a sistematic review of treatments for musical performance anxiety.pdf

8/12/2019 A sistematic review of treatments for musical performance anxiety.pdf

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A Systematic Review of Treatments for Music

Performance Anxiety

DIANNA T. KENNY

Australian Centre for Applied Research in Music Performance, Sydney Conservatorium of Music, The

University of Sydney, Australia

(Received 15 March 2004; revised 18 October 2004; accepted 28 March 2005)

AbstractA systematic review of all available treatment studies for music performance anxiety was undertaken.Interventions were categorised into psychological treatments and pharmacological treatments.Psychological treatments included behavioral, cognitive, cognitive-behavioral, combined treatmentsand other therapies. Issues such as the number of studies in each treatment modality, their samplesizes and the methodological quality of most of the studies reviewed precluded firm conclusions aboutthe effectiveness of any of the treatments assessed for music performance anxiety. The field is inurgent need of larger scale, methodologically rigorous studies to assist the large minority of musicianswho suffer from performance impairing music performance anxiety.

Keywords: Music performance anxiety, behavioral therapies, cognitive therapies, drug therapies,

alternative therapies

A Systematic Review of Treatments for Music Performance Anxiety

Several international reviews of music performance anxiety (MPA) among professional

orchestral musicians indicate that MPA is widespread and problematic (Steptoe & Fidler,

1987). For example, the International Conference of Symphony and Opera Musicians

National US survey (Lockwood, 1989), distributed to 48 orchestras (2,212 respondents)

reported that 24% of musicians frequently suffered stage fright, defined in this study as the

most severe form of MPA, 13% experienced acute anxiety and 17% experienced

depression. A Dutch study (van Kemenade, van Son, & van Heesch, 1995) reported that

59% of musicians in symphony orchestras reported performance anxiety severe enough to

impair their professional and/or personal functioning. James (1998), in a survey of 56

orchestras, found that 70% of musicians reported that they experienced anxiety severe

enough to interfere with their performance, with 16% experiencing this level of anxiety

more than once a week. A recent study indicated that MPA is not limited to orchestral

musicians, showing that opera chorus artists are also prone to high levels of performance

anxiety (Kenny, Davis & Oates, 2004). It is not difficult to imagine that most performers,

Correspondence: Professor Dianna T Kenny, Director, Australian Centre for Applied Research in Music

Performance, Sydney Conservatorium of Music, The University of Sydney, NSW, Australia. E-mail:[email protected]

Anxiety, Stress, and Coping,

September 2005; 18(3): 183/208


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by the very nature of their profession, would be affected by the general stresses related to

having to perform under conditions of high adrenalin flow, anxiety, fatigue, social pressure,

and financial insecurity (Lehrer, Goldman, & Strommen, 1990, p. 48). Sternbach (1995)

described the working conditions of professional musicians as generating a total stress

quotient that far exceeds that observed in other professions. However, since not all

performers suffer the same degree of MPA, or indeed report the same levels of occupational

stress, individual differences in a range of psychological characteristics are likely to accountfor variations in the degree to which musicians experience symptoms.

A large number of treatment modalities (e.g., behavioral, cognitive, pharmacological and

complementary) has been developed for music performance anxiety (MPA). However, a

review of this literature indicates that the field is still in its infancy with respect to the

conceptual and theoretical formulations of the nature of MPA and its empirical

investigation. The terminology surrounding the concept is also problematic. For example,

MPA is sometimes referred to as stage fright and the terms are used interchangeably, while

others view stage fright as an extreme form of MPA. Recently, a number of integrative

theories have been proposed and these have the potential to direct future research into the

aetiology and treatment of the condition.Barlows (2000) model of anxiety may have heuristic value in understanding performance

anxiety in general and MPA in particular. This model proposes an integrated set of triple

vulnerabilitiesthatcanaccountforthedevelopmentofananxietyormooddisorder.Thesearea:

i. generalized biological (heritable) vulnerability;

ii. generalized psychological vulnerability based on early experiences in developing a

sense of control over salient events, and a

iii. more specific psychological vulnerability whereby anxiety comes to be associated with

certain environmental stimuli through learning processes such as respondent or

vicarious conditioning.

Barlow argues that genetic predisposition and sensitizing early life experiences may be

sufficient to produce a generalized anxiety or mood (depression) disorder. The third set of

vulnerabilities appears necessary to produce focal or specific anxiety disorders such as panic

disorder or specific phobias. For example, social evaluation may be accompanied by

heightened somatic sensations that become associated with a perceived increase in threat or

danger. In the case of young performers who are high in trait anxiety (the expression of the

generalized biological vulnerability), who come from home environments in which

expectations for excellence are high but support for achieving excellence is low (generalized

psychological vulnerability), exposure to early and frequent evaluations and self-evaluations

of their performances in a competitive environment (specific psychological vulnerability)may be sufficient to trigger the physiological, behavioural and cognitive responses

characteristic of music performance anxiety. Anxiety may be triggered by conscious,

rational concerns or by cues that trigger, unconsciously, earlier anxiety producing

experiences or somatic sensations. Once triggered, the person shifts into a self-evaluative

attention state, in which self-evaluation of perceived inadequate capabilities to deal with the

threat, in this case, the imminent performance, is prominent. Attention typically narrows to

a focus on catastrophic cognitive self-statements that disrupt concentration and perfor-

mance. In this respect, MPA may share commonalities with social anxiety and its extreme

form appears phenomenologically similar to social phobia. One could argue that the

conditions under which one performs, that is, the degree of social evaluative threatperceived by the performer, is the defining feature of social phobia. Those perceiving most

184 D. T. Kenny


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threat are likely to experience the greatest anxiety, and those who are most anxious are more

likely to perceive performance conditions as more threatening.

In the music research literature, MPA is commonly viewed as a constellation of three

interactive yet partially independent factors: cognitions, autonomic arousal, and overt

behavioral responses (Craske & Craig, 1984; Lederman, 1999; Salmon, 1990). There is

empirical support for this three-factor model of music performance anxiety. Craske and

Craig (1984) demonstrated greater response synchrony among high trait, compared to lowtrait anxious performers, particularly when performing in a stressful situation involving

evaluation of their performances by expert judges. Low anxious individuals experienced

elevated heart rate but not cognitive or behavioral symptoms in the performance condition

when compared to a warm-up baseline condition in contrast to high anxious individuals

who experienced elevations in all three areas. High levels of self-reported performance

anxiety were also related to lower levels of confidence.

Researchers are in dispute regarding the nature of this interaction. Zinn, McCain and

Zinn (2000) argue that performance anxiety is primarily a psychophysiological event in

which the autonomic nervous system initiates and maintains MPA. Alternatively, Kirchner

(2003) maintains the symptomatic aspects of MPA are activated by the perception of threatby the performer, and not the autonomic nervous system. Wilson (2002) describes threat

perception as an interaction of three variables that play important roles in the experience of

distressing anxiety: the performers constitutional and learned tendency to become anxious

in response to situations of social stress (trait anxiety); the degree of task mastery, and the

degree of situational stress, where high anxiety is more likely to be experienced in situations

that are socially or environmentally instructive.

Theorizing in the area of test anxiety and academic competence is instructive demanding.

Three similar processes are considered relevant to performances in examinations: cognitive-

attentional processes (e.g. worry, task-irrelevant thinking, negative self-preoccupation),

cognitive skills (study habits) and self-efficacy or the exercise of human agency (how aperson influences his/her thoughts, behaviours, goals, and outcomes). In a simultaneous

test of these three theories, Smith, Amkoff, and Wright (1990) found that cognitive-

attentional processes accounted for most of the variance in both performance on tests and

test anxiety, but that both cognitive skills and self-efficacy measures added additional

unique variance. These findings suggest that multi-modal interventions are needed to

address the multiple difficulties experienced by test anxious individuals. These formulations

are directly relevant to our understanding and treatment of music performance anxiety.

