**6. Quantitative research: method**

At the start of the study 46 advanced pianists (aged 18–26 years and of mixed gender) from three higher educational institutions were randomly assigned to a therapy or control group. The therapy groups received two interventions of either CH or EMDR during a two-week period between two concerts. A quantitative assessment of the state component of cognitive anxiety of all participants was obtained from the Spielberger State-Trait Anxiety Inventory (STAI-Y1) taken at baseline and prior to both performances. The findings reported here are on state anxiety; for the full findings of the author's research, including trait anxiety, somatic/physiological symptoms of anxiety and the behavioural aspects of performance anxiety see Brooker [3].

#### **6.1 Results**

At the end of data collection to establish whether anxiety levels decreased more in the intervention groups than the Control, an ANCOVA was calculated comparing levels of state anxiety across the three groups at the first and second performances (before and after treatment). There was a main effect of condition (F (2, 42) = 4.92, *p* = .012) such that participants in the two treatment conditions, CH and EMDR, showed significantly lower cognitive anxiety than the Control group at the second performance, post-intervention and that both treatment groups were significantly effective in achieving this (Helmert contrasts, .005 significance level).

This suggests that the therapies applied between the two performances significantly lowered anxiety in both the CH and EMDR groups prior to the second performance and this required two sessions only. This effect was not demonstrated in the Control group.

**Figure 1** below shows the standard error of the mean score of state anxiety at the two performances calculated from the STAI Y-1 questionnaire, where 80 represents the highest level of anxiety and 20 the lowest. It illustrates the decrease in state anxiety at the second performance across the three groups.

#### **7. The qualitative research: case study**

Qualitative information on music performance anxiety (MPA) is documented here in the form of a case study, taken from the author's private practice [47]. A personal account of performance experience is given which allows for more detail, sensitivity and insight into the understanding of MPA which could not be obtained from quantitative research alone. It gives insight into the process of therapy by

#### **Figure 1.**

*The standard error of the means of state anxiety from the STAI Y-1 questionnaire taken 15 min prior to performances 1 and 2: error bars show 95% CI of mean.*

exploring the internal thoughts, feelings and experience of the individual. This case study begins with the individual's own words (the narrative). It then continues with an abbreviated description of the progression of treatment and documents the therapeutic outcome, as well as reflecting on the suitability of the treatment administered from a research standpoint and comparisons of possible treatment effects of other treatments. It is the documentation of an individual who received one therapy of EMDR and one of CH for the treatment of MPA, (the name is anonymised).

#### **Identifying information**

Name: Rebecca.

Music performance anxiety: Voice.

Age: 41.

Occupation: Student with the Open University studying English and Music (first instrument, voice).

#### **7.1 Case history: Rebecca's narrative**

*I had always felt very nervous when performing and always seemed to have the image of my father in the background; I felt that he was judging and criticising me and that I was letting myself down. I was having singing lessons at this time and giving small informal recitals but I was never happy with the outcome; I always felt I fell short of my*

*Cognitive Hypnotherapy and EMDR: Two Effective Psychodynamic Therapies for the Rapid… DOI: http://dx.doi.org/10.5772/intechopen.101770*

*true potential. I took Grade 8 ABRSM Singing examination but failed quite badly and this felt like the ultimate disaster. Although I was confident practising on my own, I found singing lessons 'nerve racking' and at the examination I just 'fell apart'.*

*After I moved here and restarted singing lessons I was very interested in taking part in the Christmas concert as your research was close to my heart as I always get very nervous in performance. I was singing in the second half of the concert but felt nervous in the first half and this got worse, and as soon as I started singing my throat felt tense and I had saliva in my mouth which I had to keep swallowing before the long runs, my heart was beating quickly and I could feel my cheeks flushing. Because of all this I felt that I had not connected with the audience and was disappointed with my performance. I did enjoy taking part however and being part of the research into music performance anxiety and found it somewhat reassuring that others taking part were also feeling nervous, I wasn't the only one.*

#### **7.2 Case formulation**

*Therapist's summary and interpretation of Rebecca's narrative.*

Important features in this narrative indicate that the domineering personality and the physically abusive behaviour of her father, who was against her musical ambitions, have had far-reaching consequences on Rebecca's singing performances both as a teenager and as an adult. These emotions are so strong in present-day performances that she imagines the spectre of her father while she is performing. The negative criticism that she experienced from her father has affected her selfesteem and self-worth as a musician in spite of her belief that she has talent as a singer. This was compounded by a boyfriend who had a similar attitude as her father towards her regarding her music. She is confident practising on her own where she perceives that she is not being judged; however she experiences both cognitive anxiety and distressing physiological and somatic symptoms of anxiety in a performance or examination situation where she feels she 'falls apart'.

