is a 27-year-old violinist who has played in the orchestra for

four years. Lucas appeared to start out with a normal amount of
youthful self-confidence and healthy narcissism. He said that he felt

109
 …very lucky getting this job so soon after graduating. A lot of
people want a job in an orchestra and most have to try a lot
longer than 8 or 10 months to find one.

However, his early life and attachment experiences did not allow him
to sustain this. He describes an enmeshed family in which
individuation, separation and assertiveness were not encouraged.

My parents are both professional musicians. I come from a

family of five kids and we all play music, four of us
professionally, so it’s something I was bred into. I was playing
the violin before I even knew what was happening…

He pinpoints the cause of his early MPA to insecure memory.

One thing that used to make me very nervous was when I was
playing solos in competitions which were always from
memory…one of the hardest things, which made me feel tense
and worry about performing. It was the big grim reaper of a
memory slip or a memory lapse hanging over me that I
associate with performance anxiety. It happened all through
school and university studies – memory lapses and falling into
a heap…eventually, I expected to flounder…

Lucas experienced catastrophic reactions to his memory lapses and

developed a sense of defeat and fatalism. These feelings were
reinforced as he watched his own musician parents cope with
debilitating music performance anxiety.

My dad is a professional horn player who really struggles with

performance anxiety; he has to use beta blockers. My mum is
also a musician and she uses them too. Dad has severe
problems with confidence … When you're little, you think your
parents are completely infallible and pillars of strength, but we
saw them really struggling. We knew they were nervous and
took beta blockers.

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Lucas’s parents disappointed him – he had to become prematurely
“adult” in his approach to his own anxiety because there was no
secure internalized parental base to assist him. As he says:

Maybe that helped me think logically about performance anxiety

and what effects it has…. I never play from memory now. I never
aspired to be a solo artist… maybe I should have been less
realistic, [our emphasis] but my parents wanted me to have a
steady job in an orchestra and not go overseas for more lessons
like a lot of my friends were doing and aspiring to a solo career.

He has solved his performance anxiety by never playing from memory

– this forecloses opportunities for solo performances. This is a sad
statement from a man who is still young but who has excluded himself
from the bolder possibilities and aspirations of his life. He has
introjected his parent’s anxiety about security and fear of performance
by ‘playing it safe’ i.e., remaining an orchestral musician and not trying
to overcome his fears of playing from memory, thereby accepting the
end of his grandiose childhood fantasies for virtuosity, adoration and
recognition that was perhaps denied him in his relationship with his
parents.

(iii) No experience of MPA

Only one of the self-volunteering musicians reported never having
experienced MPA. This case is illustrative in illuminating the fact that
although one can be free of performance anxiety, this does not
necessarily suggest secure attachment or represent psychological
well-being. Leila is a 45-year-old bassoon player. Her narrative is
replete with attachment trauma, yet she escaped its expression in her
music. Both parents were professional musicians but incompetent
(“not sensitive” or attuned) parents. Leila was very gifted and learnt
several instruments in rapid succession. On her choice of instrument,
Leila said

I settled on the bassoon because I wanted to do something that

would make me stand out, was challenging and weird. I
discovered at 14 that I was gay. I felt different so finding an
identity as an unusual musician is related to that. …I got a lot of

111
 self-esteem from being really good at music… because I was a
super lonely kid. I felt that there was something wrong with me
and it was my lot in life to be on my own. Loneliness made being
a musician attractive… Music made me feel special…

Leila achieved a very high level of mastery on many instruments with

comparative ease

…but it was intensely important to be the absolute best. …I’ve

been in some very competitive musical environments, but I have
never had MPA…

Leila’s account of her early life certainly suggests attachment trauma,

yet she was protected against the experience of severe MPA. Why?
We surmise that Leila’s facility with her instrument (“playing the
bassoon is like breathing”) has played a significant role in protecting
her from MPA. She, like Jenna, continues to experience emotional
distress in her everyday life and sees music as a sanctuary or haven
into which she can retreat when interpersonal relationships become
too difficult.

… I dread working with conductors who are overt bullies and

male musicians who are covert bullies. I like playing the
bassoon but I don’t like going to work – I have nightmares about
getting hassled. I ruminate about how I can deal with it.

Leila personifies a key paradox in the gifted: musical (or any other)
skill enhances self-esteem, but if self-esteem is excessively bound up
with being a ‘good’ performer it becomes persecutory (i.e., to play
badly is to perceive oneself as a ‘bad’ person or as a failure). Leila
understands the fragility of her position – she says that “…if I messed
up, if I wasn’t successful as a bassoonist, I would have been in
trouble”.

DISCUSSION
In this chapter, we argued that an attachment approach shines a light
on some of the major themes intrinsic to MPA once the latter is viewed
from a developmental rather than purely symptomatic perspective,

112
particularly when we attempt to understand the symptoms of MPA in
a relational context. This interplay between developmental relational
history and MPA emerges in a common ‘interdisciplinary' language of
attunement and ‘being on the same wavelength’; ‘being heard’; the
importance of ‘holding’ if the emotional exploration that lies at the
heart of music training and performance is to be facilitated; sibling
rivalry and dissonance versus sibling harmony and co-operation;
being seen and applauded (i.e., healthy and sometimes pathological
narcissism, both for parents of musicians and musicians themselves);
and the psychosomatic self in the sense that music performance, no
less than relationship, involves body, mind and emotions. An
attachment-informed psychodynamic approach to MPA explores
these themes, while attempting to provide the attention, reliability,
validation and a realistic non-judgemental stance that may have been
missing in childhood.

Our proposed model suggests that the emergence of severe, lifelong

MPA may depend on two sequential factors: a) suboptimal
developmental experience and relational disturbance in infancy and
early childhood and b) sensitising events and experiences in
adolescence that reinforce and strengthen pre-existing pathways to
anxiety and self-doubt. Our study found that symptoms typically
surface during adolescence in talented youngsters who have often
previously performed without undue anxiety. In the formulation that
has guided our understanding of these interviews we see
adolescence as a phase in which the attachment system is re-worked
in a number of significant ways. First, overt dependence on parents
is replaced with an ‘internal secure base’ to which the individual can
turn as a source of safety and reassurance when under threat, and
which acts as a port of first call for affect-regulation. Second, the peer-
group begins to assume the role previously occupied by parents as a
significant haven for truth-telling, trust and mutual learning. Third,
mentalization skills, especially the capacity to understand, regulate,
and verbalize one’s thoughts and feelings, and, comparably, to read
those of others begins to mature; this process can be compromised
in the MPA sufferer-to-be. Finally, identity and life-course options

113
open up; advice, role-modelling and learning is often invested in ‘older
and wiser’ non-parental mentors, and here pre-existing assumptions
based on early childhood constellations colour the teacher-pupil
relationship, for good or ill. These changes are negotiated at different
rates and with varying degrees of completion by young adults, usually
in the decade age 15-25.

The capacity to successfully negotiate these developmental phases

will depend to a large extent on earlier attachment experiences with
caregivers, and that, for musicians, insecure attachment will shape
the way in which performance anxiety is experienced and managed,
or result in lifelong MPA. An internal insecure base arises from early
developmental experiences that have been affect-dismissing
(avoidant), inconsistent (preoccupied), or persecutory, neglectful or
chaotic (disorganised/unresolved). This means that musicians may
find it hard to trust themselves and their audiences to the extent that
they perceive their prototypical ‘listener’ as affectless, inattentive, or
misattuned (as in the case of Wendell and Richard). This in turn can
lead to inappropriate preoccupation with technical perfection and
excessive self-consciousness. In the same vein, the peer group –
fellow musicians in an orchestra or band - rather than being a source
of support, feel persecutory, with the danger of ridicule or expulsion
fuelling MPA symptoms. Maestros and conductors, as musical quasi-
parents, are often perceived in this way (see Matthew’s account of his
experience in a master class and Greg’s, Richard’s, and Jenna’s
descriptions of conductors). Teachers, similarly, rather than being
trusted role-models, become fear-inducing critics. Anxiety inhibits
mentalizing, thus creating a vicious circle in which the sufferer is less
and less able to look at his or her fears of failure and view them as
‘just thoughts’ rather than a putative reality.

We were struck by the extent to which persecutory self-monitoring

was prominent in several accounts. Self-monitoring is an essential
part of any skill – observing oneself, learning from and correcting
mistakes, keeping oneself safe. For the securely attached, mistakes
and misattunements are normal and necessary, fostering the skills of
reparation and repair. For several of the musicians in this study,

114
however – e.g. Anna, who felt “suicidal in relation to music”; Greg,
who felt “immeasurable shame” when he “botched a performance”;
Richard, for whom a bad performance leaves him with “a sense of
disappointment and despair… striv[ing] for perfection. I am
disappointed if I don’t achieve it”; Matthew, who feels the “panic
slamming into me” when under perceived threat; Walter, who has the
“feeling of sitting in the corner with a dunce’s hat on” if he makes a
mistake; Lucas, for whom memory lapses were “big grim reapers”;
and Leila, for whom it was “intensely important to be the best” – errors
were a signal that to be less than perfect would lead inexorably to
depression-enhancing self-recriminations. For those with internal
working models associated with attachment insecurity, this process
may activate a critical or rejecting parent (e.g., Richard commented
that conductors trigger depression in him), or a transgressing or
disorganised child dynamic (e.g., feeling like a dunce sitting in a
corner; feeling like a sham, a fraud, or a failure).

Underlying this persecutory self-monitoring is the experience of

shame. This was observed in both the sensitizing experiences during
adolescence and the current experiences related to MPA. Allan
Schore (1998) has suggested that attachment trauma in the form of
maternal misattunemnt sensitizes children to shame experiences,
which may be manifested in several ways, of which self-denigration,
ruminations about one's defects, and the internalization of a shaming
object threatening the self with rejection are common (Schimmenti,
2012). These experiences create chronic difficulties in self-esteem
(positive affect) regulation because the early shaming experiences
become prototypical of all interactions (Schore, 2003). Thus,
attachment disorders underlie all early developing
psychopathologies, which manifest as failures of self and/or other
interactional regulation. This is hypothesized to be the underlying
cause of the panic and depression that characterizes severe MPA.

Nevertheless, in our sample more than half managed their symptoms

more or less successfully, either with personal strategies or with the
help of beta-blockers and symptomatic psychological therapies such
as CBT. Such symptom-oriented approaches have limitations,

115
however. Symptoms may persist, or, while functioning to an extent,
the musical (and indeed personal) potential of the afflicted individuals
may not be fully realised. Here we noted another pervasive theme in
the interviews – that of the need for ‘self-holding’ (Slochower, 1996).
Self-holding is a necessary part of successful performance, but if this
is to the exclusion of the audience, it can short-circuit the
communicative process, leading to excessive self-awareness,
detracting from emotional expressiveness, and creating a vicious
circle of anxiety and further alienation. Ideally, the performer is
‘talking’ to the audience about the music. The performer herself needs
to feel ‘held’ in an internal secure base (ISB) to which he/she can turn
if anxiety surfaces during difficult passages, making a mistake, or not
feeling in sufficient technical control of the material. This ISB, arising
out of secure attachment experiences in childhood, is accepting,
reassuring, forgiving, recharging, reparative, anxiety-alleviating. This
enables the performer to carry on and return to the ‘present moment’
of the music and to the communicative task. Lucas poignantly
expressed this idea – “On the night of a concert, I get out of my
receded self-obsessed state and try to relax and communicate with
the audience.”

Our study suggests that a life-course approach may helpfully reveal

the developmental origins of MPA, and that the attachment framework
can help illuminate the specific themes that arise in a performance.
The presence of an ‘internal secure base’, the capacity to trust fellow
musicians for support, and to trust that audiences will be attentive and
compassionate are the outcomes of secure attachment in childhood.
Jenna expressed this well – “There are times when the orchestra will
think as one and it raises everyone up out of themselves and you soar
along on this great euphoria.” When this has been compromised, in
the various forms of insecurity, then MPA may result, and the
worldview of musicians includes fears that fellow musicians will
criticise or ridicule them, or dismiss their anxieties, and that audiences
will be inattentive, hostile, and unforgiving.

The attachment themes outlined here do not pertain solely to

musicians, but may apply equally to other artists – actors and dancers

116
certainly. Indeed, it could be argued that everyone to a greater or
lesser extent, at some time or other, is called upon to ‘perform’ – a
presentation in class, a toast at a wedding, or a valedictory address.
To use a musical analogy, the attachment themes we have discussed
can be seen as underlying ‘leitmotifs’ which recur throughout life. For
musicians the extremity of a musical performance provides the
context in which they come to the fore. This can be exhilarating or
traumatic, or both, but is likely to evoke a person’s repertoire of both
creativity and anxiety. Implicit in our approach is the need a) to test
our qualitative conceptualisations quantitatively, and b) to explore the
efficacy of an attachment-informed psychodynamic approach to the
treatment of MPA when medication, CBT and other symptom-focused
treatments have failed. One case study has reported the efficacy of
this approach (Kenny, Arthey, et al., 2014), but further studies are
obviously required.

Finally, our findings contribute to the discussion regarding the ‘artistic

temperament’ and its association with mental illness (Kaufman, 2005;
Ko & Kim, 2008; Ramey & Weisberg, 2004; Thomson & Jaque, 2012).
For example, while most artists share a greater capacity for
absorption and imagination (Dalenberg & Paulson, 2009), they also
display a greater propensity for pathological dissociation, and report
higher rates of trauma and loss experiences in their developmental
histories. Pathological dissociation was strongly associated with
unresolved attachment as assessed by the Adult Attachment
Interview (Thomson & Jaque, 2012). Although none of the previous
studies included performing musicians, or assessed the link between
trauma, loss, or attachment quality on artistic performance, our work
has now identified a connection between attachment insecurities and
performance anxieties.

Limitations of this study

There are limitations to this exploratory, qualitative study. The first

concerns the researchers themselves. It is possible that the particular
theoretical approach was imposed on the interview material and that
researchers with differing theoretical biases might have reached

117
different conclusions. We would argue that this danger is inherent in
the methodology adopted, but that safeguards, especially the
mentalizing perspective which takes account of the researchers’
preconceptions and predispositions towards an attachment-informed
psychodynamic approach, are mitigating counter-weights.

Second, although we felt that a narrative, quasi “grounded-theory”

approach useful in this exploratory study because our aim was theory-
building, subsequent research will supplement the narrative approach
with psychometric tests on larger, representative samples of
musicians.

Third, although population studies have shown that MPA is common

in musicians (see Kenny, 2011; Ackermann, Kenny, O’Brien, Driscoll,
2014; Kenny, Driscoll, & Ackermann, 2014), the findings of this paper
should not be taken to imply that it is a near-universal phenomenon.
Of the 10 musicians who volunteered to be interviewed, nine had
experienced significant issues with MPA. Clearly, those with
unresolved issues or continuing emotional distress about their
musical lives will have been more motivated to participate in such a
study. The current sample was self-selected and their experiences do
not represent the whole domain of MPA, nor indeed, the majority of
performing musicians. Nevertheless, they have, for the authors at
least, undoubtedly deepened our understanding of the origins and
dynamics of MPA. We hope they have added to theorizing about the
underlying psychological vulnerabilities that musicians carry with
them into their adult professional lives, and pointed to ways in which
these might be alleviated through appropriate therapeutic
interventions.

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 PART 3

TREATMENT OF MUSIC PERFORMANCE ANXIETY

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 CHAPTER 5

INTENSIVE SHORT-TERM DYNAMIC PSYCHOTHERAPY

(ISTDP) FOR SEVERE MUSIC PERFORMANCE ANXIETY.