The following review of treatment for MPA reflects the differing theoretical arguments

regarding the etiology of MPA, with some focusing on behavioral change, some on cognitive

change, others on reduction of physiological symptoms through the use of pharmacotherapy,and some on idiosyncratic formulations. Assessment of their relative effectiveness may

simultaneously cast light on theoretical issues, as well as provide practitioners and researchers

with a basis for intervening more effectively in assisting musicians who suffer this condition.

The aim of this paper, therefore, is to provide a systematic review of treatments for music

performance anxiety, to identify the problems with this research and to make recommenda-

tions for future research.

Method

The aim of the search was to provide the most comprehensive list possible of both publishedand unpublished primary studies in the area of MPA interventions as the precision of the

Treatment review of music performance anxiety 185


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estimate of effectiveness depends on the information obtained, and the care taken to avoid

publication bias. Because this constitutes the first systematic review of treatments for music

performance anxiety, broad inclusion criteria were adopted.

To identify as many relevant studies as possible, several databases were searched. The

search used gateways Ovid and Science Direct to access data bases Journals@Ovid Full

Text, MEDLINE (1966 to October 2002), CINAHL (1982 to October 2002), ERIC

(1966- October 2002), PsychINFO (1967-October 2002) and EMBASE (1966-October

2002). A search of Dissertation Abstracts International was also conducted, with the last

search for relevant dissertations made in October 2003. The search history followed the

protocol recommended by the Cochrane Library.

The search included treatment studies for music performance anxiety in student or

professional musicians. Studies were included if they had a control group, although a couple

of preand post-test designs were included because they represented the only available

studies in a particular treatment modality. Articles were limited to English. Most studies

and reviews were published after 1985, except for the drug studies, which were produced

from the late 1960s to the mid 1970s. There have been no recent pharmacological studies

on MPA due to the greater ethical constraints on research that have been implemented in

the past decade.

Keywords for the search strategy in this review were music, musicians and performance

anxiety. Alternative keywords such as stage fright were also included. A second set of

keywords defined study methodology: randomized controlled trial; double blind method;

therapy; treatment; comparative studies; and evaluation studies. These were combined with

keywords music performance anxiety. A third set of keywords was used to search for specific

treatment types. Non-drug studies were searched under cognitive therapy, cognitive

restructuring, self-instruction, cognitive behaviour/behavior therapy, behaviour/behavior therapy,

behaviour/behaviour rehearsal, systematic desensitization, stress inoculation, (deep) muscle

relaxation, breathing, meditation, biofeedback, Alexander Technique (see p. 19 for definition),

music therapy and hypnotherapy. These keywords were also cross-referenced with music

performance anxiety. The same search strategy was repeated for each database.

For drug studies, the keywords were beta-blocker [Beta blockers block the effect of

adrenaline (the hormone norepinephrine) on the bodys beta receptors. This slows down

the nerve impulses that travel through the heart. As a result, the resting heart rate is lower,

the heart does not have to work as hard and requires less blood and oxygen] and SSRI [ie

drugs belonging to the group known as selective serotonin reuptake inhibitors (SSRI) are

antidepressant medications, examples of which are sertraline (Zoloft) and fluoxetine

(Prozac)].

Dissertation Abstracts International (DAI) produced 101 dissertations, of which 13 met

inclusionary criteria and were retrieved. Many of the dissertations did not appear on other

electronic lists and these proved to be a rich source of data. All retrieved articles were hand

searched for other relevant papers that may have been missed in the search strategy. An

additional nine articles were located using this method. Additional references were retrieved

by hand searching. This search yielded 125 articles.

Abstracts were assessed for relevance to the search criteria. Key review studies were

identified, with a preference for critical and systematic reviews. Brodsky (1996) and Nube

(1991) were most useful. Treatment studies were divided into drug and non-drug studies,

and these were further subdivided according to the specific form of therapy used. These

included drug type and dose for the drug studies, and hypnotherapy, Alexander technique,

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behavioral interventions, cognitive interventions, cognitive-behavioral interventions, other

combinations of therapies, and other therapies for the non-drug treatment studies.

None of the studies were true randomised controlled trials (although the majority

randomly assigned subjects to groups) and very few were directly comparable in terms of

methodology, subjects, and outcome measures, so a meta-analysis was not possible.

However, some of the studies included sufficient data to make it possible to calculate effect

sizes. Cohens d is a measure of the distance between the means (of experimental andcontrol groups). Contrary to the p value, effect size measures are not sensitive to sample size

and this is an advantage in assessing the effectiveness of treatment in studies with small

numbers. According to Cohen (1977), d/0.20, 0.50, and 0.80 constitute small, medium,

and large effects respectively.

Effect sizes are provided in Tables I/VI. The formula d/M1-M2/spooled was used to

calculate Cohens d in each instance. Where a repeated measures design was employed,

post (or follow-up) means and standard deviations of the experimental and control groups

were used to calculate Cohens d. Where a repeated measures design was employed, but no

control group was involved or control group data were unavailable, pre and post (or follow-

up) means and standard deviations of the experimental group were used to calculate

Cohens d. Where a simple two group design was employed, the means and standard

deviations of the experimental and control groups were used to calculate Cohens d. Where

insufficient data were provided or where no significant differences were found, effect sizes

were not calculated. These calculations are supplemented with a comprehensive narrative

review of all available outcomes.

Results

Behavioral Interventions

Six studies (see Table I) assessed the therapeutic effect of behavioral treatments on MPA,

two of which used samples specifically selected because they were high in MPA. Four of the

six studies provided sufficient detail for some effect sizes to be calculated. The interventions

assessed included systematic desensitization, progressive muscle relaxation, awareness and

breathing and behavioural rehearsal.

Kendrick, Craig, Lawson, and Davidson (1982) compared behavior rehearsal and

cognitive-behavioral treatments for MPA. The behavior rehearsal group did not show

improvements in state anxiety or subjective stress, but they did show significant pre- to

post-treatment improvements in performance quality and self-statements about perfor-

mance anxiety (as measured by the Performance Anxiety Self-Statement Scale: PASS). Thebehavior rehearsal group also showed greater pre- to post-treatment improvements in the

visual signs of anxiety than controls, although the cognitive-behavioral group showed an

even greater improvement than the behavior rehearsal group on this outcome measure.

Kendricks study suggests that behavior rehearsal may be an effective form of treatment for

MPA for some outcome measures (STAI, subjective stress scale) (Spielberger, 1983) but

not others (self-efficacy and visual signs of anxiety) for which a CBT intervention was

superior. Sweeney and Horan (1982) (see Table IV) found that the behavioral technique of

cue-controlled relaxation led to improvements in anxiety, MPA, heart rate, and perfor-

mance quality in students suffering from MPA, but that CBT was not significantly more

effective for these outcome measures than this simple behavioral treatment. Richard (1992)(see Table V) failed to find a therapeutic effect with cue-controlled relaxation but this



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failure may have been due to insufficient statistical power, given the very small sample size

in his study.

Reitman (1997) examined the therapeutic effect of two systematic desensitization

procedures, and found that the treatment groups did not differ significantly to a waiting

list control group on any of the anxiety, heart rate, or performance quality outcome

measures employed. However, Reitmans study is weakened by a very small sample size (18

subjects across 3 groups), and thus the lack of significance reported may reflect insufficient

statistical power.

