A Psychological Perspective on Musical Performance Anxiety: A Review of the Literature Paul G. Salmon, Ph.D. [en interest in the health needs of professional and student musicians has been accompanied by greater at- tention to the broad range of psychological variables as sociated with musical performance skills. OF these, none has attracted more interest than the problem of performance anxiety, or stage fright. It is the purpose of this paper to review some contemporary research pertaining to the con- ceptualization and psychotherapeutic treatment of musical performance anxiety. Excluded from consideration is the pharmacotherapeutic treatment of performance anxiety, notably the employment of betarblockade agents to atten: uate symptoms of autonomic arousal in performance situ- ations. Recent reviews and discussions of beta blockers are readily avalable** "74 and indeed should be consulted by clinicians contemplating their use. Among the most prevalent of all emotional disturbances in the general population,” Anxiety in its varying mani- festations may afflict between 10 and 30% of the popula- tion.” Its impact furthermore extends to individuals with wide range of highly specialized skilland capabilites. The adverse effects of anxiety have been well documented in such diverse areas as motor skills," public speaking, Anxiety in its varying manifestations may afflict between 10 and 30% of the pop- ulation. test taking, athletics,” military skill training,” writing," sexual funetioning,® and, of course, musical performance skills (see, for example, reviews, by Reubart,*' Hingley,”” and Lehrer). There is, moreover, no lack of advice on hhow ro manage the psychological stresses of performing, as wienessed by numerous articles in musical journals and pop- ular texts such as those by Ristad," Triplett,” Greene,” Paul Salmon, PhD., Department of Prychoogy, University of Ls wile; Genesis Center. Department of Psgchiaty, School of Medicine, University of Louise; and the Pesforming Ares Center for Health (PACH), Louise, Kentucky. Adis comespondence ti Pl Salon, PRD., Deparoment of Psychuogy, University of Lins, Loa, Kentucky 40292. 2 Medical Problems of Performing Ariss and Wilson. !% A legitimate question that might be posed a this juncture concerns whether in this diverse amalgam ation of clinical, popular, and scientific literature an in- tegrated perspective on the psychological conceptualizaion and treatment of performance-related problems might be achieved ‘The cerms “stage fight" and “performance anxiety” have often been used interchangeably in. referring to. unwar ranted, excessive fearfulness during public performances The intense psychological distress associated with live per- formances is often attributed by clinicians and teachers to such factors as insufficient performance experience, faulty technique, "© inappropriate repertoire,” or improper prac tice and preparation habits.!? However, itis cleatly a con- dition that afflicts many veteran performers with exemplary skills and preparatory techniques as well, and such eminent musicians as Artur Rubenstein, Pablo Casals, and Luciano Pavarotti have all reported experiencing extreme tension and psychological distress while performing before audi- Part of the problem, of course, is related to the fact that aspiring and professional musicians pursue a highly sophis- ticated craft under extreme stress associated withthe phys- ical and psychological demands of performing, as well as with the tenuous nature of music as a profession." Fully aware of the pressure under which they routinely operate, and of the potential consequences of even minor mistakes in auditions and competitions, many musicians develop careful, compulsive style of performing that transforms the fluid expression of music into a seliconscious, nerve-acking challenge." The psychological distress associated with performing ex- tends considerably beyond mere stage fright. Many musi- cians find that their apprehensions are greatest before they perform, rather than during the performance itself. An ex- Many musicians find that their apprehen- sions are greatest before they perform, rather than during the performance itself.clusive focus on the symptomatic expression of anxiety in the performance context alone therefore risks overlooking the potential impact of many factors that can heighten vulnerability to situational anxiety, including cognitive, * ppedagogical,"' psychodynamic,' skills-based,” genetic,” and Biological components. In light of such evidence, the term “musical performance anxiety” (MPA) is proposed as 4 more appropriate term than stage fright to characterize the generalized psychological distress reported by many mu- sicians wel in advance of, as well as during, performances. MPA js defined as the experience of persisting, distress ap- Drehension