PART 1: EXPOSITION AND PSYCHODYNAMIC

ASSESSMENT OF A PROFESSIONAL MUSICIAN2

The following two chapters report on the application of Intensive

Short-Term Dynamic Psychotherapy (ISTDP) with a professional
musician who had suffered severe music performance anxiety over
the course of his entire career, spanning more than 30 years, at the
time he presented for treatment. In this chapter, part 1 presents the
theoretical foundations and rationale for the treatment approach,
together with the case history of the musician and the process of the
first assessment session. Part two of this chapter presents the course
and outcome of ISTDP for this musician.
Introduction
Kenny (2010, 2011), in detailed in-depth interviews of anxious
musicians, identified three possible subtypes of music performance
anxiety, each requiring an increasingly intense treatment response.
These subtypes comprised
(i) focal anxiety that usually centred on realistically highly
anxiety-provoking situations such as auditions and solo
performances with little generalized anxiety to other
situations;
(ii) performance anxiety associated with a co-morbid diagnosis
of social anxiety (social anxiety disorder); and
(iii) a group who reported severe, performance impairing anxiety
associated with their music performance, together with panic
attacks, generalized social anxiety and either pervasive

2 With Stephen Arthey and Allan Abbass

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 dysthymia or depression. Many of the musicians in this third
category had undertaken a range of therapies including
cognitive behaviour therapy or its components such as
breath awareness and relaxation training, use of self-talk and
positive affirmations, additional practice, distraction methods
and hypnosis in an attempt to manage their often debilitating
symptoms. All of this group were reliant on medications,
mostly comprising anxiolytics, beta blockers and/or anti-
depressants, with some also reporting the use of alcohol and
marihuana to manage their performance anxiety.
Close analysis of the transcripts of interviews of severely anxious
musicians suggested that an underlying, unresolved attachment
disorder appeared likely in the majority of cases. These conditions
have been referred to variously as disorders of the self (Kohut, 1971,
1977, 1984; Kohut & Wolf, 1978), pre-verbal trauma (Winnicott, 1945,
1965, 1974); attachment disorder (Fonagy & Target, 1997; Halpern,
2004; Janus, 2006; Mills, 2005 ; Wallin, 2007) and fragile character
structure (Davanloo, 1990, 2005). Given that the majority of
musicians keep irregular hours because of their performance
schedules and are required to travel, long term psychotherapy is often
not a feasible treatment option. A shorter term therapy that addresses
the core psychopathology is therefore required for this group.
Intensive Short-Term Dynamic Psychotherapy (ISTDP)
Intensive Short-Term Dynamic Psychotherapy (ISTDP) is a short term
psychotherapy that shares with other short term psychotherapies a
number of common features, which include maintaining a therapeutic
focus (as opposed to the free association of psychoanalysis), active
therapist involvement (as opposed to the non-intrusiveness and
passivity of psychoanalysts), the use of the transference and the
therapeutic alliance and relatively short duration (between one and
forty sessions for most patients; up to 150 sessions for those with
severe psychopathology). ISTDP, like many short-term
psychotherapies, uses the Triangle of Conflict (feelings, anxiety and
defence; Ezriel, 1952) and the Triangle of Person/Time (past,
therapist and current; Menninger, 1958) to maintain the therapeutic

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focus (Davanloo, 1990, 2005). For a detailed explanation, see Kenny
(2011).
ISTDP has a moderate and growing evidence base with 21 published
outcome studies including patients with personality disorders,
depression, panic disorder, and a range of somatoform disorders.
Effects are large, superior to controls and show sustained effects in
long-term follow-up (Abbass, Town & Driessen, 2012). ISTDP
includes very broad acceptance criteria. Abbass (2002) showed that
86% of referrals were appropriate for ISTDP, with the exclusions
including psychosis and conditions with an organic origin.
The theoretical structure of ISTDP is similar to other models of
dynamic psychotherapy. Its theoretical rationale draws on attachment
theory (Bowlby, 1988; Schore & Schore, 2008). The core therapeutic
action in ISTDP is the “patient’s actual experience of their true
feelings about the present and the past” (Davanloo, 1990, p. 2) and
hence, although psychodynamic in theoretical structure, ISTDP is
also an emotion-based therapy. The main areas of innovation of
ISTDP lie in its therapeutic practices. Its founder, Habib Davanloo
(1990, 2000, 2005) developed a technique to rapidly mobilize the
unconscious therapeutic alliance (Davanloo, 1987) in order to remove
the major resistances3 to change, which were not effectively removed
through interpretation alone. In this respect, ISTDP resembles the
confronting focus on the “here and now” in the gestalt therapies
(Crose, 1990; Harman, 1996).
ISTDP allocates the same role to anxiety as most psychotherapies,
viewing it either as a response to an external threat or an internal,
emotional conflict. In situations where a legitimate external threat
exists, anxiety is an adaptive response that prepares the individual to
deal with the threat as effectively as possible. Internal emotional
conflicts are created through ruptures in attachment relationships in
the first eight years of life (Bond, 2010; Muller, 2009; Pauli-Pott &
Mertesacker, 2009). There are a wide range of events and situations

3 Resistance comprises the patient’s system of defences, which, according to ISTDP, are the

result of intense unconscious guilt and primitive murderous rage in relation to the people in the
patient’s early life (Davanloo, 2005).

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that create attachment ruptures. These include, but are not limited to
death of a parent, prolonged separation due to illness of child or
parent, emotional neglect, emotional or physical abuse, and sexual
abuse, or a subtler but equally damaging chronic parental
misattunement to, or lack of empathy with their children’s emotional
signals. The age of the child at the time the rupture first occurs, and
the frequency and duration of these experiences of rupture are
indicators of the severity of the attachment rupture (Bond, 2010). The
younger the child, the more frequently the events occur and the longer
the overall duration of the events, or the more persistent and
unrelieved the parental misattunement, the more severe is the
attachment rupture (Beebe et al., 2010;Bowlby, 1960, 1973).
The rupture in the attachment relationship causes emotional pain in
the child and a retaliatory rage towards the parent(s) for causing the
pain. However, because the child also loves the parent(s), he feels
guilty about experiencing rage towards someone he loves. The rage,
guilt, grief and love are all repressed into symptoms and are
submerged under behaviours that enable the child to continue a
relationship with his parent(s). This process eventually becomes a
characteristic defensive system (Winnicott, 1965). Whenever the
child is in a situation that has the potential for a rupture of attachment,
the repressed rage, guilt, love and pain from the initial attachment
rupture is re-activated. Anxiety is experienced to block the feelings
from entering conscious awareness and the defensive system is
automatically triggered to keep the feelings repressed and to avoid or
alter the emotionally triggering situation (Glowinski, 2011). Over time,
this pattern is automatically activated in any situation that has the
potential to trigger the repressed feelings about the initial attachment
rupture (Amos, Furber, & Segal, 2011).
The anxiety over the internal emotional conflict and the defensive
pattern become the psychological problems in the person’s life.
Anxiety can manifest in any or in a combination of four ways. The
most adaptive manifestation of anxiety is tension in the striated
muscles of the body. Davanloo (1990) discovered that this type of
anxiety has a predictable neurobiological pathway in the body,

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commencing in the thumbs, spreading to the hands, up the arms to
the shoulders and neck and head, then down through the torso to the
legs and feet. In the clinical setting it is seen with hand clenching and
sighing respirations. Chronic striated muscle anxiety is associated
with a number of physical problems including fibromyalgia, pain,
spasm, hyperventilation and panic (Abbass, 2008). In a therapeutic
context, striated muscle anxiety is an indication that the person has
the capacity to consciously experience the repressed feelings from
the attachment rupture(s).
The second manifestation of anxiety is smooth muscle anxiety.
Instead of the anxiety being directed into tensing the striated muscles,
the anxiety is somatised into the body’s smooth muscle affecting
combinations of gut, airway and blood vessels. In the the gut, this
form of anxiety leads to gastrointestinal symptoms including nausea,
reflux, cramping and the urge to defecate. The striated muscles
remain relaxed. Chronic smooth muscle anxiety is associated with
hypertension, irritable bowel syndrome and migraine (Abbass, 2005;
Abbass, Lovas, & Purdy, 2008).
The third manifestation of anxiety is cognitive perceptual disruption
(CPD). A person experiencing CPD will become confused or blank in
their thoughts and/or will have disturbances in one or more of their
senses when experiencing anxiety. This could include tunnel vision,
blurred vision, ringing or buzzing in the ears. Disturbances can occur
in any or all of the senses, but visual disturbances are most common
(Davanloo, 1995b). Physically, the person will appear relaxed as
anxiety is not being expressed in the striated muscles, but will
manifest confused thinking and not be “present” in the room. Chronic
cognitive perceptual disruption is associated with neurological
complaints (for which no medical cause can be found), dizziness and
fainting.
The fourth way in which anxiety can manifest is through motor
conversion (Axelman, 2012). Instead of becoming tense, the person
will become weak in one or more areas. Potential medical causes
must always be ruled out before concluding that the symptom is an
indication of conversion. Typically, the person experiencing

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conversion will be much less concerned about losing function than
would be expected, a condition called la belle indifférence (Stone,
Smyth, Carson, Warlow, & Sharpe, 2006).
In a therapeutic context, the experience of smooth muscle anxiety,
cognitive perceptual disruption or conversion indicates that a
psychological restructuring process is required before the person is
capable of consciously experiencing the repressed feelings from their
attachment rupture(s). In restructuring, the person is gradually
exposed to increasing levels of anxiety, via graded exposure to their
repressed feelings, and helped to develop and maintain a striated
muscle anxiety response (Davanloo, 1995a). Eventually, the patient
is able to consciously experience the previously repressed feelings
without undue anxiety. Patients may experience only one of the four
types of anxiety, or they may experience a shift from striated to
smooth muscle or CPD as the repressed feelings move closer to
conscious awareness.
In response to anxiety, defences are automatically activated. There
are three main groups of defences (Davanloo, 1996a). Isolation of
affect4 is the most adaptive defensive system. Patients are aware that
they are experiencing a particular emotion, but they don’t know how
they are physically experiencing it. Instead of the physical experience
of the emotion, patients with isolation of affect experience striated
muscle anxiety.
The second major defensive system comprises repression 5
(Davanloo, 1996a). Patients with repression do not recognize that
they are experiencing emotions. Instead feelings are repressed into
the body. Repression is linked to smooth muscle anxiety where
feelings are internalized/somatized into, for example, nausea, irritable
bowel syndrome, depression, migraine headache, or conversion.

4 Isolation of affect is the awareness of emotions in one’s head without the experience of the

emotions in the body. It is also called ‘intellectualizing’ (Abbas, Lovas & Purdy, 2008).
5 Repression, a major primary defence, is an unconscious process by which emotions are shunted

into the body and experienced as depression, smooth muscle discharge or conversion rather than
reaching consciousness (Abbas, Lovas & Purdy, 2008).

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The third form of major defences is projection6. Patients using this
cluster of defences do not perceive that they are experiencing
emotions, but rather perceive that another person is experiencing the
feelings that the patient would be expected to feel. This most
commonly occurs with anger, but any feeling can be projected.
Typically, these patients manifest weepiness (tears without feelings
of grief), temper tantrums, explosive discharge of affect and
confusion. This defensive system is associated with CPD (Davanloo,
1995b).
The combination of anxiety type and system of defence enables each
patient to be located on either the Spectrum of Psychoneurotic
Disorders (Davanloo, 1999a) comprising low, moderate, and high
resistance or the Spectrum of Patients with Fragile Character
Structure (Davanloo, 1995b).
Low resistance: These patients have had secure attachment
relationships for at least the first several years of life. Their problems
are of recent onset or are mild neurotic disorders. They have no rage
in their unconscious, only unresolved grief. These patients are very
responsive to psychotherapy.
Moderate resistance: These patients typically have had attachment
ruptures at between five and seven years of age. They have character
disorders and diffuse psychological symptoms, experience violent to
murderous rage, guilt, and grief in their unconscious from the early
attachment ruptures involving one or more figures from their early life.
High resistance: These patients experienced attachment ruptures
in the first two to five years of life. They have complex character
pathology and highly syntonic character resistance, with a
masochistic, self-sabotaging component. These patients have
intense murderous rage, guilt and grief in relation to all of their early
attachment figures.
Spectrum of Fragile Character Structure: These patients present
on a continuum from never having experienced an attachment bond

6 Projection is a primitive, defence connected to superego pathology, in which one unconsciously

projects into the therapist (and others) unacceptable feelings in oneself.

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to having all of their attachment bonds (which were weak when they
existed) rupture within the first two years of life. These patients cannot
withstand the impact of their unconscious feelings in the first interview
and require a restructuring process where they are exposed, in a
stepwise manner, to increasing intensities of their unconscious
feelings (Davanloo, 1995c). They have life-long patterns of regressive
and projective defences including temper tantrums, explosive
discharges of affect, self-harm, drug and alcohol misuse, dissociation,
and projection of their feelings into others.
Recognising the patient’s position on these Spectra enables the
therapist to determine the most effective therapeutic pathway to bring
the repressed feelings into the patient’s conscious awareness (i.e. to
help the patient to consciously, physically experience the repressed
feelings without defence or anxiety).
Access to the unconscious feelings is achieved via the use of
structured interventions designed to help the patient recognise his
defences, appreciate the costs of their defences, and then turn
against and actively work to overcome them (Davanloo, 1996a,
1996b).
ISTDP aims to give the patient access to the full experience of their
repressed feelings and the fantasies and memories that have been
repressed with these feelings. The major interventions are applied
through an over-arching framework, known as the Central Dynamic
Sequence (CDS, Davanloo, 1999a) that guides the therapist towards
the repressed feelings and memories. The CDS can be divided into
eight overlapping stages. Each stage has definable goals that need
to be achieved before the goals of the next stage can be achieved.
As the goals of each stage are achieved, they add to and build a
complex intra-psychic and interpersonal experience during which the
defences are overcome and the previously repressed feelings enter
conscious awareness. The conscious experience of these repressed
feelings triggers memories associated with early attachment ruptures,
enabling these previously repressed memories and feelings to be
resolved.

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There are five key groups of interventions in ISTDP that enable the
therapist and patient to achieve these goals:
Stage 1: Inquiry
Most ISTDP interviews commence with the therapist inquiring into the
problems that have brought the patient to treatment. Most patients,
typically all patients of Moderate Resistance or above, are unable to
give an accurate account of their problems. Inquiry begins to stir the
unconscious as the therapist begins to reach towards the core of the
patient’s problems through a structured focus on the patient’s current
problems. Inquiry therefore activates unconscious feelings leading to
anxiety and the activation of the defences.
Stage 2: Pressure (Davanloo, 1999c).
Once the patient begins to resist the therapist’s attempts to
understand him, the therapist begins to apply pressure to the patient’s
feelings or defences. Pressure is a process of “reaching through the
resistance to the person stuck underneath the defences” (Abbass,
2009). Essentially, pressure is the process whereby the therapist
communicates to the patient, “Let’s look at what you’re feeling here
with me, underneath these defences” (Abbass, 2009).
Clarification: As the therapist applies pressure, the patient’s
defences increase and solidify between the patient and the therapist.
As this occurs, the therapist begins to point out and clarify the
patient’s defences. Clarification is the process of helping the patient
become aware of his defences and examine the costs of these
defences, both in the therapy and in life. As awareness rises, the
patient recognizes the costs of his defences, and begins to turn
against them. This process is repeated for each defence as it arises
in therapy.
Stage 3: Challenge (Davanloo, 1999b).
Once the patient has turned against his defences, the therapist,
together with the patient, begin to challenge the patient not to use his
defences, but instead to experience the feelings that have been
repressed under resistance. Essentially, challenge is a process that

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communicates to the patient, “Don’t engage in these defences,
they’re bad for you” (Abbass, 2009).
Head on Collision (Davanloo, 1999a). This is the most powerful of
the therapist’s interventions. It is a combination of clarification of what
is happening in the moment within the patient in relation to the
therapist, combined with challenge not to engage in defences, and
pointing out the cost to the patient, both in therapy and life, for
continuing the defensive pattern. Head on Collision emphasizes the
health and freedom that can be achieved by relinquishing defences
and placing the responsibility for change with the patient. Head on
Collision is a complex intervention with different emphases on
particular components depending on therapeutic requirements.
Each of these interventions is implemented in response to the
patient’s type and level of anxiety and the operation of specific
defences in each moment of the therapy session to create a complex
intra-psychic situation in which the patient wants to simultaneously
overcome, and maintain their defences. The therapist’s structured
focus on both the patient’s feelings and defences creates complex
feelings within the patient towards the therapist (Complex
Transference Feelings; CTF). On the one hand, the patient feels
grateful to the therapist for their relentless efforts to free them from
the suffering incurred through their anxiety and defences while
simultaneously, the patient feels angry with the therapist for the
relentless pressure and challenge to their long-held defensive system
(Davanloo, 1990, 2000, 2005).
Stage 4: Transference resistance.
Transference resistance occurs when the patient is no longer just
trying to avoid his unconscious feelings, which he does all the time,
but is now trying to resist the therapist’s efforts to reach the patient’s
feelings. It is within this Stage that Pressure, Challenge, and Head on
Collision are repeatedly used to drive up the CTF and to overcome
defences as they are mobilized to the frontline of the patient’s
resistance. Eventually, the defences are exhausted, and the CTF are
consciously experienced.