Four other studies (three of which are dissertations) assessed behavioral treatments for

MPA on music students. Grishman (1989) and Mansberger (1988) used standard muscle

relaxation techniques, Wardle (1969) compared insight/relaxation and systematic desensi-

tisation techniques, and Deen (1999) used awareness and breathing techniques. These

studies indicated pre- to post-treatment improvements on self-report measures of

performance anxiety (Deen, 1999; Grishman, 1989; Mansberger, 1988) and heart rate

(Grishman, 1989; Wardle, 1969), but not performance quality (Deen, 1999; Mansberger,

1988; Wardle, 1969). Again, demand characteristics may have confounded these results due

to the transparent nature of the research and the reliance upon self-report measures of

MPA. Further, Mansberger (1988) obtained no pre-intervention measures.

In summary, behavioral treatments do appear to be at least minimally effective in the

treatment of MPA, although the heterogeneity of the treatment approaches employed

makes it difficult to isolate consistent evidence for the superiority of any one type of

behavioral intervention.

Cognitive Interventions

Two studies (see Tables II and IV) assessed the therapeutic effect of cognitive techniques

alone on MPA. A dissertation by Patston (1996) reported a comparison of cognitive (e.g.

positive self-talk, etc.) and physiological strategies in the treatment of MPA. No significant

improvements on vocal and visual manifestations of performance anxiety were found for

either treatment or control groups. However, the sample consisted of only 17 opera

students who were not specifically selected on the basis of their MPA severity, and the

intervention was conducted by the author, a singer and teacher, who had no training in

psychology. Consequently, this lack of significance may reflect a floor effect in that subjects

may not have been sufficiently anxious pre-treatment for a reduction in anxiety to be

detected, a lack of statistical power, or problems with the integrity of the intervention.

Further, standardised outcome measures were not employed, and the author does not make

it clear how subjects were assigned to groups.

In a methodologically superior study, Sweeney and Horan (1982) (Table IV) found that

cognitive restructuring techniques may be helpful in treating music students suffering from

MPA. They found that a treatment group showed significantly greater pre- to post-

treatment improvements on MPA, anxiety, performance quality, and heart rate than

controls. All effect sizes were large for these outcomes. While this study gives tentative

support cognitive strategies in the treatment of MPA, further studies are clearly needed. A

dissertation by Roland (1993) (Table III) suggested that self-instruction alone may be

useful in reducing MPA, although his failure to include a control group is a major

methodological weakness of his study.

188 D. T. Kenny


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Table I. Summary of Behavioral Interventions for Music Performance Anxiety

Author Year Country SubjectNo

Subjecttype

Studydesign

Treatment Control

Deen 1999 (PhDdissertation)

USA 39 Musicstudents

*2 (Groups)/2(Time) repeatedmeasures design*Randomlyassigned togroups.

Awareness/breathingexercise (6weeks practicewith a tape)

No tape Pa(Pq*ppe

Grishman 1989 (PhDdissertation)

USA 41 (51%female)

Advancedmusicstudents andprofessionals

*2 (Groups)/2(Time) repeatedmeasures design*Randomlyassigned togroups withininstrumentfamily.

Modifiedjacobsonianprogressivemuscularrelaxation(6/2 hrsessions over3 wks)

Waiting list PaQSSqMaq

(H*p

Kendricket al.

1982 Canada 53 (91%female)

Studentpianistswith MPA


Behaviorrehearsal (3weekly sessionsof 1.5/2 hrseach/homework)

1. CBT(self-instruction,attention-focusingtechniques) (3weekly sessionsof 1.5/2 hrseach/homework)2. Waiting list

SSSEPPsMPfP

AmVaPq*p


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Table I (Continued)


Subjecttype

Studydesign

Treatment Control

Mansber-ger

1988(M. MusicDissertation)

USA 19 (63%female)

Musicstudents

*Simple 2 groupcomparison*Did not

specifically statewhether or notgroup assignmentwas random

Deep musclerelaxation (3/90 min weekly

sessions)

No contact Sa(

LsSpePq*tatrjuo

Reitman 1997 (PhDdissertation)

USA 18 (72%female)

Musicstudentswith MPA


1. Verbalcopingsystematicdesensitization2. Musicassisted copingdesensitization(8/75 minweekly groupsessions)

Waiting list sHSPAQ(

Wardle 1969 USA 30 Musicstudents(Brassplayers)

*3 (Groups)/2(Time) repeatedmeasures design

1. Systematicdesensitisation(7/40minsessions)2. Insight-relaxation (7/40 minsessions)

Orientationsession*Randomlyassigned togroups

HWPBoPr*p


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Cognitive-behavioral Interventions

Three studies (see Table III) assessed the therapeutic effect of cognitive-behavioral

strategies on MPA. Harris (1987), Roland (1993), and Kendrick et al. (1982) all reported

that standard CBT techniques were effective in the treatment of MPA in students

specifically selected for study because of the severity of their MPA. Two of the three

studies (Kendrick et al., 1982 & Roland, 1993) reported moderate to strong effect sizes forimprovement in performance quality (Harris did not assess performance quality). Kendrick

et al. (1982) found that CBT was superior to behavioral rehearsal in terms of improvements

in expectations of personal efficacy and visual signs of anxiety. Harris (1987) and Roland

(1993) reported that CBT led to reductions in state anxiety as measured by the STAI,

although Kendrick et al. (1982) failed to find a significant difference between treatment and

control groups on this measure.

The evidence for improvements in MPA following CBT is quite consistent, although

further studies with larger samples are needed to confirm this evidence. While CBT may be

superior to drug therapy in treating MPA (see Clark & Agras, 1991), currently there is little

evidence to suggest that it is superior to either standard behavioral or cognitive techniques

alone.

Combined Interventions

A number of studies (see Table IV) have examined the effect of combining treatment

approaches. Only one of the four studies (Clark & Agras, 1991) provided sufficient data to

permit the calculation of effect sizes. Clark and Agras (1991) found that cognitive-

behavioral therapy was superior to drug therapy with buspirone in the treatment of MPA,

and also that improvement in performance quality, for which a strong effect size was found

(1.64), was greater in a CBT/placebo group than in a placebo group alone. [It should be

noted that since buspirone has failed in studies of social phobia to separate from placebo, itis not appropriate to describe the CBT/buspirone as a combined treatment. Saying that

CBT/buspirone in this context is not conceptually different from saying that CBT/

placebo]. Finally, Sweeney and Horan (1982) found that behavioral, cognitive, and

cognitive-behavioral treatments were all effective in treating students suffering from

MPA, when compared to a control group, but that no significant differences were apparent

between the three types of treatment. This was the case for improvements in general

anxiety, MPA, and performance quality. The only difference between treatments was with

respect to heart rate, where the behavioral and cognitive treatments alone led to greater pre-

to post-treatment improvements than the combined CBT treatment.

Brodsky and Sloboda (1997) assessed counseling, counseling/relaxation, and counse-ling/relaxation/vibro-tactile sensations in the treatment of MPA.

This study had no control group, was not conducted with a sample of MPA sufferers, and

did not report the statistics required to clearly determine the nature of any group

differences. Other studies have assessed the combined effect of behavioral, or cognitive-

behavioral, and biofeedback techniques on MPA. Niemann, Pratt, and Maughan (1993)

found that students with MPA showed significantly greater pre- to post-treatment anxiety

reduction than controls when treated with behavioral and biofeedback techniques, a finding

consistent with that of Nagel, Himle, and Papsdorf (1989), who employed a combined

CBT/biofeedback treatment. Sweeney-Burton (1997) was unsuccessful in reducing

anxiety and improving musical performance following a similar behavioral/biofeedbackintervention, but this study was conducted with music students who had not specifically



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Table II. Summary of Cognitive Interventions for Music Performance Anxiety

Author Year Country S ubject

No

Subject

type

Study

design

Treatment Control

Patson 1996

(M.Music

dissertation)

Australia 17 (71%

female)

Opera

students

*3 (Groups)/2

(Time) repeated

measures design

*Did not

specifically say

if group

assignment

was random.

Cognitive

strategies (e.g.

positive

self-talk etc.)