#### **7.3 Critical analysis: therapist**

An analysis of Rebecca's narrative suggests that she is suffering from social phobia in situations where she feels threatened and under scrutiny, such as a singing examination or a live concert performance. Social phobia, rooted in social anxiety, has been summarised [84].


Rebecca experiences cognitive anxiety as well as physiological and somatic symptoms of anxiety in a performance situation. However, although she experiences destructive and crippling anxiety when performing, this phobic reaction does not occur in other areas of her life. The therapist purports that this is as a result of the criticism and physical abuse that she received from her father during her teenage years regarding her ambitions as a singer ('my father literally tried to knock it out of me') and this I believe has had a profound psychological effect on her selfesteem and confidence in her music performances.

In therapy Rebecca presented with the following negative schemas regarding her anxiety (direct quotes):

'I know I'll screw it up'

'I can't control my thoughts'

'I'm hopeless'

'I can't control my emotions'

'I can't control my body'

'I can't control my nerves'

Physiological and somatic symptoms of anxiety were:

rapid heartbeat;

shaking/trembling;

tension in throat;

an excess of saliva.

#### **7.4 Treatment plan: EMDR and CH**

#### *7.4.1 First treatment (EMDR): 30 May 2010*

Rebecca's MPA is complex as it is not related to a single incident but the systematic criticism that she received as a teenager, undermining her self-belief in the possibility of her pursuing a professional career in music as an adult. The primary aspect of the overall treatment would be targeting the trauma experienced at this time which in the opinion of the therapist is best addressed initially through EMDR by systematic desensitisation of these experiences.

In therapy the negative criticism and upsetting experiences revealed in Rebecca's narrative regarding her father were the main targets, beginning with the most upsetting incident which she rated as 9/10 on the subjective unit of disturbance scale (SUD) (10 being the highest level of anxiety). This rating indicates that significant trauma had been experienced at this time. The most painful negative emotions when recalling this incident were of fear and anger; the strongest physical sensation was tension throughout her whole body which was accompanied by heightened breathing. After fifty minutes of EMDR her rating on the SUD scale decreased to 0, indicating that the negative memories had been desensitised. The negative schemas that she had presented with at the start of treatment had now changed. Where previously she had six negative self-perceptions (four beginning with 'I can't … '; see above), post-treatment these had changed into positive perceptions of 'I can … '). She no longer thought of herself as being hopeless or that she would 'screw it up'.

Her rating on the validity of cognition scale (VOC scale was 6/7 (7 being the highest level of positivity): negative schemas cited earlier had been reprocessed. Her bodily sensations which she had experienced at the start of therapy when recalling the traumatic memories had now gone completely, her breathing had normalised and she had no tension anywhere in her body. Having targeted and desensitised the most traumatic memories first, the lesser memories of trauma regarding performance when reviewed were more difficult to hold, and no longer caused Rebecca

*Cognitive Hypnotherapy and EMDR: Two Effective Psychodynamic Therapies for the Rapid… DOI: http://dx.doi.org/10.5772/intechopen.101770*

the former anguish or physiological/somatic symptoms of anxiety. If the past has been one of negativity or trauma regarding aspects that are important to the individual, the subjective behavioural response to a similar present-day experience will be consistent with the negative affective responses of the past [56]. An adult may experience feelings of fear and being out of control, and will react emotionally and display negative behaviour accordingly.

#### *7.4.2 Second treatment (CH): 6 June 2010*

The second treatment session (1 h) was shorter than the first (90 min), the important groundwork having been accomplished in the first session. As the disparate memories had been desensitised and reprocessed in the first session CH should now be beneficial in supporting the reprocessed cognitive perceptions. It should also enhance the positivity achieved in the previous session. Rebecca had experienced hypnotherapy some years previously but it had not been particularly effective. However it was explained that it should enhance the EMDR treatment and the combination of the two therapies would strengthen treatment effects. The most important aspects of her singing performance were discussed; she wanted to feel confident, calm and in control in performance, to connect with her audience and feel eager to do more. Her key words, which were 'anchored' on her dominant wrist during hypnotherapy, were *confident*, *calm* and *in control*; these she felt were the words that would enable her to give her optimum performance. The therapy focused on enhancement of performance and included visualisation of her perfect performance.

On completion of hypnotherapy Rebecca was given the therapist's *Self-Confidence for Musicians* CD and advised to listen to this as often as possible, and especially on the day/evening prior to a performance; this would further relax her and add to her confidence. She left feeling happy and relaxed looking forward to her next singing lesson and her next performance.