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Stage 5: Direct access to the unconscious.
The conscious experience of the previously repressed feelings,
particularly of rage, with guilt, grief, love and pain of rupture being
mobilised beneath, brings first a desire to, and then a fantasy of,
attacking the therapist. This is a very specific violent-to-murderous
fantasy that is the actual fantasy the patient had towards the
attachment figure(s) at the time of the ruptures. After the passage of
the rage, guilt is experienced about the violence/murder and the body
of the therapist transfers to the injured/murdered body of the
attachment figure(s). More guilt is experienced and loving feelings
relating to the original attachment are felt. Grief and pain about the
loss of the attachment relationship(s) are also experienced.
Unconscious memories now become accessible.
Stage 6: Systematic analysis of the transference.
At this point, the therapist moves to Stage 6, where the entire process,
including each defence, is repeatedly recapitulated to bring the
patient insight into his entire defensive system and the feelings that
have been repressed beneath the resistance.
Stage 7: Dynamic exploration of the unconscious.
Systematic analysis of the transference also has the effect of further
accessing the unconscious enabling exploration of the unconscious
to occur. In Stage 7, the therapist and patient examine the patient’s
memories of his early attachment relationship(s). Meaningful insights
and resolution of traumatic memories occur to the degree that the
resistance to their examination has been removed (partial, major,
complete) through the previous Stages.
Stage 8: Recapitulation, consolidation and treatment planning.
In this final stage of consolidation, insights and understanding of how
the attachment ruptures led to the development of defences to block
the underlying feelings and fantasies, and how and why these
defences became activated in the situations in which the patient has
been experiencing problems, are reviewed. Consolidation also
loosens the defensive system, permitting easier access to the

136
unconscious in subsequent sessions, which accelerates the process
of overall resolution of the patient’s problems.
In summary, Intensive Short-Term Dynamic Psychotherapy (ISTDP)
focuses on the experience of feelings in the here and now of the
interaction between therapist and patient. In response, the patient
begins to automatically manifest anxiety and defend against
repressed feelings from breaking through into conscious awareness.
This enables the therapist to assess the anxiety patterns and
defensive process of the patient in vivo. If necessary, the patient is
helped to restructure his anxiety pattern to striated muscle anxiety.
Once the patient is experiencing striated muscle anxiety, the therapist
continues the central dynamic sequence through one of the two
routes to the unconscious, depending on whether the patient is
primarily manifesting anxiety in the transference relationship, or a
high level of defences in the transference relationship which are
blocking the rise of anxiety and the underlying complex transference
feelings. Pressure is applied either to experience the feelings that are
creating anxiety (if anxiety is in the transference), or to the defences
that are blocking the rise of anxiety and the complex transference
feelings. This directs the resistance into the transference, paving the
way for the eventual conscious experience of the transference
feelings and the exploration of the unconscious.
This case study is the first reported application of ISTDP to a
professional musician. In this paper, we report on the first session
between the musician and the ISTDP therapist, which constituted
both an assessment and a trial therapy.
The study received ethical approval from the University of Sydney
Human Research Ethics Committee.
The Musician

The patient whom we shall call Kurt7, was a 55 year old professional
orchestral cellist with one of the eight premier state orchestras in
Australia. His orchestra was participating in a national study on the
mental and physical health of professional classical musicians at the
7 WĞƌƐŽŶĂůĚĞƚĂŝůƐŚĂǀĞďĞĞŶĐŚĂŶŐĞĚƚŽƉƌŽƚĞĐƚĂŶŽŶLJŵŝƚLJ

137
time of recruitment. During this study, a call went out for volunteers
who suffered severe music performance anxiety to participate in a trial
of ISTDP. Volunteers underwent an in depth interview with the first
author and completed the baseline protocol comprising the Kenny-
Music Performance Anxiety Inventory (K-MPAI) and tests of
depression and trait anxiety (reported elsewhere; See Kenny et al., in
press). Musicians with self-reported severe music performance
anxiety with accompanying performance impairment and whose
scores on K-MPAI fell within in the fourth quartile (125+) were eligible
for inclusion in the trial therapy study.
Kurt had been a member of the orchestra for 32 years and had
reached the position of assistant principal in his section. Due to the
recurrent ill health of the principal, he had been called upon on many
occasions to fulfil this role. By all accounts, he distinguished himself
in the position, despite experiencing long-term severe music
performance anxiety, which he had managed with a range of
therapies and self-help strategies, such as daily affirmations,
visualizations and meditation. He was expected to win the position
when it was finally vacated by the incumbent. However, on the day of
the audition, he “fell apart” – which, to most highly skilled, professional
musicians means that he did not play at his best. There was no
performance catastrophe or breakdown. Nonetheless, he failed to win
the position. This experience motivated him to volunteer for the trial
therapy study. All sessions were videotaped with permission for later
transcription and analysis.
Therapy
The second author, who, at the time of the interview, was an
advanced trainee in ISTDP under the supervision of the third author,
conducted the therapy. ISTDP commences with a “trial” therapy that
proceeds through as many of the eight steps outlined earlier as is
appropriate for the patient’s level of psychological resilience. These
will be discussed below with verbatim transcript to illustrate the
method. During this initial trial therapy interview, the therapist
attempts to establish a working relationship with the patient by
identifying any barriers to engaging in dynamic therapy, assesses the

138
presence and type of anxiety and defences operating, and
establishes the patient’s goals and willingness to explore the
underlying emotional issues.
This first session illustrates the various phases of the therapeutic
process.
Phase of inquiry
The therapist explored the patient’s presenting problem and ability to
respond. This inquiry is not simply a gathering of facts; rather, it is a
dynamic and diagnostic process that provides information about the
patient’s location on the spectrum of psychoneurotic disorders and
the degree of resistance. The phase of inquiry can rapidly move to
the phase of pressure that will continue the enquiry and reveal the
nature and level of resistance likely to be encountered.
Th: What are the problems that bring you here? [Inquiry]
Kurt: The difference between when I practice at home, and when I
actually play in an exposed situation seem to be a mountain I can
sometimes climb and sometimes not... for some unknown reason it’ll
be okay one day and not the next... I meditate and I exercise a lot, I
look after myself. I don’t drink too much. I don’t smoke... but I can’t
control the [performance] situation.
Inquiry moving into the phase of pressure
In this phase, the therapist presses the patient to be more specific, to
clarify the meaning of idiosyncratic or vague use of words, so will ask
probing questions, and will direct focus onto the actual experience of
feelings. In this part of the interview, the therapist exerts mild pressure
by asking for more detail than is offered by the patient, and continues
to press for clarification if the patient continues to offer vague and
avoidant answers. The therapist maintains a specific focus to clarify
patient’s meaning where indicated. After the therapist has a relatively
clear picture of the presenting problem, he will move his attention to
how the patient experiences these problems in his body by asking
directly, “What happens, physically, in your body?” in order to
diagnostically assess for striated or smooth muscle tension. Kurt
responded that he experienced “all sorts of funny sensations that...I

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can’t prepare for when I’m practising. I get funny feelings in my
hands”. This response prompts the therapist to press for further
specific detail in order to assess for cognitive perceptual disruption.
Kurt then stated that “I did an audition a while ago and I lost the normal
feeling in my arm. I couldn’t explain it. It was like it was somebody
else’s arm - I couldn’t control it”.
The therapist continues his inquiry, asking Kurt what other feelings
and sensations he experienced in his body during high anxiety
performances such as solos and auditions, checking for somatisation
(“Do you ever get sick in those situations?”) and cognitive perceptual
disruption (“Do you ever lose ability like having blurred vision?”). Kurt
did not get sick but agreed that he had blurred vision when very
anxious. He also gave other indications of cognitive perceptual
disruption (“Even if I know a piece or a part really well, it’s almost like
my brain sees it on the paper and doesn’t recognize it. The message
doesn’t get through”). Once the therapist has a clearer picture of the
presenting problem, he extends the inquiry to other parts of the
patient’s life (e.g. “Is it only in performance or do you become anxious
in other aspects of your life?”). This history taking will identify the
presence and extent of character neurotic process. Once this picture
become clearer, the therapist identifies and labels characteristic
defences. In Kurt’s case, the therapist summarized as follows: “So
you withdraw into yourself? You become passive and withdrawn?”
Phase of pressure
Once the therapist has developed a diagnostic picture regarding the
nature and expression of anxiety and the characteristic defences, he
returns to the presenting problem.
Th: Can you tell me about the last time you became very anxious in
performance?” [With this inquiry, the therapist transitions into
the phase of pressure].
Kurt: That was an audition a month ago. I did all the preparation. I’m
always prepared, I always work as hard as I can, making sure
the performance pieces are bullet proof. I’d worked really hard
and consistently for six months... But, with auditions goes a

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 negative side... I think “What if I flunk?” which I did. I was
auditioning for a seat I was already sitting in. I was acting
principal - I’d been doing the job and everybody said, “Yeah,
look it’s great – I like the way you’re doing it.” But in the back of
my mind, when it comes to auditions you’re standing behind a
screen... You come out, you have a piano and there’s a big
screen. Behind the screen are about 18 people sitting there
evaluating how you’re playing. You have a set piece to play and
I choked...I didn’t completely fall apart, but I didn’t feel
comfortable...
Th: You choked?
Kurt: I got to a certain part in the audition that required small motor
skills and my bowing forearm didn’t work. I had to do a small
bowing...
Th: So you lost sensitivity?
Kurt: I lost sensitivity. I got through the audition. They told me I did –
it’s all anonymous, but the people recognised my playing - said
I’d played really well. I thought I’d probably done worse than I
really had. A part of my problem was I’d sat behind those
audition screens before. I’ve been on the other side, so I knew
the whole process. I knew exactly what they were thinking, what
they were looking for so I – in a sense going back on it, I had
the cards stacked against me before I walked into that friggin’
room...
Th: In what sense were they stacked against you? [Continuously
clarifying the patient’s meaning]
Kurt: Within myself, I had them stacked against me. They would have
done anything to give me the job, because I was doing a good
job, a lot of people told me and I knew I was doing a good job.
But, unfortunately, the job gets open to anybody. I’m a bit
older...The guy who got the job is terrific; I sit next to him, he’s
fine; I’m glad he got it. But I was slightly disappointed in myself
that I didn’t play as well as I could have.

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Phase of challenge
During this phase, the therapist increases the pressure, challenging
the patient to identify and turn against his characteristic defences.
This sets up a conflict in the patient who is simultaneously maintaining
his resistance and developing a therapeutic alliance with the therapist
to relinquish his resistance. The first breakthrough occurs when the
balance between maintaining his resistance and his unconscious
therapeutic alliance with the therapist is tilted toward the unconscious
therapeutic alliance. There is considerable overlap between pressure
and challenge as will become clear from the next phase of the
interview. The phase of challenge occurs when the patient actively
resists the therapist’s attempts to reach the feelings underneath the
anxiety. The therapist can relentlessly point out the patient’s
defences, counter the patient’s rationalizations 8 or block irrelevant
and distracting talk.
Th: You’re glad the other guy got it? [Clarification with implied
pressure]
Kurt: I was disappointed in myself but I’m glad he got it because he
deserves it; he’s a good player. I don’t feel any bitterness about
that.
Th: But when you were at the audition behind the screen with
people judging you, what were the feelings you were having
toward them underneath your anxiety? [Pressure to identify
underlying feelings]
Kurt: [Sigh (a sign of rising unconscious anxiety)] Well, I’ve thought
to myself that some of those guys should be out there doing it
too.
Th: So how are you feeling toward them? [Further pressure]
Kurt: Slightly disrespectful, I suppose...
Th: What were your feelings towards them? Do you notice you’re
becoming anxious as we ask about your feelings? You’re

8 Rationalization is typically a tactical defence that finds intellectual explanations for problems

that is devoid of affect

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 holding your breath right now. [Monitoring signs of unconscious
anxiety and defence] [KURT nods] It’s interesting isn’t it? When
we draw attention to the feelings underneath your anxiety, your
anxiety goes up... So what are your feelings toward them
underneath that anxiety? [Continuing pressure to feelings]
Kurt: A slight hostility, I guess.
Th: Yep. How do you experience that hostility toward them?
Separate from that anxiety in your body, how do you feel the
hostility? [Pressure to attend to the physical experience of
hostility]
Kurt: I feel they’re judging me – they’re judging me.
Th: Yeah. But your feeling toward them about judging you is
hostility. And now you get anxious as we talk about this. [Kurt:
Yeah] So how do you feel the hostility underneath the anxiety,
because it’s like that anxiety is trying to sit on top of that hostility
right now, isn’t it? [Clarifying the link between anxiety and
hostility (anger) and the effect of anxiety] [Kurt: Mmmm] ...and
block it and push it down and not let you have this feeling of
hostility in your body. But if you push that anxiety out of the way,
how do you feel the hostility toward them? [Further pressure]
Kurt: I don’t know. I don’t know; I don’t quite know how to answer
[Resistance rising to prevent breakthrough of hostile feelings].
Th: There is a part of you that doesn’t really want you to look at that;
that doesn’t want you to actually know that you feel hostility in
your body, that would rather you were anxious. [Clarifying
destructive effect of defences]
Kurt: Well, I feel a certain amount of anger, I suppose, because I’ve
done the job reasonably well for nearly three years.
Th: Oh, three years, wow.
Kurt: Because the guy who had it before was sick all the time so I
basically took over and I did the job well, everybody said so –
everything seemed to go well. But when it came down to being
judged in an event that is not related to the actual job, I got

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 kicked in the balls... [Hostile feelings breaking through –
unconscious therapeutic alliance supporting expression of
anger and hostility]
Th: Yeah, yeah, and you were angry with them?
Kurt: Angry, yeah, angry with them and angry with the situation.
Th: But angry toward these people judging you? [Maintaining focus
on the judges]
Kurt: To a certain extent, yeah.
Th: How do you feel that anger toward them, as you look at it now?
Because there is anxiety there now, so how do you feel the
anger underneath that anxiety towards these people? [Pressure
to experience the rage]
Kurt: I’m trying to deal with it, as in that they’re only doing what they
had to do.
Th: Okay. So that’s you rationalizing it. [Clarifying the defence of
rationalization]
Kurt: I’d be doing the same thing if I was on the audition panel, I
guess.
Th: Do you rationalize your feelings a lot? [Client sighs] That was a
big sigh there. [Signs of striated muscle tension]
Kurt: No, I don’t think so.
Th: So the moment you’re feeling angry with them, you would get
anxious in your body and tense and then you rationalize and
make excuses for them? And if you don’t do that, how do you
feel that anger toward them? [Further pressure to experience
the rage. Therapist does not collude with patient’s denial or
rationalization].
Kurt: I try to dispel it...because it’s a – I try to be tolerant because it’s
only a - -
Th: But if we look at what it’s doing to you? [Focussing on the
negative effect of the defences]

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Kurt: Well, I’ve been upset about it, I suppose.
Th: You’ve been anxious as well and then you go into performances
and you have a very similar reaction, I expect? [Refocusing on
the presenting problem]. [Kurt: Mmm, yeah]. It’s quite similar in
performances to what it was behind that screen. You get
anxious, and it affects your ability to play. Underneath that
anxiety, we see that you’re angry. [Kurt: Yeah] So if we look at
those angry feelings rather than you try to dispel them, because
these are just feelings in your body, aren’t they? Anger is just
a feeling; it’s not an action, yeah? [Kurt: Yeah] ... So if we look
at that, how do you feel anger toward them, physically, in your
body, if you don’t rationalize it? How do you feel that anger
towards them? [Pressure to experience the rage].
Kurt: There’s no right answer to this, is there?
Th: Well, in your body there’s a feeling of anger somewhere
underneath this anxiety and a part of you is trying to tell yourself
that you’re not allowed to be angry [Pointing out and challenging
the resistance].
The therapist continues to pressure to physically experience the
underlying rage and to clarify the defences that emerge in the
patient’s resistance, for example, anxiety, rationalization, and turning
anger in9 on himself. This interchange continues for some time, with
the patient continually reporting symptoms of anxiety (e.g. “I feel
tight”, “my breath gets shorter”, “I feel tense”, “I feel tight in my chest”)
rather than the feelings of anger underneath and the location of those
feelings in his body.
Kurt: But if I’m angry towards somebody I don’t know how to deal with
that. I mean what do I do about it? I can’t go up and biff ‘em.
[An interchange occurs at this point about the difference between
violence and anger and the difference between acting out and feeling
that had been touched on earlier].

9 Turning anger in on oneself is a defence in which the patient directs anger inward in a self-

punishing way in order to avoid expressing anger, and/or causing harm, to a loved other

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Kurt: Well, I feel like I’m not allowed to show it for a start, so it’s really
hard for me to get it.
The therapist sums up:
Th: Okay. So what happens there, because that’s showing an
action, and we’re after your feeling? There’s a part of you
focused on me right now, in terms of you’re not allowed to show
your anger to me - that I’m not allowed to see it. [Pointing out
the appearance of complex transference feelings] You want to
keep me at a distance and not really let me in - - - [Pointing out
defence of emotional distancing 10 in the transference and its
consequences]. (Patient shifts in his chair with anxiety).
Kurt: I suppose there’s a part of me that wants to do the right thing.
Th: You tend to look and see what you can do to make people
happy around you? Do the right thing all the time? So you are
trying to perform for me now? [Kurt nods]. But that’s not good
for us because we’re here for you. And there’s a part of you
trying to abandon you at the moment and focus on what’s going
to be best for me. Does that happen a lot, that you get left to
last? You focus on everybody else first? [Clarifying cost of
defence of focussing on the other person instead of himself]
Therapist is constantly pointing out each of his defensive manoeuvres
as they appear and making links to his music performance anxiety.
Kurt: Well, it happens a lot of the time, yeah.
Th: Okay, so that’s one of the problems that you have; it’s hard for
you to be in a sense centre stage in your life?
Kurt: Yeah. In fact I don’t want to be...
Th: You don’t want to be in the centre of your life?
Therapist continues to point out and clarify the system of defences
used to defend against hostile, angry feelings and the self-destructive
consequences of such a system, how these characteristic patterns of
interpersonal interaction are evident in the therapeutic dyad, and in
10Emotional distancing refers to resistances against emotional closeness, a core part of
resistance in highly resistant and fragile patients.