1. Physiological

strategies (8/

.5 hr sessions

over 9 days)

2. Control

group (8/.5 hr

walks over 9

days)


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Table III. Summary of Cognitive-behavioral Interventions for Music Performance Anxiety


Subjecttype

Study design Treatment Control Outcomsur

Harris 1987 USA 17 (47%

female)

Students

withMPA

*2 (Groups)/3

(Time) repeatedmeasuresdesign*Did notspecifically say ifassignment togroups wasrandom.

6/2 hr weekly

sessionsinvolvingcognitiveself-Instruction,relaxationtraining,imagery &behavioralrehearsal

Waiting list PAI

STAI-SSTAI-TTest AnxInventoryAnxiety rfrom teac*Measureand post-treatment3 mth fol

Kendricket al.

1982 Canada 53 (91%female)

Studentspianistswith

MPA

*3 (Groups)/3(Time) repeatedmeasures

design*Randomlyassigned togroups.

CBT (self-instruction,attention-

focusingtechniques) (3weekly sessionsof 1.5-2 hreach/homework)

1. Behaviorrehearsal-3weekly sessions

of 1.5-2 hrseach/homework2. Waiting list

STAISubjectivScale

ExpectatiPersonal Scale forMusicianPerformaAnxietySelf-StateScale (PAVisual siganxietyPerformaquality

Roland 1993(PhD

Dissertation)

Australia 25 (88%female)

Studentpianists

*3 (Groups)/3(Time) repeated

measuresdesign*Randomlyassigned togroups

1. Selfinstruction (SI)

2. Progressivemuscle relaxa-tion(R)3. Combinationtreatment (6/1hr weeklysessions; 2hrsessions forcombin.)

None Perfor-mance quality

Measured atpre-test racital(1 wk beforetreatment),post-test recital(1 wk aftertreatment), and6 wkfollow-up.

STAI-SMusical

PerformaAnxiety SStatemen(MPASS)Performaquality*Measurepre-test rwk beforetreatment


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Table III (Continued)


Subjecttype

Study design Treatment Control Outcomsur

33 (88%female) Music

studentswithMPA

*3 (Groups)/3 (Time)repeatedmeasuresdesign*Randomlyassigned togroups.

1. StandardCBT2. ModifiedCBT (includedpre-performanceroutine & visualrehearsal etc.)(4/2 hr weeklysessions)

Waiting list

post-test (1 wk aft

treatmenwk followSTAI-S

MPASS

Self-efficPerformaqualityHR*Measurpre-test r(1 wk beftreatmenpost-test (1 wk afttreatmen5 wk follo


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been selected for their high MPA and thus the lack of significance may be due to a floor

effect. In summary, there is little evidence to suggest that combined treatment approaches

enhance improvements in MPA over and above those offered by single treatments, but

further research in this area is needed.

Other Interventions

Meditation. Although over 2,000 studies on meditation were identified in PsycInfo and

Medline databases, only one study (Chang, 2001) examined the effects of meditation on

music performance anxiety. Meditation was defined as a self-regulatory practice designed to

train attention in order to bring mental processes under greater voluntary control (Walsh,

1995, p. 388). It focuses on the use of attention, thought or concentration as a means to

achieve understanding or insight (Goleman & Schwartz, 1976). In this study, 19 music

students (mostly pianists) were randomly assigned to a meditation or control condition. Pre

and post performance anxiety measures indicated very modest support for the role of

meditation in reducing performance anxiety. Interestingly, there were no significant

differences between the groups on measures of cognitive interference (mind wandering,intrusive thoughts) that the meditation intervention specifically addressed. Once again, the

small sample size may have obscured potentially significant effects and a larger study with a

more intensive treatment intervention is needed to address this issue.

Biofeedback. McKinney (1984) assessed the use of peripheral skin temperature training

using biofeedback on self-reported MPA and quality of musical performance in 32 male

wind instrumentalists. He found that peripheral skin temperature training had no effect on

peripheral skin temperature or anxiety levels assessed by the STAI-S. There was some

evidence that biofeedback may be useful in improving performance quality (effect size/

.83). This study was not conducted with subjects specifically selected because of their highlevel of MPA and effects may have been more pronounced with subjects suffering higher

performance anxiety. Like Richard (1992), see below), the main effect of time (that is,

repetition of the anxiety provoking performance at post-test) was the most salient result in

this study, indicating that familiarity with the requirements of the task and practice effects

were more effective in reducing performance anxiety.

Music therapy. Montello (1989) and Montello, Coons, and Kantor (1990), assessed the

effect of a 12-week music therapy intervention on freelance musicians suffering from MPA

in two separate studies. The intervention consisted of musical improvisation, three musical

performances in front of an audience, awareness techniques and verbal processing of theiranxiety responses. The outcome measure in the first study was self-ratings of confidence

about performance ability. In the second study, a replication of the first, an attentional

control group and additional outcome measures were included. These were the Narcissistic

Personality Inventory (NPI), and judgments of raters regarding improvements in the

musicality of subjects performances as a function of treatment. The 10 experimental

subjects became significantly more confident (effect size/2.46) as performers as measured

by the Personal Report of Confidence as a Performer Scale (PRCP) (Appel, 1976) and less

anxious as measured by the Spielberger State/Trait Anxiety Inventory (STAI) than the 10

waiting-list control subjects after music therapy intervention. In Study II, experimental

subjects became significantly less self-involved, less stressed and more musical after groupmusic therapy intervention as compared to attentional control subjects (all effect sizes /2).



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Table IV. Summary of Combined Interventions for Music Performance Anxiety


Subjecttype

Study design Treatment Control Outco

Brodsky&Sloboda

1997 Israel/UK

54 (50%femalesapprox.)

Professionalsymphonyorchestra

musicians

*3(Groups)/3(Time) repeatedmeasures design

*Subjectsmatched beforebeing randomlyassigned to oneof threeinterventions

1. Counselling2. Counselling/relaxation/

listening to music3. Counselling/relaxation/ musicand music-generatedvibrationsensations

None GeneraQuestio(GHQ-

STAI

DerogaProfile POMS

MaslachInventoAppraisPerform(AMPSMusic PStress S*Measupost-tremonth F

Clark &Agras

1991 USA 29 Musicians(includingfull-timeprof) withsocialphobia(with regardto perfor-mancesituations).

*4 (Groups)/2(Time)repeatedmeasuresdesign*Randomlyassigned togroups.*Double blindstudy.

1. CBT/Placebo(P)2. CBT/Buspirone3. Buspirone(CBT/5 weeklymeetings) [Busp/5mg tab, up to12/day, for 6weeks]

Placebomedication

Subjectduring performSubjectduring Heart rmusicalHeart rspeechSelf StaQuestioPersonaconfide

performMusica*all mepost tre(Personconfidefollow-u


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Table IV (Continued)


Subjecttype


Nagel etal.

1989 USA 20 (60%female)


*2 (Groups)/2(Time)repeatedmeasures design*Randomlyassigned togroups.

Progressive musclerelaxation,cognitive therapy,biofeedbacktraining (6 weeklygroup sessions/6weeklybiofeedbacksessions)

Waiting list PerformInventoSTAI-TSTAI-STest AnAutonoQuestioRationaInvento*Measupost-tre

Niemannet al.

1993 USA 18 (78%female)


*2 (Groups)/2(Time)repeatedmeasures design*Assignment togroups based onstudy scheduleof students.

6/35 minbiofeedbacksessions/6/1 hrgroup meetings(training in copingstrategies; musclerelaxation,breathing

awareness,imagery) &coinciding practiceof the strategieswith sedativemusic duringindividualbiofeedbacktraining.

Waiting list STAI-S

Facilitadebilitascales *and pos


16/27

Table IV (Continued)


Subjecttype


Sweeney& Horan

1982 USA 49 (49%female)


*5 (Groups)/2(Time)repeatedmeasures design

*Matched bypretest scoresthen randomlyassigned togroups.