about andlor actual impairment of, erformance skills ina public context, toa degree unwarranted given the individual's musical aptitude, taining, and level of preparation ‘A review of the available psychological literature pro- vides empirical support for the following four general state ments concerning both the nature and treatment of MPA. 1. MPA comprises a loosely correlated constellation of physiological, Behavioral, and cognitive variables. (Currently, a model of anxiety based on these three factors developed by Lang* has received widespread support in the clinical research literature. According to this model, anx: iety is the product of interactions between distressing, fear- fal thoughts, a state of autonomic arousal, and overt behavioral responses to a perceived threat. Ie is assumed by many cognitive behaviorists? that anxiety is initiated by a cognitive appraisal of danger, which in cur activates the other components, but there is also evidence’ that phys iological arousal may initiate a chain reaction leading to anxious thoughts. There is, however, widespread agreement that, under conditions of extreme duress, these three sys- tems all become highly activated and synchronized. An acquaintance ofthe author, for example, reported that dur ing an important audition an assistant inadvertently turned several pages at once, causing him to lose his place. He became extremely flustered and experienced both hyper ventilation and tachycardia as a stream of catastrophic thoughts raced through his mind. Shaking and unable to continue, he ran off the stage. The highly synchronous activation of physiological, cog nitive, and behavioral correlates of anxiety appears to minish under less eatastrophie circumstances, which in part accounts for the variety in symptom expression commonly reported by performers and other anxious individuals. This effect, termed “response desynchtony," can int tively be corroborated by noting that one can feel phy logically aroused without experiencing correspondingly distresful thoughts, for example, or engage in avoidance behavior triggered by anxious thoughts in the absence of physiological arousal. A particularly interesting illustration ‘of response desynchrony is performers whose physiologial responses are damped by beta blockers but who continue to report anxious cognitions. This finding is consistent with studies of fear habituation, in which the attenvation of ‘anxious cognitions lags behind physiological response re- duction,” as well as with evidence from a treatment study of snake phobias,” suggesting that cognitive components of anxiety may show slower habituation than do physio- logical symptoms. Different measurement techniques are required to eval- uate each of the three categories of anxiety symptomatol- ogy. Physiological symptoms of anxiety are especially troublesome to performers because they can interfere di- rectly with skilled movements and because their effects may be perceptible to others. Associated with autonomic arousal, they include changes in respiration," skin conductance levels, and cardiovascular responses, as well as dry mouth, constricted throat, and urinary urgency. Although most of these variables can be measured directly with appropriate sensor, self-report inventories ean also be employed, among, them the Beck Anxiety Inventory,'® the Bums Anxiety Inventory, and the Symptom Questionnaire by Lehrer and Woolfolk." Behavioral indices employed in studies of MPA generally fall into three categories: © observer ratings of performance quality © overt expressions of anxiety such as tremulousness, tensed shoulders, and distresful facial expressions, and. ‘© more general measures of avoidance behavior." Although most of these measures are based on ditect observation, Lehrer and Woolfolk’s self-repor symptom questionnaite™ also assesses behavioral correlates of anxi- evy. ‘The cognitive component of anxiety has been the focus of intensive research in recent years,°?"*5? and conse- quenely is represented by many assessment procedures, re cently reviewed by Martzke, Andersen, and Cacioppo. Cognitive assessment of performance anxiety tends to focus ‘on troublesome thoughts that serve both as distractions and as cues that further increase one’s anxiety. eas Cognitive assessment of performance anxiety tends to focus on troublesome thoughts that serve both as distractions and as cues that further increase one’s anxiety. Generally, anxious cognitions reflect themes of risk and danger,” which covary closely with self-reported levels of anxiety. Lehrer™ identified a constellation of worrisome thoughts characteristic of anxious performers, including fears of becoming anxious, being distracted and having memory lapses, being criticized by others, and possessing inadequate musical abilities. Kendrick et al developed the Perfor