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other important relationships in Kurt’s life. The therapist questions,
highlights, applies pressure to attend to feelings, and draws attention
to the defences and to what the defences are helping the patient to
avoid.
Th: And how do you feel right now as you look at this system and
what it’s doing to you? What are the feelings coming up - - -
[Test to see if he has turned against his defensive system]
Kurt: Well, when it’s explained like that, I feel hopeless really,
helpless and hopeless.
Th: So there’s a part of you wanting to collapse and abandon you
again? [Pointing out the defence of going helpless]
Kurt: Yeah. Oh, where the fuck do you go from here?
Th: Let’s look at what’s happening inside you. I get a sense there’s
some sort of feeling trying to come up there? [Focusing his
attention on his feelings; encouraging him to take action against
the helplessness11] (Kurt: Mmm). And there’s a part of you that
wants to avoid me and put a distance between us, to not really
let me into these intimate thoughts and feelings that you’re
having right now. [Pointing out his detachment 12 in the
transference] ... If you don’t go to your head (i.e. use the
defences of rationalization and isolation of affect), if you stay in
your feelings in your body, what are the feelings trying to come
up in you right now, as you look at this sabotaging system and
what it does to you - neglects you, puts a wall between you and
people who are important to you, turns and attacks you, makes
you anxious? [Constant challenge to the defences] It’s a very,
very destructive system.
Kurt: Well, it’s a voice that pops up all the time, and in performances,
it’s there (Kurt is now making the link between his destructive
defensive system and his music performance anxiety).

11 Helplessness is a regressive defence triggered by excessive anxiety

12 Detachment refers to emotional distancing as a defence against intimacy

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Th: Yeah, that’s the thing that turns into anxiety, isn’t it? It’s
everywhere in your life, but it’s prominent and in your
performances?
Kurt: Mmm. So how do I deal with that? [Defence of passivity13]:
Th: That’s a good question, how are we going to deal with this
because you know, you’ve been passive in response to it for a
very long time... But why? What have you done that you
deserve this torture? [Rhetorical question to the unconscious to
try to get it to begin to turn against the punitive superego]
This interchange continues, adding progressively more pressure to
recognize and turn against his defences.
Head on collision
This phase of the interview is a consolidation of the challenges to the
system of defences that manifest as resistance in the transference.
This relentless assault on the defences that maintain the self-
sabotaging, self-defeating and self-destructive stance of the patient
intensifies the transference feelings and mobilizes the therapeutic
alliance. At this point, complex transference feelings erupt – both
anger at the pressure to give up defences and appreciation of the
therapist’s commitment to work with the patient.
Th: This system wants to detach you and try to make you distant,
close you off and find excuses for things, rather than focus on
what’s going on inside. But is that really what you want to do?
Or do you want to actually understand what’s going on inside
you and free yourself from this system? [Head on collision with
resistance. Pressure to his desire to overcome his problems]
Kurt: Of course I do.
Th: So what are your feelings that are coming up inside you right
now?
Kurt: Not feeling comfortable, that’s for sure.

13Passivity (related to helplessness) in the therapy setting = putting the responsibility for
change onto the therapist

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Th: What are the feelings coming up underneath that anxiety?
[Pointing out the anxiety and applying pressure to focus to the
feelings under the anxiety]
Kurt: A certain sadness really.
Th: Yeah. There’s sadness there. But part of you says you’re not
allowed to share that with me. Why? Why shouldn’t you have
your sadness? Why shouldn’t you be here with me and share
that with me? Because that’s what we’re here for, isn’t it, to get
to the core of these problems? [Head on Collision with
resistance – pointing out destructiveness of defences] (Kurt:
Mmm). But a part of you wants to cripple you. A part of you
doesn’t want you to really connect with anyone. [Continuation
of head on collision] (Kurt: Mmm). And what are you going to do
about that unless you want that to continue? [Pressure to do
something about the defensive system; returning responsibility
to patient] What are you going to do about that here with me
unless you want that distance to continue and that sabotaging
system to dominate you? [Challenge to change behaviour in the
transference]
Kurt: Just try and feel – try and feel real feelings underneath.
Th: Uh-huh, so when your eyes are here with me, what are the
feelings that come up in you? [Eye contact equals intimacy.
Applying pressure to feelings that intimacy brings up in him.
Intimacy activates the core attachment rupture]
Kurt: Oh, I feel pretty exposed and - - -
Th: And the feelings that come up - - -
Kurt: Wondering what the actual core of me is.
Th: Uh-huh, that’s a good question for us though, isn’t it? (Kurt:
Yeah). There’s a part of you that wants to understand what’s
going on deep inside you. What’s the engine that’s driving this
anxiety and this destructive system? What are the feelings that
are coming up inside you [Pressure to feelings in this moment
trying to overcome the defences] if you don’t let that destructive

149
 system put distance between us. [Challenge to defences]. (Kurt
sighs) What are the feelings you’re having under that sigh?
[Pressure] Your eyes want to go away and you want to settle
everything down. [Pointing out defence of avoidance] Have you
noticed that?
Kurt: Mmm, yeah, I know. I pull away sometimes.
Th: It’s a crippling system though, isn’t it? (Kurt: Probably) Then
there’s that distancing - you have put your hands across your
chest. [Pointing out how he’s building a physical wall between
therapist and him] (Kurt: Mmm). This is the part of you that
wants to build a wall here, that wants to hurt you because it
wants to push me out and make me useless to you. [Head on
collision with resistance. Pointing out the cost of continuing the
defences] Then you are left with all this misery and suffering,
not performing to your level of skill [Continuation of head on
collision with reference to the presenting problem as a way to
motivate the patient to give up his resistances] (Kurt: Mmm).
And not living the life you’re capable of, and there’s a part of
you that wants to sabotage and put a wall between you and me
and not let me in. But once that wall’s there, I’m useless to you.
[Continuation of head on collision]
Note in this phase of head on collision, two separate themes run
parallel – (i) not realizing his potential because of intense anxiety and
(ii) his defensiveness in the therapeutic dyad. These themes are
linked: the sabotage, of which the wall is a major component, prevents
him from having the life of which he is capable. The head on collision
aims to intensify complex transference feelings and resistance to the
point where the resistance breaks down, allowing the underlying
feelings to be experienced. In the following excerpt, there is a shift
away from the defences to an awareness of the sadness underneath
the anxiety and anger.
Th: And at some point today we come to the end of our time, and if
we don’t do anything and our time comes to an end and the wall
stays there, you’re going to walk out with the same problems
you walked in with. [Continuation of head on collision]

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Kurt: I just don’t know what to do – I - - -
Th: Mmm. There’s that part of you that wants you to go helpless.
[Pointing out defence of helplessness] It doesn’t want you to let
these feelings come out. And yet there’s all this sadness trying
to come up in you. (Kurt: Yeah). Did you notice that sigh right
now? There’s anxiety and you’re trying to settle everything
down and keep all that sadness inside. But why do you want to
keep distance between you and me when we’re here to try to
get to the core of these problems. [Continuation of head on
collision].
Kurt: Well, I want to get to the core, I don’t know how to get there; I’m
lost. [Despite his helpless stance, Kurt’s unconscious signalling
system - striated muscle tension and sighing respirations - is
evidence that Kurt is responding to the head on collision]...
Th: ...there’s the anxiety again trying to block everything out, trying
not to let you have your feelings. (Kurt: Yeah, yeah). And the
sadness underneath that anxiety, how do you feel that right
now?
Kurt: I feel angry I’ve got it.
Th: You feel angry? Well, let’s look at that, with whom you are
feeling angry?
Kurt: I shouldn’t say [Kurt recognizes the defence from earlier
discussion in the session of turning his anger in on himself] but
myself – but - -
Th: So it’s turning in on you again? It’s trying to attack you, to smash
you down and not let you feel your sadness. It wants to beat
you up for being sad. Now, what are the feelings you are having
toward me as I try to understand what goes on inside you?
Kurt: [raises his voice] Oh, you’re tearing away at a sore.
Th: So what sort of feelings does that bring up in you toward me as
I tear away at this sore?
Kurt: You’re not the friendly guy I thought you were. (Kurt shifts
uneasily in his chair and sighs).

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Th: So, right now, what are the feelings that come up in you toward
me, as the two of us push toward this core of you? [The use of
the phrase “the two of us” draws Kurt’s attention to the
unconscious therapeutic alliance]
Kurt: Not anger, but you’re niggling away at my anger.
Th: Mmm, not anger? [Challenge]
Kurt: OK. (Raised voice) You are giving me the shits. [Acknowledges
anger in the transference]
Th: Makes sense though, doesn’t it? Because I’m pushing, I’m
tearing away at your sore?
Kurt: Nothing personal [Distancing manoeuvre].
Th: But there’s anger toward me?
Kurt: I think you’re getting a bit too close - - -
Th: Mmm. Should we look at this, or---
Kurt: Oh yeah, you go right ahead – I mean I’ll - - -
[Striated muscle tension drops and he now has more freedom in his
movements. This indicates that the rage is beginning to breakthrough
into consciousness.]
Th: Okay. How do you feel this anger toward me? It’s good you’re
being honest.
Kurt: [angrily] Oh, I want you to go away; I want you to piss off. I’ve
had enough.
Th: Uh-huh. So there’s the anxiety; it wants you to run away, it
wants you to avoid? (Kurt: Yeah).
Th: Uh-huh, but underneath that anxiety?
Moving towards a breakthrough into the unconscious
Kurt: Look, when I was a kid, I was bred that kids should be seen and
not heard. You’re not allowed to cry or have your own thoughts.
You just go outside and shut up. I don’t want to hear about you
and all that sort of shit.

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[The unconscious transference alliance (UTA) is now in a dominant
position over the Resistance. The passage of rage has not been
experienced, but there is a clear link to the Past that explains his
defences as they have manifest in the Transference.]
Th: Who was that?
Kurt: Oh, it was my mother and father.
Th: Both of them?
Kurt: Yeah, both of them. So I could hang it on them...
Th: But we’re not looking at blame, we’re looking at understanding.
Kurt: Yeah, yeah, I’m understanding of it and I’m understanding that
---
Th: At the moment there’s anger in you that wants to come up
toward me and there’s sadness in you about what this
destructive thing is doing to you. That old system of “you’re not
to be seen or heard” is trying to crush you rather than let us look
at these feelings that have been pushed down inside you since
you were a boy. That sadness has just got much stronger.
[Therapist commenting on Kurt’s body language] (Kurt: Mmm).
Breakthrough into the unconscious
After application of repeated pressure, challenge and head on
collision with the patient’s resistance, there is a breakthrough to the
unconscious in which the patient himself identifies the source of his
emotional pain in his early depriving and abusive relationship with his
parents (i.e. the attachment rupture).
Th: Why do you need to fight it now? Why do you need to go to that
destructive system instead of giving yourself the freedom to
feel?
Kurt: Yeah [crying]. [First breakthrough into the unconscious. There
is grief about the defences and grief about his childhood that
created the destructive defensive system.]
Th: There’s a lot of pain and feeling there.
Kurt: [crying] I had a really cruel childhood.

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Th: Yeah. Let that pain come up here, it’s been trapped there a
long time.
Kurt: [Crying] I was just abused as a kid, both physically and mentally
I was abused and it hurt.
Th: Yeah, let it come up; don’t crush yourself. Let all that pain come
up. You don’t have to crush that or push it back down.
Kurt: [crying] I never got listened to; never got understood.
Th: There’s waves of sadness and pain that are coming up inside
you...who abused you?
Kurt: My mother and father. My father beat me, and my mother was
just crazy.
Th: You had a crazy mum.
Kurt: She loved me but - - -
Th: Yeah, she loved you. [This stirs up more painful feelings]
Kurt: But she was fucking crazy, mad, in and out of the loonie bin.
Th: Mmm hmm, and that brought you a lot of pain. You don’t need
to fight that.
Kurt: [Sobbing] oh, fuck, oh fuck....
Th: You can face that now. That’s what you and I are here for - to
face this. There’s a lot of pain you’ve been carrying for a long
time. (Kurt turns his head and looks at the floor) Did you notice
that a part of you is really trying not to be here with me right
now? (Kurt: Yeah). But we want to get to these things, don’t we?
Why should you have to carry all this around inside you?
[Pressure to his motivation to deal with his problems]
Kurt: My mother’s dead anyway, but my father’s still alive.
Th: But the feelings aren’t dead. (Kurt: No). You’ve been carrying
those painful feelings since you were a little boy. Imagine what
must happen to you every time you come before an audience.
[Linking presenting problem with painful childhood feelings]
Kurt: Yeah. It’s pretty torturous sometimes.

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Th: Yeah. The judgments. The abuse. (Kurt: Yeah). All that floods
through your mind at some level when you stand up to perform.
(Kurt: Yeah, it does).
Imagine the conflict in a performing artist who has been “bred” to be
seen and not heard, and abused for expressing himself!
Kurt’s Position on the Spectrum of Psychoneurotic Disorders
Kurt manifested striated muscle anxiety. He reported that, at times,
during performances, he experienced cognitive perceptual disruption;
however, he did not manifest any symptoms indicating CPD during
the Trial Therapy and therefore, was not placed on the Spectrum of
Fragile Character Structure. Kurt built a solid “wall” of defences in the
transference relationship. His primary defences were: passivity,
helplessness, rationalising, detaching, and turning (anger) in on
himself. He responded well to intervention, turning against his
defences as he saw their cost. He engaged well with the therapist to
gain access to his previously repressed emotions related to his
ruptured attachment. On the Spectrum of Psychoneurotic Disorders,
he is placed between moderately resistant and highly resistant.
Discussion
In a 90-minute trial therapy session of ISTDP, the patient was able to
access some of the rage, guilt, pain and grief of his difficult childhood
that had been defended against by anxiety all of his life. He was able
to make the link between his destructive defensive system and
resistances to acknowledging and dealing with his painful feelings
and his anxious musical performances.
The ISTDP therapist constantly tracks the emotional state of his
patient, assessing the quality of the therapeutic alliance (“I really do
want to work on this problem”) and the level of anxiety, which inhibits
exploration of the patient’s habitual defensive patterns. Often, by the
time adults come into therapy, their pattern of defences are
experienced as syntonic and when challenged, vigorously defend
their defensive systems. The central dynamic sequence is applied
repeatedly throughout therapy to gain further access to the core
psychopathology. Based on his responses in this session, Kurt was

155
deemed a suitable candidate for ISTDP and he was provided a further
six sessions as part of this research protocol. His positive response
to therapy will be described in a second paper, in which we outline
the process of therapy, the process of termination and the outcomes
of therapy.

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 CHAPTER 6
INTENSIVE SHORT-TERM DYNAMIC PSYCHOTHERAPY
(ISTDP) FOR SEVERE MUSIC PERFORMANCE ANXIETY:

PART 2: THE PROCESS AND OUTCOME OF

PSYCHOTHERAPY WITH A PROFESSIONAL MUSICIAN

Part 2 of this chapter reports on the process of therapy using Intensive

Short-Term Dynamic Psychotherapy (ISTDP) with a professional
musician who had suffered severe music performance anxiety over
the course of his entire career, spanning more than 30 years, at the
time he presented for treatment. The first paper described the nature
of the therapy, the case history of the musician, and the process of
the first assessment and trial therapy session. In this paper, we
describe the process of therapy and the outcome in terms of his
overall psychological wellbeing and his performance anxiety.
The first chapter in this section presented a detailed exposition of the
nature of the psychopathology with which patients with severe music
performance present, the assessment process that places them on a
spectrum of resistance from low to high, or the spectrum of fragile
character structure, and the types of defences that they employ to
avoid their feelings (Kenny, Arthey, & Abbass, 2016). Techniques
used by ISTDP to rapidly mobilise the unconscious therapeutic
alliance were described together with the critical importance of the
Central Dynamic Sequence (CDS) (Davanloo, 1999a) in achieving
this mobilisation, which comprises eight stages, as follows: Inquiry,
pressure, (including clarification), challenge, head on collision,
transference resistance, direct access to the unconscious, systematic
analysis of the transference, dynamic exploration of the unconscious,
and recapitulation, consolidation and treatment planning. Responses
in each stage of this sequence guide the therapist towards access to
repressed feelings and memories. The therapist also assesses the
routes to the experiencing of unconscious feelings – either through
the expression of anxiety or defences in the transference relationship.