1. Cue-controlledrelaxation (CCR)2. Cognitiverestructuring (CR)

3. CCR/CR (Allhad 6 weeklysessions of 60 mineach)

1. Standardtreatment(ST)control

(MusicalAnalysisTraining)2. Waitinglist

AchieveTest ScMusicaCompe

BehavioAnxietyPulse raPiano PAnxietyAnxiety(AD)*Measupost-tre

Sweeney-Burton

1997 (D.Ed.Dissertation)

USA 30 (43%female)

Musicstudents

*2 (Groups)/2(Time)repeatedmeasures design*Did notspecifically sayif groupassignment wasrandom.

Diaphragmaticbreathing,progressive musclerelaxation,autogenic training,biofeedback.

No training STAI-Tresults for S.AdjudicPerformForm*Measupost-tre


17/27

The holistic group music therapy intervention was recommended as a way to reduce

performance anxiety by helping musicians to: (1) become more aware of the underlying

dynamics of performance anxiety; (2) experience unconditional acceptance and support in

a safe group environment; (3) bond with their music-selves; (4) transform anxiety through

creativity (reparation); and (5) bond with others in the spirit of musical community (p. 4).

Despite the small sample size, there were many methodological strengths in this study,

including the choice of subjects with severe MPA. This approach appears to warrant furtherconsideration as a treatment for music performance anxiety in experienced, professional

musicians.

Ericksonian resource retrieval. This technique refers to the use of unconscious mechanisms

within the individuals personal history to adapt to a current life challenge. Resources are

defined as automated patterns of feeling, perceiving and behaving (Lankton & Lankton,

1983, p. 121). Resource retrieval is a process oriented intervention that focuses on assisting

the person to access existing strengths rather than teaching him/her new skills. The

technique involves identification of current life challenge, identification of relevant personal

resource, cognitive and emotional re-experiencing and practicing of resource, andexperience of the current challenge in the context of the cognitions and emotions related

to the resource. Richard (1992) assigned 21 volunteer music students to one of three

conditions: Ericksonian resource retrieval, cue-controlled relaxation and a wait list control.

He found that Ericksonian resource retrieval reduced MPA at about the same rate as that of

cue-controlled relaxation. However, repeated measures analysis found that all three groups

improved over time on measures of anxiety and confidence as a performer. Treatment and

control groups did not differ in pre- to post-treatment improvements on self-reported MPA,

performance quality, or performer confidence. Small subject numbers and attrition from

the treatment conditions make the results difficult to interpret, and a larger replication with

better compliance is needed to fully assess the potential of this technique in reducing MPAand in improving jury performances.

Hypnotherapy. Only one study (Stanton, 1994) has assessed the therapeutic effect of

hypnotherapy on music performance anxiety (MPA). In this study, a group of music

students suffering from MPA were given two 50-minute sessions of hypnotherapy, while a

control group of students discussed their performance and anxiety with their lecturer for a

similar length of time. The Performance Anxiety Inventory (PAI) was administered pre and

post-treatment, and at 6 month follow-up. A significant pre- to post-treatment reduction in

MPA (as measured by the PAI) was found for the treatment group, but not the control

group, and a further significant reduction was found at 6 month follow-up. This study wasweakened by the fact that the criteria for subject selection were somewhat subjective, with

students selected by their lecturer for inclusion if they appeared to be prone to MPA.

Stanton also suggested that some experimental subjects may have discussed the study with

control subjects both during and after the treatment period, giving rise to a potential

confound. In summary, Stantons findings suggest that hypnotherapy may be useful in the

treatment of MPA, but further methodologically superior studies are required.

Alexander Technique. Alexander Technique is an educational process in which the student

learns a set of skills that result in lessening of the areas of tension in the body, so that

movement becomes easier and less effortful. The aim is to cultivate a more naturalalignment of head, neck and spine that has associated with it qualities of balance, strength



18/27

and coordination. The method aims to teach conscious and voluntary control over posture

and movement and to undo involuntary muscle tension. The Alexander Technique is a

method for eliminating unwanted muscular patterns or habits that interfere with smooth

performance. For a performer, the technique is a method for using kinaesthetic cues, the

sensations of tension, effort, weight, and position in space, in order to organize ones field of

awareness in a systematic way.

Only one study has assessed the therapeutic effect of the Alexander Technique on MPA.In this study (Valentine, Fitzgerald, Gorton, Hudson, and Symonds, 1995), one group of

music students were given 15 lessons in the Alexander Technique, while a control group

received no lessons in the Alexander Technique. The outcome measures were heart rate,

musical quality, technical quality, the Nowlis Mood Adjective Checklist (NMAC), and the

Music Performance Anxiety Self-Statement Scale (MPASS). Measures were taken at

audition, in class prior to treatment, in class post-treatment, and at final recital. Controls

showed a greater increase in heart rate variance from audition to recital than the treatment

group. The treatment group showed pre- to post-treatment improvement in musical and

technical quality, but the effect sizes were weak (.25 and .13 respectively), and an increase

in scores on the active and warm-hearted scales of the NMAC, whilst controls showed theopposite pattern of results. The treatment group also showed a greater pre- to post-

treatment decrease in anxiety than controls, and an increase in positive attitude to

performance (as measured by the MPASS). These findings provide very weak evidence that

the Alexander Technique may be effective in improving the quality of performance and

mental state of the performer (insufficient data to calculate effect size), and may help to

modulate increased variability of heart rate under stress. However, a number of

methodological weaknesses need to be highlighted. Subjects were not specifically selected

for their high levels of MPA, and thus the extent to which the results can be generalized to

genuine MPA sufferers is unclear. Further, the sample size was inadequate, and the design

lends itself to confounding by demand characteristics. Data were insufficient to calculate

effect sizes for three of the five outcome measures. Given these shortcomings and the

scarcity of studies that have investigated the efficacy of the Alexander Technique in treating

MPA, any conclusions must at this stage be tentative.

In summary, there are too few studies available that provide any evidence for the

effectiveness of these treatment modalities from which to draw conclusions. Better and

larger studies are needed before any of these treatments can be confidently recommended to

anxious musicians.

Drug Interventions

Lehrer (1987) and Nube (1991) have published comprehensive reviews of the impact ofbeta-blockers on music performance anxiety and a brief overview of other drugs, such as

anxiolytics and antidepressants has been provided by Sataloff, Rosen, and Levy (2000).

Accordingly, only a brief summary of drug interventions will be provided in this paper and

the interested reader is referred to these earlier papers for a more comprehensive review.

Beta-blockers have become increasingly popular among performers in recent years. For

example, Lockwood (1989), in a survey of 2,122 orchestral musicians, found that 27% used

propranolol to manage their anxiety prior to a performance; 19% of this group used the

drug on a daily basis. Performers prefer beta-adrenoceptor blocking agents over anxiolytic

drugs (egdiazepam) because of their reduced impact on central functions such as mental

alertness and cognitive function. Beta blockers appear to be most effective for thosemusicians who report primarily somatic manifestations of their anxiety (e.g. palpitations,

200 D. T. Kenny


19/27


20/27

Table V (Continued)


Subjecttype

Study design Treatment Control Outcome m

assigned togroups.

2. Cue-controlledrelaxation(6/45 min

weeklysessions)

Performer Cognitive sassessmentPerforman

competenc

Stanton 1994 Australia 40 Musicstudentswith MPA

*2(Groups)/3(Time)repeatedmeasuresdesign*Paired on ba-sis of PAIscores thenrandomlyassigned togroups withineach pair.