#### **7.5 Rebecca's self-assessment of treatment**

*My singing in front of audiences can be adversely affected by pre-performance nerves, which seem to stem from my first solo concerts when I suffered with acute stage fright. The EMDR treatment brought my worst singing nightmares to the surface and I was initially sceptical that anything could be done to help my anxiety when performing. However I came away from the first treatment feeling unburdened as if a weight that I had been carrying around for years had lifted. It was like coming out from underneath a dark cloud. The CH treatment in the second session focused my mind on enjoying singing so that when I performed I was in control and relaxed. It appeared to reinforce everything so that I am now looking forward to performing instead of dreading it.*

*(Email message, June 2010)*

### **7.6 Therapist's assessment of treatment and reflections from a research standpoint**

This case study supports current research into anxiety which suggests that negative affect and beliefs from the past control the individual in the present; however they can be healed quickly, effectively and profoundly when past negative-rooted traumas are changed [58, 64]. The negative cognitions and previous perceptions of subjective performance that this patient held were successfully desensitised and reprocessed in two treatments.

#### *Complementary Therapies*

There can be no doubt that the treatment was effective; however reflecting on this as a researcher there are other possible explanations for the resolution of the problems presented here which need to be explored. These outcomes may be explained by a number of different factors. For instance some individuals improve because they have entered therapy, regardless of the specific treatment: a variant of the placebo effect. Fascinating research has been conducted into the well-known phenomenon of the placebo effect with various medical conditions: headaches, pain reduction and even the visual effects of packaging in headache tablets [85, 86].

It could further be suggested that 'narrative smoothing' plays a part in resolving psychological issues, and many psychotherapists support this view [87–89]. It is believed that the process of reconstruction of the initial narration gives more control over the story and can change the patient's perception into something more positive; this underpins the central goals of therapy [87]. Rebecca's narrative was highly charged with specific negative experiences and relating this allowed a different subjective perception.

CBT might also be effective as a therapy in this instance as it similarly uses narration in therapy but treats the presenting symptoms rather than the cause. CBT has similarities with psychodynamic therapies but there are a number of different elements which are distinctive. CBT focuses on the way individuals think and act in specific circumstances and how emotional and behavioural problems may be overcome [90]. However, although CBT appears to be the preferred treatment for anxiety-based conditions, no theory/therapeutic action is without flaws, and a number of issues have been identified with this approach [34]:


In fact there is increasing concern regarding the relapse rate at follow-up sessions for those patients who have undergone symptom-based CBT [19, 90]. It treats the symptoms rather than the cause and as such this may only provide a short-term solution to the problem [16, 34].

#### **7.7 Longitudinal outcome**

Since Rebecca's therapy treatments in 2010 she has completed her Open University degree and now holds a Masters in Professional Voice Practice. She still enjoys performing and has regular engagements. Her dream of becoming a professional musician has been realised.

#### **8. Conclusion**

The aim of this chapter was to give more exposure to and greater understanding of two highly effective therapies for the rapid reduction of cognitive anxiety: CH and EMDR. The complexities of cognitive anxiety were discussed and the role that

### *Cognitive Hypnotherapy and EMDR: Two Effective Psychodynamic Therapies for the Rapid… DOI: http://dx.doi.org/10.5772/intechopen.101770*

dysfunctional memories, particularly implicit memories no longer consciously perceived, can exert on present-day experiences. The chapter reviewed CBT and the benefits of hypnosis as an adjunct to this therapy, now called CH, as well as comorbid conditions where CH has been an effective treatment. The background and theory of EMDR was documented discussing the role of disparate memories in EMDR practice. The procedures and protocols used in EMDR were highlighted before reviewing the clinical studies that have adopted EMDR as a treatment. The final section of the chapter documented the author's research using CH and EMDR, giving both quantitative and qualitative findings. Both the quantitative and qualitative research documented above (pp. 8–13) gave evidence for the effectiveness and rapid results of CH and EMDR in comparison with other complementary treatments where the main drawback appears to be the length of time required to effect positive change. This chapter further highlighted the important contribution that CH and EMDR have made to current research and in doing so has shown the need for further scientifically-based research into the complexities of anxiety and the role that implicit memories play in maintaining this.

In the UK the treatments of choice being advocated by the National Health Service (NHS) for PTSD and anxiety disorders still tend to be medication or CBT and as such there is no financial cost incurred by the patient. Where individuals experience no positive effects, or are dissatisfied with treatment, they are guided towards private therapists at their own financial cost. The medical profession are aware of CH and EMDR but as yet these treatments are not widely available to the general population, although EMDR is available for PTSD in the military domain. This state of affairs needs to be remedied given the effective and dynamic results which are being seen from both CH and EMDR.