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Each of these strategies directs the resistance into the transference,
paving the way for the eventual conscious experience of the
transference feelings and the exploration of the unconscious.
The therapy: Recapitulation of the first session
A detailed account of the fourth, fifth and the sixth sessions of ISTDP
with Kurt is presented. During his assessment, Kurt reported a
number of self-help strategies that he had employed over the years
to help him with his performance anxiety, including meditation,
visualisation, self-affirmations and practical strategies such as
increasing his practice for high pressure performances, to make sure
the pieces to be performed were “bullet-proof”. He said that these
strategies were at best “a 50/50 proposition”. He explained that he
had been placed on a beta blocker (Noten) by his physician for high
blood pressure and noted that this medication had assisted him to
overcome the very problematic trembling he experienced when
anxious. He reported that “the mind plays tricks with me” causing his
brain to become “overloaded” which resulted in Kurt becoming
“overcautious,” sensing that he was in a “very dangerous situation,”
because “the brain can just trip me up” and then “very bad things
could happen”, which, when pressed, he described as “funny
sensations that...I can’t prepare for when I’m practising. I get funny
feelings in my hands.” All of these symptoms were disruptive to his
capacity to perform well. During his recent audition, he described
losing the normal feeling in his arm – “it was like somebody else’s arm
– I couldn’t control it.” Kurt also reported cognitive perceptual
disturbance, an example of which was that his “brain sees it [the
music] on the paper but doesn’t recognize it. The message doesn’t
get through.” Extended inquiry beyond the presenting symptom of
music performance anxiety revealed that Kurt was socially anxious
generally and that he managed this anxiety by “sitting still and shutting
up” which the therapist interpreted to mean he became passive and
withdrawn. These behaviours were later identified as characteristic
defences for Kurt. This phase of inquiry and pressure then progressed
to challenge whose aim was to further develop the therapeutic
alliance and to assist the patient turn against his characteristic

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defences. The therapist relentlessly pointed out the patient’s
defences, countered the patient’s rationalizations and blocked
irrelevant and distracting talk. At this stage, there was the expected
marked elevation in anxiety, indicating that the patient was defending
against unconscious feelings rising to awareness. In this phase, Kurt
talked about his feelings of “slight hostility” towards the judges in his
audition, which increased his anxiety and with which he coped using
the defences of rationalization and turning anger in (against himself).
The therapist identified complex transference feelings - “You’re not
allowed to show your anger to me - I’m not allowed to see it” - and the
associated defences -“You want to keep me at a distance and not
really let me [know about these feelings]”; and “[you are] trying to
focus on what I want; but we’re only here for you,” to which Kurt
responded: “Do you mean I’m trying to answer the questions to please
you? (Th: Yeah) I’ve done it for so long I can’t get out of the bloody
habit.” The therapist at this point was able to make the links between
Kurt’s anxiety, his habitual defences and his failure to do well at his
audition. “We can see in that audition that the anxiety that came out
of the fear of feeling your anger actually stopped you getting that job.”
Kurt responded: “…when it’s explained like that, I feel hopeless really,
helpless and hopeless” which was identified as another maladaptive
defence structure. After noting that Kurt became detached in the
transference to avoid his feelings, the therapist moved into the phase
of head on collision, which constitutes a consolidation of the
challenges to the system of defences that manifest as resistance in
the transference. The focus at this point was on the “here and now”
of the patient’s transference interactions and the therapist’s relentless
pressure to expose the feelings underlying Kurt’s anxiety until there
was a breakthrough into the unconscious. “When I was a kid, I was
bred that kids should be seen and not heard. You’re not allowed to
cry or have your own thoughts. You just go outside and shut up. I
don’t want to hear about you and all that sort of shit… I had a really
cruel childhood.” [Kurt himself identified the source of his emotional
pain in his early depriving and abusive relationship with his parents].
The therapist responded:” You’ve been carrying those painful feelings
since you were a little boy. Imagine what must happen to you every

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time you come before an audience… The judgments, the abuse… All
that floods through your mind at some level when you stand up to
perform” - thereby linking his presenting problem with performance
anxiety with his painful childhood feelings. The central dynamic
sequence was applied repeatedly to good effect to gain access to
Kurt’s core pathology and the nature of his attachment ruptures with
both parents, which were accessed during this first session. Sessions
two and three continued with the work of the first session, with
increasing progress towards the needed breakthroughs into the
unconscious so that the feelings associated with the original
attachment ruptures could be experienced and expressed, first in the
transference and then towards his parents. This actually occurred in
session four with both of his parents.
Session four
The patient described an incident while running [for exercise] in which
he had a vision of murderous rage toward his father. As he examined
it, he realised that, in this image of his violence, he was attacking
himself. This brought caring feelings for himself and he envisioned
himself now hugging the child part of himself: [“[I] picked this poor
bastard up, which was me, and held him really dearly”]. Kurt
recognised that he had been attacking himself throughout his life. This
realisation led to his experiencing himself in a more connected and
compassionate way.
Kurt then recounted an incident from his childhood. He had gone to a
friend’s birthday party and his friend gave the patient a hammer. They
started hitting an old car in his friend’s back yard with the hammer.
Kurt recalled that it turned out to be his friend’s father’s pride and joy
[which Kurt had not known at the time]. He was subsequently severely
beaten by his father [“I got absolutely fucking thrashed for it”]. His
father did not listen to the patient’s pleas of ignorance about the car.
Kurt became anxious and sad as he recounted this experience;
pressure was applied to his feelings towards his father, towards whom
Kurt subsequently reported feelings of rage. However, when the
therapist attempted to explore his rage with Kurt by applying pressure
to feel the rage towards his father physically (i.e., in his body), Kurt

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reported sadness, which the therapist interpreted as an avoidance of
the feelings of rage (Th: “What did you do with the rage?). Kurt replied
that he “just let it blow over him” to which the therapist responded by
clarifying the avoidance of his feelings of rage and the cost of that
avoidance (Th: “To where is it blowing because it’s been inside you
all this time? It wouldn’t blow anywhere really…there’s a part of you
that doesn’t want to look at this, but when you’re not looking at this,
you’re really still smashing yourself up, aren’t you?”). This interchange
continued for several minutes, with the therapist maintaining pressure
on Kurt to stop avoiding and to allow himself to physically experience
his rage towards his father, repeating the question with variation and
increasing pressure, “Physically, how do you feel that intense rage
toward your father?” several times, helping Kurt to distinguish
between his feelings of anxiety about his rage and his actual rage.
“There’s a part of you that’s terrified to face this rage towards your
dad that would prefer to turn it all into anxiety…” and “It’s the reason
that we’re here together because there’s a part of you right now
saying you should be anxious instead of feeling your rage.” Kurt
expressed anxiety and helplessness, wanting the therapist to give him
the answers, thereby bringing his resistance into the transference: Th:
“You want me to look after you and find that answer for you.” With his
next question, “What are you feeling toward me at the moment?” the
therapist invited Kurt to express his transference feelings. The
following exchange ensued:
Kurt: Oh, I’m not going to touch you.
Th: And your feelings here towards me at the moment?
Kurt: Oh, you’re a friend.
Th: But your feelings here towards me at the moment, because I’m
aware you’ve just gone dead. [Pointing out the shutting down of
his feelings in the transference] [Kurt laughs] So if we look at
those raw feelings that want to come up here toward me right
now; what are your feelings toward me right now? [Pressure to
express his feelings towards the therapist].
Kurt: Oh, I just want to give you a shake, that’s all.

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Th: How do you feel that toward me? If you don’t go dead, if you
don’t go passive, if you don’t turn on yourself, if you don’t go to
the anxiety; how do you feel that desire to lash out at me right
now? How do you feel that in your body? [Challenge not to
engage in his defences combined with pressure to the physical
experience of his desire to lash out at the therapist].
Kurt: I just want to kick the table over; I don’t know [physically slumps
in his chair].
Th: But if you don’t go helpless and collapse, you will understand
these feelings.
After a few more similar interchanges, Kurt finally says:
Kurt: I’m embarrassed by it because it’s a dumb thing to feel over all
these years and I still feel it. [Here, Kurt makes his own present-
past link between current and past feelings and response to
those feelings]
Th: So there’s a part that wants to attack me, let’s look at that, how
do you feel that here towards me? You don’t go to anxiety and
you don’t pull back, you don’t let this thing cripple you; how do
you feel that rage towards me right now? Because there’s a self-
destructive system in operation here, isn’t there? [Challenge to
self-destructive defences and pressure to experience rage
towards therapist].
Kurt: Well, I guess I’d like to unleash it but - -
Th: You don’t need that anxiety now… The anxiety’s just a crippling
force that’s done massive damage to your life, professionally
and personally. [Therapist makes the vital link between his early
anxiety, current anxiety in the transference, and his experience
of performance anxiety as a professional musician].
A lengthy exchange follows in which the therapist exerts relentless
and increasing pressure on Kurt to relinquish the destructive part of
himself (the defensive wall) that keeps his feelings hidden and the
therapist at a distance. Eventually, overcoming his embarrassment,
Kurt expresses closeness and warm feelings towards his therapist.

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Th: And as you focus on it, if you really let that be there, what does
it bring to mind for you?
Kurt: It brings a feeling of… the first thing that came to my head was
being nurtured by my mother. [Patient spontaneously makes
the therapist-past link - from feelings of closeness with the
therapist to feelings of nurturing by his mother].
Th: But at some point you got scared of closeness.
Kurt and his therapist enter into a discussion regarding when and how
he became afraid of intimacy. Kurt revealed that he had felt close to
his mother as a young child, but all good feelings towards her
vanished as he became a teenager and his mother increasingly
succumbed to serious mental illness.
Kurt: Whenever I see a mother with a child it gives me a nice feeling.
Th: There’s some sadness there as well for you. Can you let that
come up? There’s a painful feeling there too, isn’t there? [Kurt:
Yeah]. Can you let that come up and not push that away.
There’s a part of you wanting to clamp down on this, but you’re
here trying to look after yourself and clamping down is going to
hurt you, isn’t it? When you see a mother and a child and they’re
close, it brings up sadness as well as caring feelings in you
[Kurt: Yeah]. They both come up together. There’s this
closeness and how much you liked that, and the sadness is
about what you lost [Kurt: Yeah] because it got taken away.
Kurt: [Crying]. I was driving in the car one day and I saw a woman
with a disabled child. I saw her cuddling her child as if it was the
most beautiful thing in the world…it just crippled me…
Th: She could love that child no matter what [Kurt: Yeah]. No matter
what, that child was the most important person in the world to
her. [Kurt: Yeah]. And you didn’t have that… There’s a lot of
pain and sadness that you weren’t the centre of your mother’s
world. Why do you want to fight that pain? Why don’t you want
to take care of yourself in this moment, let yourself feel these
feelings, because that’s what we’re here for, isn’t it?

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Complex feelings of pain and sadness were accompanied by anger
that his mother did not protect him from his father’s violence. Kurt said
that his love for his mother died as he moved into adolescence, which
was an expression of his unconscious desire to kill his mother as a
teenager, made possible by the Unconscious Therapeutic Alliance.
The therapist helped Kurt to recognize both his loving and angry
feelings towards his mother whom he had “killed off in his life long
before she actually died in order to survive” and the attendant feelings
of guilt about having killed someone whom he had loved, which Kurt
described as putting down a loved animal.
Th: You killed her and you loved her and you have carried this guilt
and pain around with you ever since [Kurt: It seems so]. You
loved her but you killed her, just like an animal, you put her
down. It is a very painful thing to kill someone you love. There’s
guilt and pain and love and anger… it’s complex.
[The therapist now makes the parent-other link with his next
intervention].
Th: You have been carrying a lot of intense feeling since you were
in your teen years; your mother became dead to you at that age.
Does this relate to why it’s hard for anyone to get close to you?
[Kurt nods agreement]. What comes to mind?
Kurt: I’m afraid I’m going to put somebody else down [laughs].
[Patient spontaneously makes the link from feelings in his past
relationships to his current relationships].
The therapist can now make the link from Kurt’s rage in the
transference to his rage from the past.
Th: If anyone tries to get close to you now, all these old feelings
from the past, the old rage, the old guilt, the old grief all come
up and then you erect your defensive wall. [Therapist links the
past to Kurt’s current relationships and why the defensive wall
prevents intimacy in his current relationships].
Kurt: I think I killed myself off too; I shut myself down.

164
Session Five
Almost the entire session was focussed on helping Kurt to access and
express his angry, violent feelings towards the therapist and then
towards his mother. In this process, Kurt continued to make important
links between his past and current relationships, which were, in this
instance, focused on his wife. He described feelings of abandonment
and anger towards her when she left him in charge of the children to
attend what he perceived to be cult-like retreats four times a year.
Kurt accessed defences of inadequacy (self-attack) and neediness
during this session, as well as his anger, which he turned inward. With
the relentless therapeutic focus on the defences, Kurt experienced
anger toward the therapist, which Kurt reported feeling physically (if
somewhat ambivalently).
Kurt: I wish I could punch you but not hurt you.
Th: There’s a part that wants to hurt me and there’s a part that
wants to protect me. [Therapist points out the simultaneous
occurrence of love and hate]. There are violent feelings towards
me but we know you’re not going to act on these feelings.
After repeatedly challenging his defences and the intense anxiety that
was suppressing expression of his rage, Kurt became aware of angry
impulses, first, to punch the therapist without hurting him, then to
throw the therapist out of the window, and then to, “punch him and
not care a shit about whether it hurts,” to finally, “I want to fucking tear
you apart like a dog would tear a fucking bone apart…”
Th: You have positive feelings towards me but there are also angry
feelings. This will get in the way when anybody tries to be close
to you, won’t it? …these… feelings will come up inside and then
the system will kick in and you will get anxious, weak, detached,
self-attacking, all to keep a distance and to punish yourself for
these angry feelings, to protect the other person from these
angry feelings, but never to resolve them.
After a long head on collision phase in which the therapist continually
clarified what was occurring within the patient in relationship to the
therapist, combined with the challenge not to hide behind defensive

165
anxiety and transference resistance, the complex transference
feelings emerged. This fantasy is a facsimile of the patient’s
murderous rage towards his attachment figures, the experience of
which followed almost immediately upon the patient’s accessing his
unconscious rage, guilt, love, pain and grief in relation to the therapist
in the transference.
Kurt: I’m doing my best to close the door on them (i.e., resistances).
And it’s not easy, because there’s a fucking internal battle going
on in there. It’s like a fucking battleground, I can tell you…
Whenever I was really angry at home, I would race into my
bedroom and I would tear into a pillow and chew the shit out of
it.
Th: Who were you really tearing into? Who were you really
chewing?
Kurt: My mother
Hence followed a painful accessing of his murderous rage towards
his mother and feelings of guilt, remorse and love, following which
Kurt remembered that he had been left crying in his cot for hours,
unattended.
Th: Being left alone in a cot crying for hours is abandonment. That’s
why things have been coming up so strongly with your wife
going away. [Therapist makes the past-other link, identifying
similar feelings of abandonment when his wife leaves him to go
on retreat]
The patient accesses feelings of longing and loss and reports that he
has never told anyone about his emotional pain. The therapist
recapitulates and consolidates Kurt’s emotional learning to date,
especially his access to loving feelings and how his destructive
feelings have impacted on his feelings of music performance anxiety.
Th: How could you let anybody get close because there’s this
savage animal inside that wants to come up, because as soon
as you start to care for someone it triggers all these old feelings
about your mum. There are very complex, mixed up feelings
there - loving, caring feelings and violent, savage, brutal rage.

166
 So you start to get anxious when people get close. You start to
rationalise and find excuses to keep away because those
feelings have never gone away. They all just got buried but they
are as intense as they were in those moments, all those years
ago. The unconscious guilt that you feel about killing someone
that you loved drives this destructive system. As you face the
guilt, the destructive system weakens.
Kurt: Next week I’ve got to do a concert which is a major event for me
as I try to deal with everything that we have worked on here. I
am going to bury that bastard and see how I go. I’ve had that
going on in my head when I’m playing, up to now; that other
dark fuck would come up and say, watch out, or try to trip me
up the whole time. Now I want people to see how I can play. I
have always been trying to pick myself up on the negative with
that tumorous fucking animal trying to feed off me.
Th: Yeah, but you faced it today and you let some of that guilt come
up. You recognised that there’s a lot of love there too. It’s not
just this violent anger, not just this guilt; you haven’t been free
to feel the loving feelings that are really at the core of you...
What we’re doing is giving that some space to be - the loving
part of you.
Session Six
KURT: In the past week, I have been feeling more aware of my body,
the physical side of things. I woke up yesterday morning…I
usually don’t feel like eating before a performance; I usually feel
sick in the stomach. I get diarrhoea and I feel like shit. I really
feel terrible. Well, I woke up and I felt pretty good and thought
“Geez”, you know, I was a bit worried that I was feeling good.
And I thought, “Oh, God!” I didn’t have any diarrhoea - I had a
normal breakfast… I got on stage; I was nervous but I didn’t
have this fucking fight with this other voice coming in when I
was playing. I actually could focus clearly for 95% of the time.
It was an incredible experience. It was the best fucking
performance I have ever done. Fuck! I was almost dangerous,
in the sense that I could do almost what I want to do.