mance Anxiety Self-Statement Scale to assess their subjects! cognitions before, during, and after performing, and te- ported that cognitive manifestations of anxiety included themes involving inadequacy, anticipation of punishment! ticism, and loss of status. Finally, from a different per- spective, the violinist Havas™ has suggested that the acous- tic and semantic qualities of certain words, such as “sip, pull, push, hit, press, stretch . . . good, bad, loud” are March 1990 3cognitive cues that can foster anxious, effortful perfor- Empirical support fora three-factor model of MPA comes, from a recent study by Craske and Craig,"® who assessed cognitive, physiological, and behavioral responses of low anxiety and high-anxiety pianists. This mode! predicted a greater degree of response synchrony at high levels of anx- iety, and less at lower levels. An altemative, and not un- reasonable, prediction was that response synchrony would be maintained irrespective of anxiety level in a manner consistent with the self-efficacy theory of Bandura.* Self- efficacy theory asserts that manifestations of anxiety vary in a synchronized manner with selF-assessments of one's capabilities to master stressful situations. The study was conducted by asigning 40 proficient piano students to either high- or low-anxiety groups based pri marily on scores obtained from the Report of Confidence as a Performer Scale (RCPS) by Appel? (subsequently up- dated by Craske et al.) All subjects played a sel-selected piece of music from memory under two conditions: a prac- tice “run through,” followed one week later by a perfor- mance under conditions intended to induce distres. A video ‘camera was prominently displayed, and an audience of five “judges” was present, Subjects were told that all of the judges were accomplished pianists and experts in behavioral assessment, Dependent measures included (1) a varie of cognitive self-report measures assessing state (situational) anxiety, self-efficacy, and subjective dstres; (2) behavioral measures of performance quality and overt behavior; and G) measures of autonomic arousal involving skin con- ductance and cardiac and respiratory functions. Craske and Craig found that the simulated performance condition was a potent elicitor of tension, particularly among subjects high in anxiety to begin wih. As predicted by the three-factor model, there was greatest response synchrony in cognitive, behavioral, and physiological measures for the anxious performers, particularly when performing before an audience. In contrast, the less anxious group manifested lower synchrony among the three classes of anxiety mea- sures. Desynchrony was evident specifically in terms of an overall mean inerease in heart rate for individuals low in trait anxiety performing before an audience, whereas be- havioral and cognitive measures remained stable or dimin- ished slightly over che baseline (warm-up performance) condition, In addition to providing empirical support fo the validity of a three-factor model of MPA, the Craske and Craig study demonstrates sound methodology worthy of emulation in research of this nature, In terms of subject screening pro: cedures, multivariate approach to anxiety measurement, Performers who perceive themselves as anxious tend to manifest both the symp- toms and synchrony characteristic of marked anxiety. 4 Medical Problems of Performing Arist and comparison of baseline and stressful performance con- ditions, the study is rigorous and thorough. Results of this, study clearly underscore the degree to which self-report levels of anxiety (the basis for classifying subjects as high ‘or low anxious) accurately correspond to the overall level of arousal during the stressful performance, Performers who perceive themselves as anxious tend to manifest both the symptoms and synchrony characteristic of marked anxiety 2. The physiological component of MPA reflects arousal associated with the autonomic nervous system (ANS) which, largely through conditioning, has become exces- sively associated with fear. Te is widely accepted asa truism that “abit of anxiety is helpful” during a performance. In realty, itis heightened state of arousal—not anxiety—thae performers attempt to optimize, and which psychologists have conceived of as a biologically-based, motivating force.”? The concept of arousal has been linked to personality variables as well, most notably by Eysenck,!