Identifying attachment ruptures underlying severe music performance anxiety in a professional musician undertaking an assessment and trial therapy of Intensive Short-Term Dynamic Psychotherapy (ISTDP)

Kenny (2009, 2011) has identified three possible subtypes of music performance anxiety—(1) focal anxiety associated with realistically highly anxiety-provoking situations such as auditions and solo performances with little generalized anxiety to other situations; (2) performance anxiety associated with a comorbid diagnosis of social anxiety (social anxiety disorder); and (3) performance anxiety associated with severe, performance-impairing anxiety, co-occurring with panic and either pervasive dysthymia, dysphoria or depression. Kenny hypothesized that an unresolved attachment disorder was implied in the majority of subtype 3 and may be implicated in subtype 2 to a lesser extent, with attachment ruptures occurring later in childhood than in subtype 3. Subtype 3 has been referred to as a disorder of the self (Kohut 1971, 1977, 1984; Kohut and Wolf 1978), pre-verbal trauma (Winnicott 1945, 1965, 1974); (reactive) attachment disorder (Fonagy and Target 1997; Halpern 2004; Janus 2006; Mills 2005; Wallin 2007) and fragile character structure (Davanloo 1990, 2005).

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 time-limited contracts, maintaining a therapeutic focus (as opposed to the free association of psychoanalysis), active therapist involvement (as opposed to the non-intrusiveness of analysts), and the use of the transference relationship involving the Triangle of Conflict (feelings/impulse, anxiety and defence) (Ezriel 1952) and the Triangle of Person/Time (past relationships, usually parents, therapist and current relationships) (Menninger and Holzman 1973) to maintain the therapeutic focus (Davanloo 1990, 2005). For a detailed explanation, see Kenny (2011).

The theoretical structure of ISTDP draws on Freudian psychoanalysis (Freud 1933), attachment theory (Bowlby 1988; Schore 2003), and the short-term psychotherapies (Malan 1979). The core therapeutic action in ISTDP is the “patient’s actual experience of his true feelings about the present and the past” (Davanloo 1990, p. 2). Davanloo (1990, 2005) developed a technique to rapidly mobilize the unconscious therapeutic alliance (Davanloo 1987) in order to remove the major resistances to change, which were not effectively removed through interpretation alone.

Internal emotional conflicts are created through ruptures in attachment relationships in the first 8 years of life (Bond 2010; Muller 2009; Pauli-Pott and Mertesacker 2009). Many are due to chronic parental misattunement to, or lack of empathy with 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 his parent(s), he feels guilt about experiencing rage towards someone he loves. The rage, guilt, grief and love are all dissociated into symptoms and are submerged under behaviours that enable the child to continue a relationship with the 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 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 dissociated 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 dissociated feelings about the initial attachment rupture (Amos et al. 2011), such as an evaluative musical performance.

The anxiety over the internal emotional conflict and the defensive pattern become the psychological problems in the person’s life. Anxiety can manifest in four ways:

1. (1)

   Tension in the striated muscles of the body, which is associated with a number of physical problems including fibromyalgia, pain, spasm, hyperventilation and panic (Abbass et al. 2006). In a therapeutic context, striated muscle anxiety is an indication that the person has the capacity to consciously experience the dissociated feelings related to the attachment rupture(s).

2. (2)
3. (3)

   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 (e.g., tunnel vision, blurred vision, ringing or buzzing in the ears). 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) including dizziness and fainting.

4. (4)

   Conversion (Axelman 2012). Instead of becoming tense, the person will become weak in one or more limbs, experience pain in one or more areas of the body, or lose the function of one or more senses (e.g., vision). Potential medical causes must always be ruled out before concluding that the symptom is an indication of conversion.

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 dissociated feelings from their attachment rupture(s). In restructuring, the person is gradually exposed to increasing levels of anxiety via graded exposure to their dissociated feelings and helped to develop and maintain a striated muscle anxiety response (Davanloo 1995a). Eventually, the patient is able to consciously experience the previously dissociated feelings without undue anxiety.

In response to anxiety, defences are automatically activated. There are three main groups of defences (Davanloo 1996); (1) Isolation of affect is the most adaptive defensive system. Patients are aware that they are experiencing a particular emotion, but they do not know how they are physically experiencing it. Instead of the physical experience of the emotion, patients with isolation of affect experience striated muscle anxiety; (2) repressive defences (Davanloo 1996). Patients with repressive defences do not recognize that they are experiencing emotions. Instead feelings are dissociated into the body. Repressive defences are linked to smooth muscle anxiety where feelings are internalized/somatised into, for example, nausea, irritable bowel syndrome, depression, headache, or conversion; (3) projective/regressive defensive system. 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. Typically, these patients manifest weepiness (tears without feelings of grief), temper tantrums, explosive discharges of affect, and confusion. This defensive system is associated with cognitive perceptual disruption (Davanloo 1995b).

The combination of anxiety type and system of defence enables each patient to be located on either the Spectrum of Neurotic Character Structure (Davanloo 1999a) comprising low, moderate, and high resistance or the Spectrum of Fragile Character Structure (Davanloo 1995b).

• Low resistance These patients have had secure attachment relationships for at least the first 7 years of life. Their problems are of recent onset or are mild neurotic disorders. They have no rage in their unconscious. These patients are very responsive to psychotherapy.

• Moderate resistance These patients have had attachment ruptures at between 5 and 7 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 2–5 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 may never have experienced an attachment bond or had their attachment bonds rupture within the first 2 years of life. They cannot withstand the impact of their unconscious feelings in the first interview and require a restructuring process where they are exposed to increasing intensities of their unconscious feelings (Davanloo 1995c). They habitually use regressive and projective defences (e.g., temper tantrums, explosive discharges of affect, self-harm, drug and alcohol misuse, dissociation, and projection).

ISTDP assists the patient to fully experience their dissociated feelings and fantasies and memories that have been dissociated with these feelings. The major interventions are applied through an over-arching framework, the central dynamic sequence (CDS) (Davanloo 1999a) that guides the therapist towards the dissociated feelings and memories. The CDS can be divided into eight overlapping stages. Each stage has definable goals that need to be achieved before progressing to the next stage. 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 dissociated feelings enter conscious awareness. The conscious experience of these dissociated feelings triggers memories associated with early attachment ruptures, enabling these previously dissociated memories and feelings to be resolved.

Aims

The first aim of this paper was to report on the trial application of the eight stages of the central dynamic sequence of ISTDP in the first assessment session and to evaluate the degree to which early attachment trauma was present and acknowledged. The second aim was to assess the nature of the possible relationship between the attachment trauma and this musician’s MPA.