167
Th: Wow! Congratulations!
Kurt: Yeah, yeah. I remember you said last week that the anxiety
feeds off a certain guilt that I have, which I have recognised,
and you have helped me recognize, as trying to kill off my
mother because of feelings of abandonment. I can clearly see
that because it is a funny thing that whenever I had a
performance, I would try to deal with issues that were closest to
me, like the physical things and doing meditation but there was
always this underlying feeling that there was something else
that I could not deal with and that overrode all the other
techniques that I had. So it feels like I’ve got to the root of the
problem; it might not be solved but I have got to the basis of it
and it goes way, way back to early on and that is why it is
inexplicable to the intellectual mind. [Kurt demonstrates
profound insight into his emotional process]
Th: Exactly, it doesn’t exist in the intellectual mind.
Kurt: ...and I could never rationalize it or deal with it intellectually. It
has always been there, a backdrop that I couldn’t get rid of, so
in those ways I felt a certain palpable thing yesterday. I was
really pleased and everybody said, “Fuck, you played well.” And
I thought, “Jesus, what’s happened?” I played the best
yesterday that I have ever played in public, ever...ever.
Summary and Conclusion
A person with unprocessed unconscious emotions from early life
does not distinguish the past from the present. These patients
interact with people in their lives in the present through virtually the
same emotional and defensive lenses that they developed as
children. These feelings towards attachment figures from the past and
the defences that they developed in order to manage those feelings
result in self-punishment for having those feelings and serious
difficulties maintaining attachment relationships with the people they
love. When they commence therapy, those templates quickly assert
themselves in the transference (i.e., relationship between therapist
and patient). The therapeutic benefit of mobilising complex

168
transference feelings is the ability to directly examine the unconscious
and the unconscious therapeutic alliance in the present.
Kurt’s early attachment relationships were dominated by neglect and
abuse from those he loved. This caused him emotional pain and
feelings of murderous rage towards his parents. However, because
he also loved his parents, he experienced unconscious guilt about his
rage. Initially, these feelings caused anxiety; gradually, he developed
patterns of avoidance, passivity, helplessness and compliance in
order to reduce his anxiety, protect his parents from his murderous
feelings, and punish himself for the guilt he felt about having those
murderous feelings towards people he loved. As he grew up, these
defences became solidified into his character and, to a degree,
allowed him to function in his relationships, but denied him the full
experience and expression of his loving feelings in his most important
relationships.

However, on stage in front of an audience, a situation that is all about

judgement, Kurt’s defences were ineffective. As a professional
musician, he could not become avoidant, passive, helpless or
compliant and perform at the level required. He was, therefore, left
defenceless in a situation that stirred up earlier feelings of rage and
guilt about the negative judgements he experienced from his parents
as a child. Without the defences to repress these feelings,
unconscious anxiety was his only mechanism to keep these feelings
repressed. Kurt therefore experienced anxiety whenever he had to
perform.

In his relationship with the therapist, Kurt’s unconscious feelings were

mobilised as the therapist tried to reach towards an emotionally close
relationship. This activated Kurt’s defensive template, allowing the
therapist to help Kurt identify and examine his anxiety and defences
and how they were creating an emotional barrier between Kurt and
the therapist.
Kurt was encouraged to overcome his defences and to fully
experience all of his towards the therapist. As the defences were

169
overcome and the unconscious feelings were consciously
experienced, his early memories became accessible, thereby
allowing Kurt and his therapist to work through previously repressed
memories and fantasies from his early life. As this occurred, the
anxiety and defences that previously kept this material repressed
became redundant and were relinquished, leaving a more integrated
and less anxious and defended person. Kurt experienced the benefits
of these changes immediately, in his solo performance between
sessions 5 and 6.
This wok provides an initial demonstration that moderate to severe
performance anxiety, in at least some cases, has its origins in
unresolved complex emotions and defences arising from ruptures to
early attachment relationships. These results are encouraging but
further, systematic research is required to identify both the underlying
attachment pathology and its treatment via ISTDP before this form of
treatment can be confidently recommended to the treatment of MPA
in severely anxious musicians.
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Glowinski, A. L. (2011). Reactive attachment disorder: An evolving
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Kenny, D.T. (2011). The Psychology of Music Performance Anxiety.
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professional musician undertaking Intensive Short-Term
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 CHAPTER 7

SHORT-TERM PSYCHODYNAMIC PSYCHOTHERAPY

(STPP) FOR A SEVERELY PERFORMANCE ANXIOUS
MUSICIAN: A CASE REPORT14

Most people experience performance anxiety (PA) at some time in a

range of diverse endeavours. However, for those in careers related to
the performing arts (music, theatre, dance), public speaking, or sport,
it can be a career-limiting or career-ending experience. Little attention
has been paid to performance anxiety, empirically, diagnostically, or
therapeutically. This paper contributes to the theory proposed by
Kenny (2011) that the underlying psychopathology of severe
performance anxiety is an attachment rupture in early life that is
unresponsive to cognitive behavioural therapies. Accordingly, a short-
term psychodynamic psychotherapy (STPP) whose therapeutic focus
is the resolution of attachment ruptures was undertaken with a young
female musician who was in danger of failing her final year at a
prestigious music school because she could no longer perform
without breaking down. This paper describes the application of the
triangle of conflict and the triangle of time/person in the resolution of
the attachment ruptures of the three key attachment figures in the life
of this young musician. This paper represents only the second
detailed case report on the treatment of debilitating music
performance anxiety using STPP. Given the successful outcome of
both case reports, further investigation of this therapeutic approach
for severe performance anxiety is warranted.

Introduction: The extent of the problem

Performance anxiety is a very common source of psychological

distress. Most people have experienced it at some time in any one of

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175
a range of diverse endeavours that include test-taking, mathematics,
and sexual performance. However, for those in the performing arts
(music, theatre, dance), public speaking, or sport, it can be a career-
limiting or career-ending experience. Prior to 1994, performance
anxiety was not included in the classificatory systems of psychological
or psychiatric disorders. In the DSM-IV (Association, 1994) and DSM-
IV-TR (APA, 2000) performance anxiety is briefly discussed in a
section on differential diagnosis in social phobia.

Performance anxiety, stage fright, and shyness in social

situations that involve unfamiliar people (a potentially hostile
audience) are common and should not be diagnosed as Social
Phobia unless the anxiety or avoidance leads to clinically
significant impairment or marked distress. Children commonly
exhibit social anxiety, particularly when interacting with
unfamiliar adults. A diagnosis of Social Phobia should not be
made in children unless the social anxiety is also evident in peer
settings and persists for at least 6 months (APA, 2000,
300.323).

DSM 5 gives a similar short shrift to performance anxiety; it is again

tucked away in Social Anxiety Disorder (Social Phobia) 300.323
where it is given only as a specifier - Social Anxiety Disorder –
Performance only “if the fear is restricted to speaking or performing in
public” (APA, 2013, p. 203). The specifier states:

Individuals with the performance only type of social anxiety

disorder have performance fears that are typically most
impairing in their professional lives… Performance fears may
manifest in work, school or academic settings in which regular
public presentations are required. Individuals with performance
only social anxiety disorder do not fear or avoid non-
performance situations (APA, 2013, p. 203).

It is disappointing that such scant attention has been given to a

condition that affects approximately one quarter of the population at
least once over their lifetime. In the National Comorbidity Survey
Replication (NCS-R) (Ruscio et al., 2008) comprising a nationally

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representative survey of 9,282 people over 18 years, 24%
respondents identified at least one lifetime social fear, the most
common of which was public speaking (21.2%) and speaking up in a
class or meeting situation (19.5%). People who reported more
individual fears showed greater severity of the condition and more
social and occupational impairment than those describing fewer
fears. There was a strong relationship between the number of fears
reported and earlier age of onset. Those reporting more than five
fears had earlier onset, between early childhood and mid-
adolescence, compared with those with fewer fears who showed later
onset, typically in their mid-20s.

Comorbidity was very common, with two-thirds of those suffering

between one and four social fears qualifying for at least one other
diagnosis. The comorbidity rates increased with the greater number
of social fears; there was a 90% comorbidity rate in those who
reported more than 11 social fears (Ruscio et al., 2008). Shared
vulnerability factors such as low positive affect may account for the
high comorbidity between social anxiety and mood disorders (Brown,
Campbell, Lehman, Grisham, & Mancill, 2001). People with lifetime
social phobia are three times more likely to have a major depressive
disorder and dysthymia (chronically depressed mood) and were six
times more likely to have bipolar disorder (Kessler, Stang, Wittchen,
Stein, & Walters, 1999). Based on a number of NCS studies, Kessler
concluded; “The combination of high prevalence, early onset,
chronicity, impairment, risk of secondary co-morbidity, and low
probability of treatment makes social phobia an important disorder
from a public health perspective” (p. 565).

The lack of a clear definition of performance anxiety and the failure to

make explicit the criteria that distinguish performance anxiety from
other anxiety disorders, including its close relatives, specific social
phobia and social anxiety disorder is a theoretical impediment to the
field that compromises identification of those who need treatment and
hinders the development of appropriate treatments. In view of the
prevailing unsatisfactory definitions of (music) performance anxiety,
Kenny (2009) offered an evidence-based definition, as follows:

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 Music performance anxiety is the experience of marked and
persistent anxious apprehension related to musical
performance that has arisen through underlying biological
and/or psychological vulnerabilities and/or specific anxiety
conditioning experiences. It is manifested through combinations
of affective, cognitive, somatic and behavioral symptoms. It may
occur in a range of performance settings, but is usually more
severe in settings involving high ego investment, evaluative
threat (audience) and fear of failure. It may be focal (i.e. focused
only on music performance), or occur comorbidly with other
anxiety disorders, in particular social phobia. It affects
musicians across the lifespan and is at least partially
independent of years of training, practice and level of musical
accomplishment. It may or may not impair the quality of the
musical performance (Kenny, 2009, p. 433).

The nature of music performance anxiety

Following more than 10 years of research into performance anxiety
(Kenny, 2011; Kenny & Ackermann, 2015; Kenny, Arthey, & Abbass,
2014; Kenny, Driscoll, & Ackermann, 2016; Kenny & Holmes, 2015;
Kenny & Osborne, 2006) and clinical presentations of musicians
seeking therapy, Kenny challenged the prevailing view that music
performance anxiety (MPA) is a unidimensional construct occurring
on a continuum of severity from career stress at the low end to stage
fright at the high end. She argued that MPA is better understood as a
typology comprising three subtypes to account for qualitative
differences in presentation as well as variations in severity. The three
subtypes are: (i) MPA as a focal anxiety, where there is no
generalized social anxiety, depression or panic and the anxiety is
specifically focused on an objectively highly stressful performance
such as an audition or solo recital; (ii) MPA comorbid with other
anxiety disorders, in particular social anxiety disorder; and (iii) MPA
with panic and depression. Many of this latter group are reliant on
medications comprising anxiolytics, beta blockers and/or anti-
depressants, with some also reporting the use of alcohol and
marihuana to manage their performance anxiety (Kenny, Driscoll, &

178
Ackermann, 2014). An underlying, unresolved attachment disorder
was proposed as the central psychodynamic feature of this
presentation (Kenny, 2011; Kenny, Arthey & Abbass, 2014; Kenny &
Holmes, 2015).

There are different levels of severity within each MPA subtype. The
theoretical model underpinning this typology is that MPA represents
an intersection between an individual’s developmental history, which
may be more or less disturbed – mildly, or not at all, in the case of
focal anxiety and more severely in the third subtype - and the specific
psychosocial conditions of musicianship - talent, achievement of
technical mastery, preparedness, performance demands, exposure,
competitiveness, and so on. Accordingly, MPA will have some of the
general characteristics of other psychological disorders, in particular,
the anxiety disorders, which are shared by non-musicians, and some
that are specific to MPA and other performing artists such as dancers,
actors, and athletes. This conceptualization of performance anxiety
awaits further empirical examination.

Aims
The aim of this paper is to contribute to a better representation and
understanding of the third proposed subtype of MPA that I observe in
my clinical practice, which constitutes the most debilitating form of the
condition and to report on the efficacy of short-term psychodynamic
psychotherapy (STPP). In view of the hypothesis that an underlying
attachment disorder is associated with severe MPA, this paper
reports on the process of resolution of the attachment ruptures with
significant caregivers and the impact of this resolution on the capacity
to perform.

Participant

The musician, Penelope, aged 22, was an advanced tertiary student

in her final year at a prestigious music school in Australia. Penelope
self-referred for urgent treatment as she had been unable to perform
in public for several months. Failure to complete her final recital would
result in non-award of her degree. In addition, final year students are

179
expected to apply through audition for employment, and she had been
unable to attend these auditions, even though she had indicated her
intention to do so. She was fearful that her future as a professional
musician was bleak.

Penelope began playing piano at five years of age. She commenced

violin at seven years and singing at 12 years. She was awarded a
music performance diploma with distinction in violin at 13 years, a
milestone not generally achieved before the age of 18 years.
However, she chose classical singing as her major for her Bachelor
of Music degree. She stated that MPA “has been a prominent issue
since as far back as I can remember and has prevented me from truly
enjoying the one pursuit I consider a means of refuge in my life. Such
anxiety has begun to affect the outlook I have on other areas in my
life.”

Treatment modality

Short-term dynamic psychotherapy (STPP) is an umbrella term that

incorporates a group of therapies that share common goals and
processes. Examples include Experiential Dynamic Therapy, Affect
Phobia Therapy (Johansson, Frederick, & Andersson, 2013), and
intensive short-term dynamic psychotherapy (ISTDP) (Davanloo,
1990). The theoretical rationale for STPPs is founded on
psychoanalytic theory (Freud, 1933), object relations theory
(Fairbairn, 1946, 1958; Kenny, 2014), and attachment theory
(Bowlby, 1988; Schore, 2003). ISTDP has manualized the principal
tenets of STPP into a formalized treatment process that involves
inquiry, pressure, diagnosis based on the degree of resistance
observed and the degree of fragility in the character structure,
challenge, clarification, “unlocking the unconscious”, recapitulation
and consolidation (Abbass & Town, 2013).

The common goals of STPPs are to restructure the defences,

regulate anxiety and facilitate the awareness and expression of affect.
There is a growing evidence base for the efficacy of STPP for the
treatment of a range of psychiatric conditions (Abbass, 2002;
Leichsenring, Rabung, & Leibing, 2004), including panic disorder

180
(Milrod et al., 2001). ISTDP has been the most researched form and
there is now research supporting the efficacy of this approach
(Abbass & Town, 2013; Abbass, Town, & Driessen, 2012). The
common procedural features include a more or less explicit focus on
early attachment ruptures (as opposed to a focus on the anxiety
symptoms in CBT), active therapist involvement (as opposed to the
non-intrusiveness of analysts), and the explicit use of the transference
(i.e., directing attention to the patient’s feelings towards the therapist).
The importance of the therapeutic alliance is stressed because this
enables the patient to cooperate with treatment, collaborate with the
therapist, and face painful feelings.

Maintenance of a therapeutic focus (as opposed to the free

association of psychoanalysis) is of central importance. This is
achieved through the use of the Triangle of Conflict [impulse/feeling,
anxiety and defence; (Ezriel, 1952) and the Triangle of Person/Time
– (parents/past - P), here-and-now (therapist-T), and current
relationships (Other-O)] (Menninger, 1958)] (Malan, 1979). Figure 1
presents a schematic representation of how the triangles guide the
therapeutic process. Keeping these triangles in mind, the therapist
interprets the patient’s reactions and behavior according to the
linkages in these triangles. Three linkages are interpretable for each
apex of the triangle of conflict (anxiety, defence and hidden
impulse/feeling). These are the other (current relationship i.e., other-
therapist link (O/T); therapist-parent link (T/P) and other/parent link
(O/P). For a detailed explanation, see (Kenny, 2011). There has been
insufficient attention paid in the literature with respect to working
therapeutically with the triangles. One of the aims of this paper is to
more fully elucidate and illustrate this process.

181
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Š›Ž—ȱ
ȱ’œŠ—ȱ™Šœ

Figure 1 Triangles of conflict, person and time and the links between
them that are made in psychotherapy (Kenny, 2011; after
Ezriel, 1952; Menninger, 1958; Malan, 1979). T/P
link=therapist/parent link; O/P link=other/parent link; O/T
link=other/therapist link. Triangle of conflict rotates over the
triangle of person e.g., anxiety, defence and hidden impulse
can appear in the transference, the other and parent.

The main therapeutic focus in this treatment for severe MPA is the
resolution of attachment ruptures, not resolution of the presenting
symptoms of performance anxiety. Therapies that focus only on the
symptoms of anxiety in severe performance anxiety are rarely
effective or enduring. It has been my experience clinically that the
more debilitating symptoms of performance anxiety spontaneously
resolve if the early trauma and its associated painful affect are
accessed, expressed and understood (i.e., processed) (Kenny,
Arthey, et al., 2014; Kenny & Holmes, 2015). However, particular
attention is directed to the role of anxiety, which is viewed either as a
response to an external threat or an internal, emotional conflict. In
situations where a legitimate external threat exists, anxiety is an

182
adaptive response that prepares the individual to deal with the threat
as effectively as possible. In performance anxiety, this would pertain
to issues like repertoire choice and suitability, practice routines, task
mastery, self-care, performance preparation, and other practical
matters. These issues may need to be considered in the treatment.

Internal emotional conflicts are created through ruptures in

attachment relationships in the first eight years of life (Bond, 2010;
Muller, 2009; Pauli-Pott & Mertesacker, 2009). There are a wide
range of events and situations that create attachment ruptures. These
include, but are not limited to death of a parent, prolonged separation
due to illness of child or parent, emotional neglect, emotional, physical
or sexual abuse, or a subtler but equally damaging chronic parental
misattunement to, or lack of empathy with their child’s emotional
signals and needs. The age of the child at the time the rupture first
occurs, and the frequency and duration of these experiences of
rupture are prognostic of the severity of the attachment rupture and
its associated affect, anxiety and defences recruited to manage the
pain associated with the rupture (Bond, 2010). The younger the child,
the more frequently the events occur, and the longer the overall
duration of the events or experiences, the more persistent and
unrelieved the parental misattunement in the absence of other
compensatory attachments (Kenny, 2000), the more severe the
attachment rupture (Beebe et al., 2010; Bowlby, 1960, 1973).