® who has suggested that intro: verted individuals manifest higher average levels of acti vation, ad are correspondingly more sensitive to stimulation and more prone to anxiety than are extroverts, Playing from memory before a large au- dience generally had the most debilitating effect on performance. ‘The idea of “optimal” arousal can be traced tothe “Yerkes- Dodson law,” which characterized the relationship be ‘owen motor skills and arousal as an inverted U shape: both low and high arousal levels impair performance, whereas a moderate level enhances performance. An early application of this principle by Easterbrook’? suggested that whereas low and high arousal levels impair cue utilization (and therefore sensitivity to information), moderate arousal ean, ‘optimize such information processing. The clinical im cations of this were subsequently spelled out more clearly by Wachtel,'°" who has provided evidence that excessive arousal results in a constricted narrowing of the focus of attention, leaving less available for rask-related activity ‘An interesting parallel can be drawn between Wachtel’s analysis of the relationship between arousal and attention and that proposed by the actor Stanislavski years eatlie.”= Stanislavski proposed the image of a “circle of attention” to represent the focus on one's conscious attention during a performance. Under conditions of excessive arousal, the focus of this circle becomes too narrow, overly limiting the span of one’s apprehension. Conversely, if arousal is too low, the focus of attention becomes too broad and diffuse Predictably enough, there is evidence that excessive anx- jety tends to degrade performance, as shown in a study by Leglar.®! She systematically varied the “demand” charac teristics of performance situations by having onganists play, with or without musical scores, for critical audiences of varying sizes. Leglar found that playing from memory before a large audience generally had the most debilitating effectcon performance, and corresponded to maximum levels of physiological arousal. On the other hand, a study by Ha- rmann’* of instrumentalists and vocalists supported the hy pothesis that situation designed ro heighten arousal above ‘a minimal level could facilitate performance. A substantial majority of subjects whose performances were taped before a knowledgeable audience (instructor and peers) were rated as “superior,” whereas less than half (42%) of those whose performances were taped, but with no audience present, received comparable ratings. The facilitating eect of the performance situation, however, was most apparent in sub- jects with the highest level of formal training and experi- cence, a finding reiterated in a later study.” ‘Approaching the manipulation of arousal from a different ‘vantage point, Weinberg and Ragan varied arousal evel by inducing diferent degrees of threat to self-esteem while subjects performed motor task. In the high threathigh arousal condition, subjects were told that eheie performance was at the lowest 10th percentile, and that they needed to improve substantially. Subjects receiving moderately threatening feedback were told that they were performing in the 40th percentile, or close to average. Subjects re- ceiving low-threat feedback were told that they were doing well, at the 70th percentile level, Subjects in the moderate stress condition performed best, whereas those in the re- maining ‘wo conditions performed significantly more pooly. However, Weinberg and Ragan also reported an interaction between trait and anxiety and stress condition, such that subjects high in trait anxiety performed best in the low- stress condition, whereas performance for subjects low in trait anxiety was optimal in the high-stress condition, “The results ofthe Weinberg and Ragan study are instruc- tive because they illustrate the mediating impact of indi vidual difference variables, such as trait anxiety and introversion, on what constitutes optimal arousal. There are other qualifications as well, discussed in a recent review by Neiss.°” Among the most important of these is the fact that a particular degree of arousal does not by itself induce a specific emotional experience or necessarily enhance or diminish performance capabilities. Three sources of evi- dence support this conclusion 1. People differ substantially in terms of chit sensitivity to internal cues of arousal. Hypochondriacal individuals, for example, are more sensitive to, and spend more time ‘monitoring, intemal sensations, than do non-hypechon: driacs.°? The well-known sensitivity of many musicians to feven minute alterations in their physical state (€.8., vo calists and their voices; pianists and theit fingers) may make such individuals excessively reactive to, and potentially adversely affected by, minor variations in physical state A particular degree of arousal does not by itself induce a specific emotional ex- perience or necessarily enhance or dimin- ish performance capabilities. Furthermore, perceptual acuity with respect to physical sen- sations varies within the individual according to one’s state of arousal. Hypervigilance is a correlate of anxiety, ac- cording to current clinical diagnostic criteria,” and increases sensitivity to the associated symptoms of arousal. In effect, 2s the physiological symptoms of arousal increase in strength, the threshold for thei detection is simultaneously lowered. 