Hypnotherapy(2/50minsessions 1week apart)

Discussionwith lecturer(matched forsession length)

PerformanInventory (

*Measuredand 6 mon

Valentineet al

1995 UK 25(84%female)

Musicstudents

*2 (Groups)/4 (Time)repeatedmeasuresdesign*Randomly as-signed togroups

AlexanderTechnique(15 lessons)

No lessonsin AT

Heart rateMusical quTechnical qNowlis MoAdjective CMusic PerfAnxietySelf-Statem*Most meaat auditionprior to trein class foltreatment,recital.


21/27

hyperventilation, tremor, trembling lips, sweating palms etc) (Gates et al., 1985; James &

Savage, 1984) and less effective for those experiencing more cognitive or psychological

effects, such as low self-esteem, social phobias, or generalised free floating anxiety

(Lehrer, 1987).

Nube (1991) identified nine studies examining the effects of various beta-blockers

(Atenolol, Metopolol, Nadolol, Oxprenolol, Propranolol, Pindolol) on MPA. Two

additional studies were identified (Berens & Ostrosky, 1988; Liden & Gottfries, 1974)bringing to 11 the total number available for review. Generally, the sample size in these

studies is small (n/8-30 subjects) and most used subjects who had not been formally

diagnosed with music performance anxiety. Three used student musicians, two used

professionals and four used a combination of students and professionals. Drug type and

dosages varied as did time of administration and outcome measures, making meta-analysis

impossible. However, in seven of the nine studies reported by Nube (1991) and in both

additional studies, symptoms associated with sympathetic overactivity was significantly

improved by medication. The findings regarding the effects of beta blockers on other

outcome measures were less conclusive. For example, James, Griffith, Pearson, and

Newbury (1977) and James, Burgoyne, and Savage (1983) reported a positive impact ofmedication on intonation in string players while Pearson and Simpson (1978), (as cited in

Nube, 1991) found no difference in intonation between medicated and unmediated

musicians. Similarly, results were different for different drugs / both propanolol and

oxprenolol reportedly reduced anxiety and bow shake while nadolol had no such effect. For

those studies that used subjective as well as physiological measures to assess outcome, most

reported no effect on measures such as perception of performance (Brantigan et al., 1982;

Gates et al., 1985; James et al., 1983), state or trait anxiety (Brantigan et al., 1982; Gates et

al., 1985), stage fright rating scale (Neftel et al., 1982), or judges ratings of quality of

performance (James et al., 1983).

Berens and Ostrosky (1988) assessed the impact of beta-adrenergic blocking agents priorto musical performance on 150 musicians and singers. This study concluded that the drug

decreased tachycardia and improved the quality of the performance, while drawing

attention to the potential difficulties with drug withdrawal and unwanted side effects.

Symptoms that have been reported in at least 10% of users include bradycardia,

hypotension, cold extremities, gastrointestinal upset, sleep disturbance and muscle fatigue.

Discussion

This systematic review of treatment for music performance anxiety indicates that there is

considerable scope for the further development and evaluation of appropriate interventions.The number of well-conducted studies that meet current standards for the conduct of

randomized controlled trials is very small, and this review was therefore forced to rely on

studies of uncertain methodology, unpublished dissertations, small sample size, potentially

resulting in lack of power to detect significant treatment effects, and design flaws such as

lack of a control group or inappropriate experimental designs (e.g., no pre-test scores). The

use of heterogenous volunteer subjects, who were not selected on the basis of a prescribed

level of music performance anxiety, and who had not reported problematic music

performance anxiety may have obscured significant treatment effects due to floor effects.

Some of the studies combined student and professional musicians, a practice not supported

by evidence that the nature and causes of anxiety in novice and mature performers may bequite different.



22/27

A rigorous definition of MPA is needed to advance treatment. However, defining MPA as a

social anxiety (social phobia) using criteria set out in DSM-IV-TR (APA, 2000) as the

inclusion criteria may be too restrictive, particularly if the musician presenting for treatment

experiences MPA as a focal anxiety (ie does not meet other criteria for social anxiety). Few of

the intervention studies reviewed acknowledged that performers need a certain amount of

arousal or anxiety to maximise their performance. For example, increased anxiety may

facilitate performance, especially for performers with high task mastery, and be associatedwith better adjudicator ratings (Steptoe & Fidler, 1987). Experienced performers may also

need more anxiety in order to achieve peak performance (Steptoe, 1989). Wolfe (1989)

distinguished between the potentially facilitative aspects of anxiety, such as arousal and

intensity, and the negative aspects such as apprehension and nervousness that impair

performance. Similar distinctions have been made in the test anxiety literature. For example,

Raffety, Smith & Ptacek (1997) found that debilitating trait anxiety was associated with lower

examination scores, less effective coping and higher levels of tension, worry and distraction

than those with facilitative trait anxiety. Further, MPA is task and context specific, becoming

apparent only with difficult pieces performed under stressful conditions, such as examina-

tions, auditions and major performances as opposed to technically less demanding piecesplayed under neutral or reassuring conditions (Wilson, 2002). These are issues that must be

addressed by health professionals planning interventions for music performance anxiety.

Such treatments need to promote sufficient relaxation to counteract the negative symptoms

of excess sympathetic nervous system activity, while maintaining sufficient arousal and

concentration needed for an optimal musical performance (Brotons, 1994).

Much more work needs to done on the role of cognition in MPA and its effect on

performance quality. Research on the role of cognition in test anxiety is instructive here,

although findings are complex and to some extent counter-intuitive. Early research

indicated a simple relationship between cognition, test anxiety and test performance.

High test anxious subjects engaged in negative cognitions that impaired task performancewhile low test anxious subjects engaged in problem solving cognitions that enhanced

performance (Wine, 1980). Subsequent research reported that high test anxious children

engaged in more negative and positive coping cognitions than low test anxious children and

that positive coping was not task facilitating (Zata & Chassin, 1985). Several researchers

have since concluded that the absence of negative thinking may be the more salient factor

than the presence of positive thinking and that this relationship held across low, moderate

and high anxious children. Further, coping cognitions of high anxious (but not low and

moderate anxious) children interfered with task performance. Only positive self-evaluations

showed a positive relationship with task performance (Prins, 1994). The most likely

explanation for these findings is that on-task and coping cognitions distract attention fromthe task or in feet remind children that they are in an unpleasant anxiety-arousing situation.

These findings could form the basis for the development of hypotheses to be tested in music

performance settings.

None of the studies could be pooled in a meta-analysis primarily because too few

provided sufficient data to calculate effect sizes, use of diverse subject groups and

treatments, duration and intensity of treatment, and use of disparate outcome measures.

Further, many of the studies reported in this review constituted the only study of its kind for

the treatment genre (hypnotherapy, biofeedback, meditation, Alexander Technique,

Ericksonian resource retrieval, and music therapy).

Standard treatments for anxiety do not seem to be directly transportable to treatment formusic performance anxiety, although it is premature to make such an assertion in view of

204 D. T. Kenny


23/27

the lack of methodologically sound research with musicians. With respect to behavioral

interventions, effect was somewhat dependent on the outcome measure, with some

techniques showing improvement on self-report measures but not performance quality

(Deen, 1999; Mansberger, 1988; Wardle, 1969), while others showed positive effect on

both measures (Sweeney & Horan, 1982). Interventions leading to an improvement in

performance quality are most desirable, since they will have a self-reinforcing, confidence-

enhancing effect on future performances, obviating the need for further treatment. Behaviorrehearsal, cognitive restructuring, combined self-instruction and progressive muscle

relaxation and combined self-instruction and attentional training all had significant positive

effects on performance quality. Systematic desensitization, deep muscle relaxation, visual

rehearsal and awareness and breathing interventions alone did not improve performance

quality. There is some evidence that biofeedback combined with a CBT intervention can

reduce anxiety but the finding that biofeedback alone did not produce significant post

treatment effects suggests that the effective component was CBT.