The rupture in the attachment relationship causes emotional pain in

the child and a retaliatory rage towards the parent(s) for causing the
pain. However, because the child also loves his parent(s), he feels
guilt about experiencing rage towards someone he loves. The rage,
guilt about the rage, grief and craving for attachment and positive
feelings are all repressed into symptoms and submerged under
behaviors that enable the child to continue a relationship with his
parent(s). This process eventually becomes a characteristic
defensive system (Winnicott, 1965), variously called pathological
accommodation (Brandchaft, 2007) or fragile character structure
(Davanloo, 1990; 1995). Whenever the child is in a situation that has
the potential for a rupture of attachment, the repressed rage, guilt

183
about the rage, grief and pain from the initial attachment rupture is re-
activated. Anxiety is experienced to block the feelings from entering
conscious awareness and the defensive system is automatically
triggered to keep the feelings repressed and to avoid or alter the
emotionally triggering situation (Glowinski, 2011). Over time, this
pattern is automatically activated in any situation that has the potential
to trigger the repressed feelings about the initial attachment rupture
(Amos, Furber, & Segal, 2011).

A psychoanalytic understanding of music performance anxiety takes

as its starting point that the performance situation stirs conflicting
unconscious desires, wishes and conflicts. The audience has a
pivotal role in this process because of “the universal propensity of
performers to experience an audience as though it were a person
from childhood, real or imagined” (Weisblatt, 1986, p. 64). As for all
causes of anxiety, music performance anxiety in its severe form is
multiply determined.

The anxiety associated with the internal emotional conflict and the
defensive patterns used to avoid experiencing emotional pain
become the psychological problems in the person’s life. Anxiety can
manifest in any of four ways, alone or in combination. The most
adaptive manifestation of anxiety is tension in the striated muscles of
the body (Davanloo, 1990). Chronic striated muscle anxiety is
associated with a number of physical problems including fibromyalgia,
pain, spasm, hyperventilation and panic (Abbass, 2008). In a
therapeutic context, striated muscle anxiety is an indication that the
person has the capacity to consciously experience the repressed
feelings from the attachment rupture(s). Other, more problematic
manifestations of anxiety include smooth muscle anxiety that is
somatized into the gut, leading to gastrointestinal symptoms including
nausea, reflux, cramping and the urge to urinate and/or defecate. The
striated muscles remain relaxed. Chronic smooth muscle anxiety is
associated with hypertension, irritable bowel syndrome and migraine
(Abbass, 2005; Abbass, Lovas, & Purdy, 2008). Anxiety may also
manifest as cognitive perceptual disruption (CPD) which is
experienced as tunnel vision, blurred vision, or ringing or buzzing in

184
the ears, and feelings of depersonalization (Davanloo, 1995b).
Physically, the person will appear relaxed as anxiety is not being
expressed in the striated muscles, but will manifest confused thinking
and not be “present” in the room. Chronic cognitive perceptual
disruption is associated with neurological complaints, for which no
medical cause can be found such as dizziness and fainting. In rare
cases, anxiety may manifest as conversion (Axelman, 2012).

In a therapeutic context, the experience of smooth muscle anxiety,

cognitive perceptual disturbances or conversion indicates that a
psychological restructuring process is required before the person is
able to consciously experience the repressed feelings associated with
their attachment rupture(s). In restructuring, the person is gradually
exposed to increasing levels of anxiety, via graded exposure to their
repressed feelings, and helped to develop and maintain a striated
muscle anxiety response (Davanloo, 1995a). Eventually, the patient
is able to consciously experience the previously repressed feelings
without unmanageable anxiety. This process is akin to systematic
desensitization in CBT, although in CBT, the focus is on overt
symptoms, not repressed feelings. Patients may experience only one
of the four types of anxiety, or they may experience a shift from
striated to smooth muscle or cognitive perceptual disruption as the
repressed feelings move closer to conscious awareness.

In response to anxiety, defences are automatically activated. There

are three main groups of defences (Davanloo, 1996a). Isolation of
affect is the most adaptive defensive system. Patients are aware that
they are experiencing a particular emotion, but they don’t know how
they are physically experiencing it. Instead of the physical experience
of the emotion, patients with isolation of affect experience striated
muscle anxiety. The second major defensive system comprises
repressive defences (Davanloo, 1996a). Patients with repressive
defences do not recognize that they are experiencing emotions.
Instead feelings are repressed into the body. Repressive defences
are linked to smooth muscle anxiety where feelings are
internalized/somatized into, for example, nausea, irritable bowel
syndrome, depression, headache, or conversion symptoms. The third

185
major system is the projective/regressive defensive system, which is
associated with cognitive perceptual disruption (Davanloo, 1995b).
Patients using this cluster of defences do not perceive that they are
experiencing emotions, but rather perceive that another person is
experiencing the patient’s feelings. This most commonly occurs with
anger, but any feeling can be projected, including hatred, envy and
guilt. Typically, these patients manifest one or a combination of the
following symptoms - weepiness (tears without feelings of grief),
temper tantrums, explosive discharges of affect, confusion, self-harm,
drug and alcohol misuse, dissociation, and projection of their feelings
into others (Davanloo, 1995b). Each patient is carefully assessed with
respect to the form of anxiety expression and the system of defence
(Davanloo, 1999). This gives important information to the clinician
about how to proceed with therapy. Patients with much earlier and
more severe attachment ruptures will be more fragile and will require
a longer and slower-paced therapy (Davanloo, 1995b).

The aim of therapy is to help the patient to abandon his/her defences

to allow the previously repressed feelings into conscious awareness.
The conscious experience of these repressed feelings triggers
memories associated with early attachment ruptures, enabling these
previously repressed memories and feelings to be resolved
(Davanloo, 1996a, 1996b). Much of the work is achieved through the
transference, through which the murderous rage towards the original
attachment figures may first be expressed. Once the patient accesses
his/her rage, s/he will also experience the pain and grief at the loss of
the attachment relationship.

In summary, STPP focuses on the experience of feelings in the here

and now of the interaction (i.e., transference) between therapist and
patient. In response, the patient begins to automatically manifest
anxiety and defend against repressed feelings related to unprocessed
emotions about early attachment ruptures from breaking through into
conscious awareness through the transference. This enables the
therapist to assess the anxiety patterns and defensive processes of
the patient in vivo. If necessary, the patient is helped to restructure
his/her anxiety pattern to striated muscle tension. The patient is

186
encouraged to experience the feelings that are creating anxiety (if
anxiety is in the transference), or to overcome the defences that are
blocking the rise of anxiety and the transference feelings. This directs
the resistance into the transference, paving the way for the eventual
conscious experience of the transference feelings and the exploration
of the unconscious.

This paper describes those sections of a 40 session therapy that

specifically related to the resolution of the triangles of conflict, time
and person for the patient’s three significant attachment figures
towards whom she experienced murderous rage, and how this
resolution reduced her performance anxiety.

Assessment

Family history
Penelope is the elder of two daughters – her sister (Elissa) is 20 and
studying business/law. This is an immigrant family. Mother is the sole
bread winner who works as an ethnic welfare officer. Father has
Bipolar Disorder and hasn’t worked at all in the past 20 years. He is a
failed musician who also suffered from extreme MPA; he started a
university degree in his early adulthood that he never finished. He sits
around smoking and playing his guitar all day when he is not sleeping,
which is much of the time. His moods are labile and he is really a third
child in the family. He has problems with alcohol abuse, during which
times he becomes verbally abusive, particularly towards Penelope
who provokes him. He lives the life of an invalid, relying on his wife to
earn money and run the family.

Penelope’s mother calls her husband a “lame dog” - she told

Penelope that she does not regret marrying him because “my
situation has made me strong”. Penelope asked her mother why she
did not leave him – and her reply was that she could not throw a lame
dog onto the street. Penelope has expressed anger towards her
father for failing her. She seems somewhat enmeshed with her
mother and sister (“we always do everything together”), although
recently she has expressed envy and anger towards her sister, who

187
apparently knows her own mind and is pursuing her goal to become
a lawyer. Penelope wanted to pursue an acting career but knows that
this is not realistic. Her family is totally opposed to the idea.

Penelope had 10 sessions of cognitive behavior therapy in the year

prior to this therapy and liked the structure and homework, but the
effects were short-lived and she felt devastated by her failure to
resolve her issues with this approach. She has expressed suicidal
ideation on several occasions.

Trial therapy

The first three sessions were an assessment and trial therapy. The
aim was to ascertain the nature of the defensive patterns, the degree
of resistance, character structure, response to intervention, and
suitability for the treatment modality. In the first session, Penelope
presented as socially “polished” but it felt highly rehearsed, like a
“false self” (Brandchaft, 2007; Winnicott, 1965). When asked what
problems had brought her to therapy, she produced five pages of
typed notes about herself that showed remarkable intellectual insight
into her difficulties. She indicated that she viewed herself as an
outsider, as defective and a failure, dependent on others and afraid
of becoming independent.

Penelope worried that she would end up like her father, “a hopeless
mental patient who had done nothing with his life.” She said that
music was her “main solace in life” and without it, she feels bereft.
She entertained grandiose fantasies – “I wish to be great at what I do”
- and strivings to be perfect, but with underlying depression and
depletion that expressed itself as a lack of motivation, “I don’t have a
goal”; self-criticism, “I deserve strong criticism,” “I did not realise how
much I hate myself”; and failure of individuation, “My self-esteem is
based on how people view me;” “I cannot tell who I really am.” She
felt humiliated by her “failures” - musically, interpersonally, and with
respect to her body image. She perceived herself as overweight and
ugly and was self-denigrating of her tendency to binge eat.

188
After an outpouring of self-loathing, Penelope remarked that she was
scathing of self-affirmations. I hypothesized that there was probably
a T/P link here, but waited to hear more. She told me that she would
think very ill of me if I advised her to use them. She was impatient for
answers and a solution and constantly asked for strategies and
homework at the end of each session. I commented that she was
feeling unsure about whether this therapy would help her, given her
disappointment with her last therapy. She apologized for being
“mean” and justified her impatience and uncertainty by saying that
she was feeling quite desperate.

We identified the vicious cycle of high expectations, disappointment

at perceived and actual failure, and the ferocious self-denigration that
followed. She described herself as “a useless piece of carbon” and
“wondered why I am even breathing.” She could not accept that she
had “any achievements worth anything in the scheme of things.” She
then launched into a panicked account of an impending assignment
and how no-one would help her. I wondered out loud whether she felt
that I was not helping her either, making an O/T link to bring the
experiences of her current life into the transference. She
acknowledged that she was left feeling abandoned at the end of
sessions with no strategies to implement or homework to perform.

Following these three sessions, Penelope was judged to be suitable

for STPP. She was articulate, motivated, and showed considerable
psychological insight into her difficulties. Much of her anxiety was
expressed through striated muscle tension and sighing respirations.
There was no evidence of smooth muscle involvement or cognitive
perceptual disruption, except for the report of a “globus15” when she
tried to sing. She was able to acknowledge intense emotions,
including murderous rage, towards significant attachment figures. Her
defences comprised isolation of affect (intellectualization), turning
anger in on herself, and tactical defences (cover smiles, practised
social poise, breaking eye contact), suggesting that work could

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189
commence on mobilizing her feelings related to early attachment
ruptures.

Music history and history of music performance anxiety

One of Penelope’s earliest musical memories was as follows: At the

age of six Penelope had to sing a duet with her sister in a concert.
She broke down during the performance and ran from the stage
crying, while her sister completed the performance alone. Although
she has many musical accomplishments, including gaining her
performance diploma at a young age, and wins at many
eisteteddeodau, she regarded herself as a musical failure because
she could no longer perform in front of an audience. This problem had
become urgent as she was soon to graduate (if she could complete
her final recital) and would then be seeking professional work through
auditions, another situation that terrified her.

Penelope described her MPA as “demons” on her shoulder, who

whispered destructive comments in her ear every time she tried to
perform, such as “Why bother? You are going to botch this
performance like all the others. You are a failure.” She said that she
tries to flick the demons off her shoulder but they “clawed and clung
to her clothes and climbed right back” up onto her shoulder, all the
while denigrating her and her incapacity to perform.

Penelope then said that the voices were so difficult to silence because
she thought that they were speaking the truth – that she really was a
failure, useless and without purpose. “How can you combat the truth?”
she asked. I asked her whose faces she saw on the demons on her
shoulder. Without hesitation, she said she saw her father’s face and
the faces of some of her music teachers who had had such high
expectations and who had now expressed such disappointment in
her. She had also felt pressured by her music teacher to give up her
university studies and become a full time music teacher in her
teacher’s studio. This teacher, whom she described as a “second
mother,” had told her that she was not capable of finishing her
university degree or competing in the cut throat world of the
professional musician.

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Penelope acknowledged feelings of rage towards these people but
wondered how she would express it - whether it would be “word vomit”
and not make any sense. I wondered whether she was concerned
about what I might think of her if she vomited her meaningless words
in my presence. She acknowledged that she had worried about this.
Penelope also talked of her panic each time she was asked a
question in her lectures and described this feeling as similar to her
music performance anxiety as she walked on stage to perform.

Attachment relationships

Penelope recounted a recent experience in which she was trying to

assemble a piece of furniture and her father just sat and smoked and
watched as she struggled with the heavy pieces. She became
enraged and shouted at him that he was not her father. Her mother
remonstrated with her. “You need to have your antennas tuned when
your father is having a bad day.”

Penelope’s rage towards her father was close to awareness but she
defensively turned the anger in on herself, deriding herself for being
defective and a failure, clearly attributions that belonged to her father.
She was also angry that her mother was more interested in her
father’s feelings than hers and expected more of her than her father,
who “is supposed to be an adult.” I pointed out and clarified the
system of defences Penelope used to defend against her hostile,
angry feelings and the self-destructive consequences of such a
system, how these characteristic patterns of interpersonal interaction
were evident in the therapeutic dyad - her disappointment in me at
the absence of a quick fix was barely concealed – but she would
increase her self-critical comments when these negative
transferential feelings threatened to erupt. This led to the
interpretation of the T/P link.

In response to this focus to attend to her feelings, the defences she

used and what the defences were helping her to avoid, Penelope
disclosed an urge to self-harm and wished that she were dead. “I was
standing on the railway platform watching the trains go by and I had
an urge to just let myself fall onto the tracks.” I suggested that

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Penelope would rather be dead than acknowledge her anger and
disappointment in her parents. Focused attention on these feelings
and encouragement of Penelope to take action against
helplessness16 by pointing out her detachment17 in the transference
(e.g., Penelope broke eye contact when feeling anxious, vulnerable,
or suicidal, and laughed and became self-denigrating when
connecting with painful feelings) and her use of the defences of
rationalization (e.g., “I can’t be angry with my father; he can’t help
himself”) and isolation of affect (e.g., “I have a job to do; I should just
get up and do it”) as strategies to avoid confronting her painful
feelings towards her parents. I gradually increased the focus on the
central issues, continually pointing out her defences, countering her
rationalizations 18 and blocking irrelevant and distracting talk,
including her frequent self-attacks.

The challenge for Penelope was to acknowledge her hostility towards

her father rather than avoiding, then rationalizing it and turning the
hostile feelings onto herself. Penelope expressed her fear that she
would end up like her father – “a lame dog,” passive and a failure. I
again made the link between her negative feelings towards me for not
giving her a quick fix and the increase in her self-denigration when
she became aware of hostile feelings towards me (e.g., “I feel like a
waste of space. What am I even breathing for, taking up so much
oxygen?”). I then made the T/P link with her father. In response,
Penelope reported a major altercation in which her father accused her
of being negative and wearing her anger and frustration on her face,
and that he was sick of it. He had tried to throw her out of the car
during one of their arguments.

Completion of the triangle of conflict with father

Davanloo (1999) calls the process of working first with the anxiety,
and then the defences to clear the way for accessing and
experiencing the hidden impulses and feelings (rage, guilt about the

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192
rage, grief, attachment longing) that have arisen as a result of
significant attachment ruptures in early life, the “unlocking of the
unconscious”. The hitherto unacknowledged and unexpressed
murderous rage is accessed emotionally but must also be felt
physically (i.e., in the body), as the extract from the therapy transcript
below demonstrates. Guilt for these feelings of rage towards a parent
follows and further defensive manoeuvres come into play to manage
these.

In this session, Penelope had just returned to university from an inter-

semester break. She launched into an account of her first week back
at university. She had felt positive in the inter-semester break, had
completed her readings and was motivated to do well. In the first
tutorial, she was confronted with some students whom she thought
had an easy life; they had rich parents, lots of opportunities, dressed
expensively, and were smart and confident, attributes that she
believed were absent in herself.

DK How do you feel about these students as you talk about them
now?
P I feel intense hatred and jealousy towards them.
DK Where do you feel that in your body?
P [points to her head] There is a huge pressure in my head.
DK So you are struggling very hard to keep the lid on those feelings
to prevent them from spilling out, exploding like a volcano?

