Several years ago, the CEO of a large financial company referred a high-performing partner to me to improve his presentation skills for a large conference. Let’s call him Nathan*. He was a 45-year-old, experienced speaker who had given many presentations and conferences throughout his career. The CEO knew about my work as a performance psychiatrist who works with professional athletes and executives.
For three months, his stress was mounting. He was convinced he would shake in front of the audience and that the presentation would flop. The more he thought about it, the more anxious he became. By the time we met, the presentation was occupying his mind day and night. It was beginning to interfere with his other work. The conference was still a few months away, so we had time to address the challenges.
My approach to performance psychiatry is individualized, but five elements are essential to how I work with people who want to perform at a high level.
Goal Setting
The first is goal setting. Research shows that specific, measurable goals increase motivation and “task performance.” Nathan initially said he wanted to stop being anxious, but anxiety is a normal part of high-level performance and is not always within our control, although it can be reduced. Together, we set a more useful goal: “I feel confident, enthusiastic, composed, and fulfilled while giving my presentation at the Annual Conference, working five hours a week on this preparation and practice, following my strategy, and keeping track of the mental performance strategies I learn.” The goal was never to eliminate fear. It was to help him perform effectively, even when anxiety was present.
Cognitive Behavioral Therapy and Self-Talk
The second element is based on cognitive behavioral therapy, which focuses on the interaction between thoughts, feelings, and behaviors. We discussed the automatic thoughts driving Nathan’s fear. Some of these thoughts included “People will notice that I am trembling,” “I shouldn’t be nervous—I’m a leader and executive,” and “I will embarrass myself.” We examined the evidence for and against these fears and worked through worst-case, best-case, and most-likely scenarios. We also practiced realistic self-talk, which differs from positive thinking. Nathan used short, evidence-based phrases such as “This is practice” and “I did the work,” and repeated them during preparation and on the morning of the event.
Visualization
The third element is visualization, or the mental practice of a behavior. Nathan and I visualized every stage of the presentation, from entering the room to clearly communicating his message, and described it aloud in the present tense. We kept it realistic, rather than imagining a flawless, fear-free performance, and he practiced noticing fear as he continued to speak. We recorded five different visualizations, and he listened to them twice a day.
Emotional Regulation
The fourth element is emotional regulation. When Nathan became overwhelmed, he started imagining worst-case scenarios. I taught him mindful breathing, inhaling through the nose and exhaling longer than the inhale, which can trigger a calming response, along with grounding techniques that bring attention back to the present. He found labeling particularly helpful. Rather than saying “I’m anxious,” he would say “Oh…anxiety is here.” Research suggests that labeling emotions in this way can reduce activity in the amygdala. The goal was never to make the fear go away. It was to notice it, regulate the reaction, and refocus on the task at hand.
Detailed Strategy
The fifth element, and one of the most important, is creating a detailed, written strategy. We made a plan for when and how often Nathan would practice, and what he should focus on at each stage. We continued with the visualizations. He also practiced the presentation out loud. Research supports that the more practice resembles the real event, the better. The goal wasn’t to memorize the presentation. The goal was to become very comfortable executing under pressure.
By the time of the conference, Nathan and I had met for 10 sessions. He still felt nervous as the date got closer, but he now had strategies for working with it, and he understood that some fear was normal and not a sign that something was wrong. On the day of the presentation, he was better prepared than ever before. It went well. The delivery wasn’t perfect, and that was fine. After that, he felt proud, both of how it had gone and of everything he had learned.
This is the work I do with executives and athletes who want to perform at their best under pressure. Fear rarely disappears completely, but with the right approach, it doesn’t have to take the lead.
*Disclaimer: Nathan is not a real client. Details in this document, including identifying information, have been amended to ensure confidentiality.