With respect to the other treatments reviewed, even fewer conclusions can be drawn

because in each case, results are based on one methodologically compromised study.

Tentative support is demonstrated for Alexander Technique although more methodologi-cally robust studies are needed to confirm its potential effectiveness. Similar conclusions

may be drawn for hypnotherapy and meditation. Neither biofeedback training to increase

peripheral blood flow to the fingers nor Ericksonian Resource Retrieval produced the

desired effects of anxiety reduction during performance or improved performance quality.

The music therapy model proposed and tested by Montello appears to have real promise in

the management of MPA. Although subject numbers were small, the study was

methodologically well constructed and a replication study confirming and extending the

findings of the first study lends support to the conclusions drawn. The central musical focus

of this intervention and the secondary focus on psychological processes may be the

underlying factor contributing to the positive outcomes of this intervention. Once again,

further research is needed before such an approach can be recommended. This therapy was

designed for mature freelance musicians and included music improvisation as part of the

treatment. This approach may not be suitable for younger, less experienced musicians as

the expectation to improvise may itself cause additional anxiety in young performers with

little or no experience in musical improvisation.

Of great interest is the finding that a combined cognitive-behavioral intervention and

placebo medication resulted in better performance quality ratings and self-report than

combined cognitive-behavioral treatment with buspirone (Clark & Agras, 1991). Perhaps

the expectation that an external agent (placebo) will control the symptoms of anxiety is

better than the use of the actual agent (active drug), since there are no physiological side

effects related to placebos. However, as pointed out earlier, buspirone has not been shownto be effective in the treatment of social phobia, so its use for MPA is perhaps equivalent to

placebo. In the current research climate with its more stringent requirements related to

participant safety and informed consent, drug trials of the type conducted in the 1970s and

1980s are no longer possible, or desirable.

Future Directions

There are numerous possibilities for future research in the area of MPA including greater

attention to the conceptual and theoretical issues underpinning the concept, the need for

properly controlled studies that compare treatment effectiveness for MPA across two ormore treatment modalities, and which investigate the effectiveness of combined treatments.



24/27

A small number of comparative studies have been conducted, but they have been weakened

by numerous methodological flaws discussed earlier. The publication of well designed and

controlled comparative treatment studies is essential if the field is to arrive at a position in

which best practice in treating MPA can be determined. Such studies need a sound

theoretical basis, drawing on developments in related areas of test and sport anxiety, should

use a consistent definition of MPA, appropriate and robust samples, and standardized

outcome measures in relation to self-reported MPA, functional impairment, and perfor-mance quality. In addition, random assignment to groups, the inclusion of appropriate

control groups and control variables, and the use of pre/post repeated measures designs

should be common to all future treatment studies in this area.

To determine the optimally effective parameters of any treatment approach, future

research studies will need to systematically vary the intensity and duration of treatment,

with the ultimate aim to develop an effective short-term treatment approach that can be

tailored to different sub-groups of MPA sufferers. Given that the aetiology of MPA may

differ for students and professional musicians, effective treatment approaches may need to

be tailored to the needs of each sub-group. Further, the inclusion of follow-ups in future

treatment studies is essential, with maintenance of improvements over time being one of thecrucial determinants of the effectiveness of any anxiety-related treatment approach.

Researchers will also need to investigate the value of relapse prevention strategies in

maintaining improvements in both anxiety levels and performance quality.

In addition to further research on treatment effectiveness, there is an urgent need for

further work on the assessment of MPA. This systematic review of the literature on treatment

approaches to MPA highlights the heterogeneous approach to assessment in the MPA

literature, and the subsequent difficulties in comparing the results of studies with

substantially different methodologies and outcome measures. It is important that future

studies avoid over-reliance on self-report measures of MPA, and that standardized measures

of MPA, functional impairment, and performance quality be developed and employedconsistently across treatment studies. Until these fundamental assessment and measurement

issues are resolved, it will be difficult to develop a progressive treatment literature on MPA.

In conclusion, the literature on treatment approaches for MPA is fragmented, incon-

sistent, and methodologically weak. These limitations make it difficult to reach any firm

conclusions about the effectiveness of the various treatment approaches reviewed. For

significant progress to be made, future research will require a clear definition of MPA,

consistency and strength in methodology, and the development of robust and appropriate

outcome measures. Only then will firm conclusions about the effectiveness of various

treatment approaches for MPA be possible. This comprehensive review can form the basis

for the development of a more robust science of MPA and its treatment.

References

Appel, S. S. (1976). Modifying solo performance anxiety in adult pianists. Journal of Music Therapy, 13 , 2/16.

American Psychiatric Association (2000). Diagnostic and Statistical Manual-4th Edition-Text Revision (DSM IV-

TR). American Psychiatric Association (APA).

Barlow, H. (2000). Unravelling the mysteries of anxiety and its disorders from the perspective of emotion theory.

American Psychologist, November, 1247, 1263.

Berens, P. L., & Ostrosky, J. D. (1988). Use of beta-blocking agents in musical performance induced anxiety. Drug

Intelligence and Clinical Pharmacy, 22 , 148/149.

Brantigan, C. O., Brantigan, T. A., & Joseph, N. (1982). Effect of beta blockade and beta stimulation on stagefright. The American Journal of Medicine , 72 , 88/94.

206 D. T. Kenny


25/27

Brodsky, W., & Sloboda, J. A. (1997). Clinical trial of a music generated vibrotactile therapeutic environment for

musicians: main effects and outcome differences between therapy subgroups. Journal of Music Therapy, 34 , 2/

32.

Brodsky, W. (1996). Music performance anxiety reconceptualised: A critique of current research practices and

findings. Medical Problems of Performing Artists , II, 88/98.

Brotons, M. (1994). Effects of performing conditions on music performance anxiety and performance quality.

Journal of Music Therapy, 31 , 63/81.

Chang, J. C-W. (2001). Effect of meditation on music performance anxiety. Doctor of Education Dissertation,Teachers College, Columbia University. Dissertation Abstracts International, AAT 3014754.

Cohen, J. (1977). Statistical power analysis for the behavioral sciences (rev. ed). New York: Academic Press.

Clark, D. B., & Agras, W. S. (1991). The assessment and treatment of performance anxiety in musicians. American

Journal of Psychiatry , 148, 598/605.

Craske, M, & Craig, K. (1984). Musical-performance anxiety: The three-systems model and self-efficacy theory.

Behavior Research and Therapy , 22 , 267/280.

Deen, D. R. (1999). Awareness and breathing; Keys to the moderation of musical performance anxiety. Unpublished

doctoral dissertation, University of Kentucky.

Gates, G. A., Saegert, J., Wilson, M, Johnson, L., Shepherd, A, & Hearne, E. (1985). Effect of beta blockade on

singing performance. Annals of Otolaryngology, Rhinology and Laryngology , 94 , 570/574.

Goleman, D. J., & Schwartz, G. E. (1976). Meditation as an intervention in stress reactivity. Journal of Consulting &

Clinical Psychology, 44 , 456/465.Grishman, A. (1989). Musicians performance anxiety: The effectiveness of modified progressive muscle relaxation

in reducing physiological, cognitive, and behavioral symptoms of anxiety. Dissertation Abstracts International,

50(6-B), 2622.

Harris, S. R. (1987). Brief cognitive-behavioral group counselling for musical performance anxiety. Journal of The

International Society for the Study of Tension in Performance , 4 , 3/10.

James, I. (1998). Western orchestral musicians are highly stressed. Resonance: International Music Council [France] ,

26, 19/20.

James, L., Griffith, D. N., Pearson, R. M., & Newbury, P. (1977). Effect of Oxprenolol on stagefright in musicians.

The Lancet, 2 , 952/954.

James, I. M., Burgoyne, W., & Savage, I. T. (1983). Effect of pindolol on stress-related disturbances of musical

performance: Preliminary communication. Journal of the Royal Society of Medicine , 76, 194/196.