We then discussed the specifics of her feelings and Penelope was

able to identify that her real anger and hatred was for her father (“who
spends 23-24 hours in bed, only getting up to eat and smoke”) who
had deprived her of the life she could have had, like the students in
her tutorial class (O/P link).

DK How do you feel about your father as you describe him lying in
bed all day?
P I feel anger and frustration and even hatred
DK Where do you feel it in your body?

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[Penelope made strong fists with her hands and started waving them
about]

DK What would you like to do with those fists?

P I want to grab my father and shake him and tell him to wake up
to himself
DK But your hands are in fists
P Maybe I want to do something worse
DK What would you like to do?
P I want to do a home invasion on him with three masked people
who put him through some torture trials. If he survives all the
trials, he gets to have mum and Elissa and me.
DK Who are the masked torturers?
P Me
DK You feel so angry with your father that you want to put him to
the test through torture to see if he has qualified to be your
father?
P [Laughs and looks away] I am so embarrassed about this. He is
my father, after all
DK You are experiencing strong emotions of anger and
disappointment with your father, yet you break eye contact,
laugh and put distance between you and me so that we cannot
deal effectively with the feelings that have come up in relation
to your father.

I made the anxiety/defence link; Penelope became anxious when her

hostile feelings towards her father were coming into awareness, so
her defences were activated to prevent this from happening. We were
then able to complete the triangle of conflict with respect to her father.
I then made the link between her father’s helplessness and failure and
that part of him in her that is sabotaging her. She burst out
spontaneously,

P I am going to make it. I will see it through and I will succeed

194
DK So are you not your father – neither the father who lies in bed
all day nor the internal father who is helpless and irresponsible
and who sabotages you.

Penelope was fascinated with how her feelings about the students in
her tutorial were connected to her feelings about her father (O/P link)
and in turn, her self-sabotage perpetuated by her internalized father.
These experiences led to a significant deepening of rapport and
strengthening of the unconscious therapeutic alliance. After this
session Penelope reported a conversation with her father.

P: I told my father how I felt about the fact that he never tries to
improve his life, get a job, help Mum or be a father to us. He
burst into tears and said his life was over but that he wanted
better for his daughters. I felt good that I told him how I felt and
now I feel I don’t have to be responsible for him feeling better. I
know that I can’t expect much of him and I am OK about that
now.

Completion of triangle of conflict with mother

Over a series of sessions, Penelope described some experiences
related to the apex of the triangle of conflict (i.e., hidden impulse or
feeling). In the first of these, Penelope complained that she was
feeling totally overwhelmed by her university course and couldn’t
cope. Uncharacteristically, she went to see her lecturer, who lent her
a book with a summary of the lecture in it. Penelope did not feel
comforted by the lecturer’s facile assurances and said they felt like
her mother’s empty clichéd reassurances. I remembered her
vehement aversion to positive affirmations in her first session and
made the O/P link with respect to these.

Penelope reported that she had finally got some distance between
herself and her father – that she had put him in the “angry box” and
stopped worrying about what he was doing with his life (e.g., “He is a
waste of space and oxygen”). She asked whether she had to do
something similar with her mother. She promptly answered her own

195
question, saying that her mother needed to go into an “angry box” as
well, because of the weight of all the expectations that her mother put
on her, for constantly comparing her with her sister, for never offering
meaningful emotional support instead of sprouting clichés about how
everything would be fine.

Penelope then described two incidents with her mother. In the first,
both Penelope and her father were having a bad time. Penelope
approached her mother to complain about her life and to seek comfort
from her. Her mother put her hands to her lips and said “Shhhh…” to
Penelope, pointing to her father reclining listlessly on the couch. This
incensed Penelope who called her mother “selfish” and stormed out
of the room. I suggested that she felt particularly angry that her mother
treats her father like a baby and does not expect anything from him,
yet she is expected to behave like an adult and be considerate of her
father even when she herself is in need of maternal care.

Penelope came in very distressed for her next session, having had
yet another fruitless interchange with her family. The theme of this
session was her recognition of her enmeshment with her family, such
that they are “one tree with several branches, rather than four trees
growing in proximity”. She said that she had not realised how
“machine-like and robotic” Elissa was, apparently having taken on her
mother’s persona of “do your work, face life without complaining, and
don’t rock the boat.”

Penelope told her mother that she hated her and that she was no
longer her child. She subsequently ignored the rest of the family
because she was “sick of being blamed for everything that went
wrong.” I suggested that she was struggling to have an independent
mind and separate existence from her family which her other family
members found challenging. Penelope again addressed the issue of
wanting to leave home, with her mother’s words ringing in her ears –
“If you leave home, I will not help you and you won’t be welcomed
back.” This was understood as mother attempting to keep Penelope
within the orbit of the family, where independent thought is punished.
Penelope was afraid that she had been so protected from the world

196
that she wouldn’t know how to live independently. She also had some
legitimate concerns about having sufficient money to live
independently, even though her need to leave home was growing
more insistent.

P All my life as a child, my parents treated me as an adult; now

that I am an adult, they want to treat me like a child.
DK You want to walk into your future with your adult self and your
child self, hand-in-hand. You are now an adult who is able to
take care of your child.
P Yes, yes, that is it. [Pointing to her throat] Now all this tension I
was feeling in my throat is gone; it feels relaxed.
DK It is a relief to feel understood.
P [tears] Yes, it is. Thank you so much.

In the following week, Penelope exclaimed in great excitement that

she had performed well and with enjoyment in a musical concert.
Afterwards, she felt satisfied with her performance and did not engage
in her usual post-performance rumination which inevitably ended in
self-denigration. At the end of the session, she said, “I am not a waste
of space. I have achieved a lot of things. I have survived the
challenges of a family living with a member with a mental illness; I
have managed financial hardship; I studied hard and got my diploma
and then got entry into university. I have got to fourth year. I have
done things. As well as all that, I was able to recognize that I wasn’t
doing well emotionally and that I needed help. I am proud of myself
for doing that – recognizing my issues and finding help.” She then
said,

P I hope I don’t come in next week in a big dip again.

DK We will deal with whatever you come in with next week together.

A few days after this session, Penelope rang me in a hysterical state

asking for a phone consultation. Fortunately, I had time, and given the
intensity of her distress, I agreed. She said that a distant relative had
died and was buried today. The family asked her if she would sing at
the funeral. She agreed to do an a cappella duet with her sister.

197
Penelope reported that it went well, she had not been overcome with
panic and she and her sister were happy with their performance.
When they left with their family to drive home, her mother attacked
her viciously, saying that her performance was awful, that she could
never step up when needed, and that she should forget about her
music altogether. Penelope told her mother that she was happy with
her performance and did not want to give up performing. A huge
argument ensued between Penelope and her mother. Elissa sided
with her mother, changing the focus to Penelope’s “hysterics” rather
than her mother’s sadistic comments. Her father, as usual, laughed
at Penelope’s distress. The argument continued and Penelope
screamed that her mother was a “dictator” and a “puppeteer” and her
father was a “total failure.” Penelope said that her mother always had
to have things organized her way and was an oppressive martyr (e.g.,
“Look at what I do for all of you”). I suggested that her mother might
need to make some adjustments in her relationship with Penelope
who was now less dependent on her and went to her less often for
solace now that she was feeling stronger in herself. I reminded
Penelope that her mother called her father “a lame dog” and that
perhaps she was good at caring for lame dogs but not for maturing
adult children. I suggested that her father laughed because he could
not cope with others’ emotions, and that perhaps Elissa sided with
her mother for the same reason. This all made sense to Penelope and
she eventually calmed down.

In the following sessions, Penelope continued to struggle with the

cataclysmic family conflict. She reported that her mother had spat in
her face and told her that she did not want her in her house any
longer. Penelope said, “In all the years and arguments my mother has
ever had with my father, she has never spat in his face or told him to
leave.”

DK How did you feel about your mother spitting in your face?
P Very, very angry
DK How are you feeling that anger in your body? [Penelope points
to her chest and her forehead].
DK What do you want to do to your mother right now?

198
P She was invading my personal space and I wanted to push her
out of my face [makes a forceful pushing away gesture with her
hands, palms facing outwards].
DK What happens then?
P She falls.
DK And then?
P I have some sort of weapon in my hand.
DK What is it?
P A large knife
DK What do you want to do with the knife?
P Cut her to pieces.
DK So, you have cut your mother to pieces and she is lying, lifeless,
in a pool of blood on the floor. Looking at her lying there, what
are your feelings towards your mother?
P I feel the most enormous sense of relief and freedom that I have
cut the puppeteer’s strings tying me to her. I can breathe.

Completion of triangle of conflict with sister

Over a number of sessions, Penelope discussed her complex
relationship with her sister. Her initial early descriptions of her sister
were idealized. “I don’t know why I can’t be more like Elissa. She has
got her whole life figured out; she knows what she wants and she is
working to make it happen. She never argues or raises her voice or
makes a fuss. We grew up in the same family. Why are we so
different?” According to Penelope, Elissa “had her act together”, knew
her goals, was disciplined, focused and unemotional and was sure to
succeed, unlike herself, whom she described as having the opposite
of these characteristics.

Penelope subsequently reported a “very serious fight” with her sister.

It related to Elissa’s condescension towards Penelope with respect to
her frequent emotional outbursts, which Elissa viewed with barely
concealed contempt. As Penelope was recalling the fight, she
reported a growing constriction in her throat that she sometimes
experienced during vocal performances. I asked her to focus on it and
she said, “It makes me feel like I want to vomit.” I commented that she

199
might be referring to vomiting her feelings of rage and envy that she
held onto so tightly but which were now demanding acknowledgement
and expression. Penelope responded that her mother had told her
that she was very jealous of Elissa when she was young. I replied that
that was understandable because her mother had diverted a lot of
attention from her to her fragile second child (and her mentally ill
husband) and Penelope was expected to grow up quickly and fend
for herself emotionally, which had left her with feelings of neediness
and deprivation. We discussed how some chinks in her idealized
perception of her sister were starting to show.

For the next few sessions, Penelope was focused on dealing with the
impediments to her singing. She described her fear of a serious throat
constriction (i.e., globus) every time she got up to sing in public. In
one session, she reported a globus in her throat and throbbing in her
temples. I suggested that these physical sensations represented
suppressed feelings that she was “strangling” or preventing herself
from expressing and that these feelings were literally getting stuck in
her throat. I made the link between this restriction in her throat when
she was becoming aware of her hostile feelings towards members of
her family and how she felt on stage, when all the previous anguish,
expectations and criticisms from her family were re-triggered by the
evaluative performance setting.

I asked Penelope what she would say or feel if she allowed herself to
express the “unexpressable.” She painted a very vivid picture of
herself as a little girl in a fancy dress on stage, black except for a
spotlight on her. She makes a gesture with her hands to the audience
which said “Please listen to me; pay attention, keep quiet and listen.”
I asked whether she was appealing to the audience like a little girl
appealing to parents who are too distracted to pay her any attention
or to understand her needs (O/P link).

Penelope then described a feeling of intense hatred for her sister

whom she felt had received much more attention from her parents
than she had. Penelope recalled Elissa standing in the doorway
laughing at her while she became more and more distressed trying to

200
explain herself to her mother on the day of the funeral, and who
remained impervious to her pleas. At that moment, she realized that
Elissa would turn on her and not care about her in the pursuit of her
own goals.

P She has parts of both my mother and father in her – she is a

goodie-goodie who thinks only of herself, who bosses like my
mother and taunts like my father.
DK What do you want to do with Elissa?
P Rip out her vocal cords
DK You want to tear out her throat to stop the laughing
P Yes
DK How do you do that?
P I just lunge and grab her throat with my bare hands
DK What happens next?
P She has a look of disbelief on her face for one moment before
she slumps on the floor next to my mother
DK Looking at Elissa on the floor, what are your feelings towards
her?
P Well, she is not laughing now. She is not moving. I used to envy
Elissa because she seemed to have her life together, her goals
in place and strategies to achieve them. As I look at her now, I
feel that I have freed myself of that envy because she does not
understand herself or me. She would rather be a robot. My
family has been deriding me for seeing a psychologist. My
father hates psychologists and psychiatrists because he says
they have done nothing for him, but I am so glad that I persisted
because you have helped me to discover a life I can live.

In the following week, Penelope had two musical performances that

she managed without panic and with considerable enjoyment. She
said, “The lump in my throat reduced a lot because I think I expressed
a lot of emotion last week. That constricted feeling that I get when I
try to sing in public did not worry me this time so I was able to sing
out for the first time in ages and become absorbed in the music.”

201
Penelope then discussed her desire to leave home as soon as she
could, stating that she could do it; she could take care of herself. At
the end of this session Penelope expressed the first genuinely felt joy
I had observed in her; she laughed and clapped her hands, said she
was feeling happy, and that she was confident that she could move
into the future with renewed hope of pursuing a musical career.

Commentary and Discussion

Many patients, particularly young adults, are time and money poor. If
they are university students, they spend many hours attending
lectures and studying, often under conditions of financial strain. Many
have casual jobs to pay the rent. When they seek psychological
services, they expect a time-limited, once a week, affordable
treatment. The short term dynamic psychotherapies fulfil these
requirements.

STPPs have been criticized for falling into the errors of “therapist
knows best,” one-person psychology models, and that the triangles of
conflict and person/time locate the problems as intrapsychic rather
than relational (e.g., Ringstrom, 1995). I would argue that this position
fundamentally misunderstands the central importance of the
relational aspects of working with the triangles and the therapeutic
alliance in which the therapist and the patient team together to
overcome the self-defeating defences and resistances that prevent
change. ISTDP is the most prescriptive of this group of therapies;
some patients may respond better to a less confrontational approach
while working within the framework of the model. Indeed, some
therapists also prefer to work with a gentler frame than ISTDP while
adhering to its central tenets, as was the case in the therapy reported
here.

The most interesting feature of the segments of this therapy

presented in this paper is that while severe music performance
anxiety was the ostensible reason for seeking treatment, the identified
problem was, in fact, only one manifestation of the diverse
psychopathology experienced by this young woman as a result of the
ongoing emotional trauma caused by chronic parental misattunement

202
and frank emotional abuse that she had suffered throughout her
young life. Musicians presenting for urgent assistance with their music
performance anxiety in circumstances in which they might not
otherwise be able to perform, attend auditions, or complete
requirements for their university degrees would, prima facie, provide
a prominent focus for the therapeutic work. My clinical experience has
demonstrated that too rigid a focus on the ostensible presenting
problem may prove counter-productive and contribute to treatment
failure. This was in all probability one reason for the failure of her CBT-
based treatment. Although Penelope said that she enjoyed the
sessions, the strategies and the homework, it had no effect on the
underlying attachment ruptures responsible for her symptoms.
Musicians spend many solitary hours practising between lessons, so
the structure of CBT in which strategies and homework are planned
during the session and then practised between sessions would have
been familiar to Penelope, and therefore comforting in its familiarity.
The collusive focus of CBT on the symptoms of performance anxiety
served to keep the hidden impulses and feelings towards her parents
and sister from reaching awareness.

The main symptom preventing Penelope from singing, the hysterical

globus (i.e., psychosomatic throat restriction), resolved only after she
was able to identify the strangulated feelings of rage and envy that
were seeking expression but that were defensively kept at bay; they
were literally stuck in her throat, the result of simultaneous competing
impulses to express and repress. Penelope’s presentation gradually
changed over the course of the therapy from her “false self” to a more
integrated “real” self. She no longer needed to play act because she
was feeling freer to be herself, a self that could own her painful
feelings and experience joy and confidence in her growing autonomy.
However, this emergent autonomy was fraught with danger because
her mother gave her the message at the funeral, “If you find your
voice, I will hate and reject you.” Perhaps there was a similar dynamic
happening in the marital relationship. If her “lame dog” husband
recovered or asserted himself, she would need to kick him to make
him lame again. Penelope was angry with her father because he

203
could not protect her from her mother’s envious attacks. Her mother
appeared to need a helpless husband and dependent daughter with
whom she could be a “puppeteer” pulling all the strings in order to feel
in control, to maintain her wall of defences against her own rage and
envy.

Penelope’s therapy dislodged this pathological family system; her

mother felt threatened by her growing autonomy and worked hard to
restore the status quo. The sadistic attack on her singing performance
in the family car, in which there was no escape for Penelope was
emblematic of the suffocating hold that her parents were attempting
to reassert over their daughter. In a similar way to her parents’
trapping her in the family car, Penelope had to consign her parents to
“angry boxes,” that is, to quarantine their influence on her as she
struggled to achieve a separate mind. She has not yet achieved
personhood but she has become closely acquainted with her
depressed and deprived child whom she can now nurture rather than
subjugate to the relentless attacks of the punitive internal and external
parents in this pathological family.

In this chapter, I have focused a spotlight on the importance of

resolving attachment ruptures in musicians who are severely
performance anxious. Although most of my work to date has been
with musicians, I believe that the same dynamics would apply to other
performance-based professions. This assertion awaits further
empirical investigation, as does this form of therapy for this
population.

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