James, I., & Savage, I. (1984). Beneficial effect of nadolol on anxiety-induced disturbances of performance inmusicians: a comparison with diazepam and placebo. American Heart Journal, 108, 1150/1155.

Kendrick, M. J., Craig, K. D., Lawson, D. M., & Davidson, P. O. (1982). Cognitive and Behavioral Therapy for

Musical-Performance Anxiety. Journal of Consulting & Clinical Psychology , 50, 353/62.

Kenny, D.T., Davis, P. & Oates, J. (2004). Music performance anxiety and occupational stress amongst opera

chorus artists and their relationship with state and trait anxiety and perfectionism. Journal of Anxiety Disorders,

18, 757/777.

Lankton, S.R., & Lankton, C. H. (1983). The answer within: The clinical framework of Ericksonian resource retrieval.

New York: W.W. Norton.

Lederman, R. J. (1999). Medical treatment of performance anxiety: a statement in favour. Medical Problems of

Performing Artists , 14 , 117/121.

Lehrer, P. M. (1987). A review of the approaches to the management of the management of tension and stage fright

in music performance. Journal of Research in Music Education , 35, 143/53.Lehrer, P., Goldman, N., & Strommen, E. (1990). A principal components assessment of performance anxiety

among musicians. Medical Problems of Performing Artists , 5, 12/18.

Liden, S., & Gottfries, C.-G. (1974). Beta-blocking agents in the treatment of catecholamine-induced symptoms in

musicians.The Lancet, 2 , 529.

Lockwood, A. H. (1989). Medical problems of musicians. New England Journal of Medicine , 320, 221/227.

Mansberger, N. B. (1988). The effects of performance anxiety management training on musicians self-efficacy,

state anxiety and musical performance quality. Unpublished doctoral dissertation, Western Michigan University.

McKinney, H. V. (1984). The effects of thermal biofeedback training on musical performance and performance anxiety.

Unpublished doctoral dissertation, University of Northern Colorado.

Montello, L. (1989). Utilizing music therapy as a mode of treatment for performance stress of professional

musicians.Dissertation Abstracts International: Section A: Humanities and Social Sciences (I-A) , 50/10.

Montello, L., Coons, E. E., & Kantor, J. (1990). The use of group music therapy as a treatment for musicalperformance stress. Medical Problems of Performing Artists , 5, 49/57.



26/27

Nagel, J. J., Himle, D. P., & Papsdorf, J. D. (1989). Cognitive-behavioral treatment of musical performance anxiety.

Psychology of Music , 17, 12/21.

Neftel, K., Adler, R., Kappeli, L., Rossi, M., Dolder, M., & Kaser, H. et al., (1982). Stage fright in musicians: a

model illustrating the effect of beta blockers. Psychosomatic Medicine , 44 , 461/469.

Niemann, B. K., Pratt, R. R., & Maughan, M. L. (1993). Biofeedback training, selected coping strategies, and

music relaxation interventions to reduce debilitative musical performance anxiety. International Journal of Arts

Medicine , 2 , 7/15.

Nube, J. (1991). Beta-blockers: Effects on performing musicians. Medical Problems of Performing Artists ,6, 61/68.Patston, T. (1996). Performance anxiety in opera singers. Unpublished masters thesis, Sydney Conservatorium of

Music, University of Sydney, Australia.

Prins, J. (1994). Cognition in tests-anxious children: the role of on-task and coping cognition reconsidered. Journal

of Consulting and Clinical Psychology , 62 , 404/409.

Raffety, B. D., Smith, R. E., & Ptacek, J. T. (1997). Facilitation and debilitation trait anxiety, situational anxiety

and coping with an anticipated stressor: A process analysis. Journal of Personal and Social Psychology , 72 , 892/

906.

Reitman, A. D. (1997). The effects of music-assisted coping systematic desensitization on music performance

anxiety: A three systems model approach, Unpublished doctoral dissertation, Temple University.

Richard, J. J., Jr. (1992). The effects of Ericksonian resource retrieval on musical performance anxiety. Dissertation

Abstracts International: Section B: the Sciences & Engineering, 55(2-B), 604.

Roland, D. J. (1993). The development and evaluation of a modified cognitive-behavioral treatment for musical

performance anxiety. Dissertation Abstracts International: Section B: the Sciences & Engineering, 55(5-B), 2016.

Salmon, P. (1990). A psychological perspective on musical performance anxiety: a review of the literature. Medical

Problems of Performing Artists, 5, 2/11.

Sataloff, R., Rosen, D. C., & Levy, S. (2000). Performance anxiety: What singing teachers should know. Journal of

Singing, 56, 33/40.

Smith, R. J., Amkoff, D. B., & Wright, T. I. (1990). Test anxiety and academic competence: A comparison of

alternative models. Journal of Counseling Psychology , 37(3), 313/321.

Stanton, H. E. (1994). Reduction of performance anxiety in music students. Australian Psychologist,29, 124/127.

Steptoe, A. (1989). Stress, coping, and stage fright in professional musicians. Psychology of Music , 17, 3/11.

Steptoe, A., & Fidler, H. (1987). Stage fright in orchestral musicians: A study of cognitive and behavioral strategies

in performance anxiety. British Journal of Psychology , 78, 241/249.

Spielberger, C. (1983). Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists.

Sternbach, D. J. (1995). Musicians: A neglected working population in crisis. In S. L Sauter, & L. R. Murphy(Eds.), Organizational risk factors for job stress (pp. 283/302). Washington, DC: American Psychological

Association.

Sweeney-Burton, C. (1997). Effects of self-relaxation techniques training on performance anxiety and on

performance quality in a music performance condition. Unpublished doctoral dissertation, University of North

Carolina, Greensboro.

Sweeney, G. A., & Horan, J. J. (1982). Separate and combined effects of cue-controlled relaxation and cognitive

restructuring in the treatment of musical performance anxiety. Journal of Counselling Psychology , 29, 486/497.

Valentine, E., Fitzgerald, D., Gorton, T., Hudson, J., & Symonds, E. (1995). The effect of lessons in the Alexander

technique on music performance in high and low stress situations. Psychology of Music , 23 , 129/141.

van Kemenade, J. F. L. M., van Son, M. J. M., & van Heesch, N. C. A. (1995). Performance anxiety among

professional musicians in symphonic orchestras: A self-report study. Psychological Reports , 77, 555/562.

Wardle, A. (1969). Behavior modification by reciprocal inhibition of instrumental music performance anxiety.Research in music behavior: modifying music behavior in the classroom. In C. K. Madsen, C. H. Madsen & R.

D. Greer (Eds.) (1975), Research in Music Behavior(pp. 191/205). New York: Teachers College Press.

Walsh, R. (1995). Phenomenological mapping: A method for describing and comparing states of consciousness.

Journal of Transpersonal Psychology, 27, 25/56.

Wilson, G. D. (2002). Psychology for performing artists (2nd ed). London, UK: Whurr.

Wine, J. D. (1980). Cognitive-attentional theory of test anxiety. In I. G. Sarason (Ed.), Test anxiety: Theory, research

and applications (pp. 349/385). Hillsdale, NJ: Erlbaum.

Wolfe, M. L. (1989). Correlates of adaptive and maladaptive musical performance anxiety. Medical Problems of

Performing Artists , 4 , 49/56.

Zatz, S., & Chassin, L. (1985). Cognition of test anxious children under naturalistic test-taking conditions. Journal

of Consulting and Clinical Psychology , 53 , 393/401.

Zinn, M. L., McCain, C, & Zinn, M. A. (2000). Music Performance Anxiety and the High Risk Model of Threat

Perception. Medical Problems of Performing Artists , 15(2), 65/71.

208 D. T. Kenny


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