2. A second line of evidence underlying the complexity of the arousalefficiency relationship is based on studies of spinal-cord~injured individuals" whose perceptions of in remal, visceral sensations have been impaired. This re- search suggests that the perception of arousal is nt a necessary concomitant for emotional experiences, and is consistent with evidence that some performers taking beta blockers (which temporarily attenuate arousal cues) report emotional reactions normally asociated with heightened arousal. For such individuals, the concept of “optimal arousal” i clearly affected by factors other than physiological state per se. A specific level of arousal may or may not optimize performance, depending on how it is interpreted by the performer. 3. Finally, arousal appears to he subject to cognitive appraisals that play a role in determining the nature of the consequent emotional response. For example, a study by Schachter and Singer"? suggested that the emotional con- notations of arousal are determined in part by contextual ‘cues in such a way that contextual cues in part determine the nature of the emotional response. Although subsequent research has failed to replicate all of Schachter and Singers findings, there is nonetheless considerable evidence that people engage in interpretive activity of inner states, and react emotionally in part based on their cognitive appraisals ‘of these stares.” A number of recent studies have reported, for example, that the arousal states induced by lactate in- fusions” or epinephrine™ determine only in part how aroused or distressed the individual actually reports feeling: expec- tations, feedback, and interpretations of these states sig nificantly affect the impact of physical arousal. Two performers about to go onstage, for example, may experience com- parable degrees of arousal yet interpret the sensations quite differently. One may interpret the sensations as a sign of imminent collapse, whereas the other may have come co interpret such feelings as inevitable and even necessary precursors to a good performance. Consistent with this, Craske and Craig!” found that both high- and low-anxious pianists experience rapid heart beat while performing for an audience, but are likely to have interpreted the sensation in markedly differing ways To summarize, recent studies of arousal suggest that al- though there appears to be a relationship between arousal level and performance efficiency, it is difficult to generalize about what constitutes “optimal” arousal. A specific level of arousal may or may not optimize performance, depending oon how it is interpreted by the performer. The utility of March 1990 5the Yerkes-Dodson relationship lies i is implication that arousal states do indeed provide a motivating force that i channeled and hamessed more effectively by some perform es than by others 3. The anticipation of stressful events, musical or oth- exwise, ean evoke as much (if not more) ansiety than the event itself There is ample evidence that many anxious thoughts have a future orientation, witha focus on things that may, but not necessarily will, appen.**? Anxious musicians worry incessantly about upeoming performances and any number of catastrophes that may befall them. Aaron! discusses the rituals and pre-performance anxieties of stage actors who often must be literally pushed out onto stage to pesform, afer which they regain their composure. If such thoughts and behaviors were the simple result of previous failures on stage, they might be explained asa form of icty" that was eminently realistic. Bur this i seldom the case, at least in the author's experience. In fact, Some musicians become steadily more anxious the longer they go without an untoward experience onthe performance stage, in an unusual cwist ofthe “gamblers fallacy." They become convinced that the law of averages will catch up with them sooner or later, and that catastrophic failure is inevitable! They constantly question the adequacy of theit coping skills in an automated manner that seems t be relatively unaf- fected by feedback feom their actual performances. Actors have a saying that, "You're only as good as your next pet- formance,” which represents an open invitation to obses sive, anticipatory anxiety. Some musicians become steadily more anxious the longer they go without an untoward experience on the performance stage. They become convinced that the law of averages will catch up with them sooner ot later, and that catastrophic fail- ure is inevitable! That anxious ruminations tend to ine ipated, stesful event becomes ieuminent has been amply demonstrated with groups such as musie students facing ‘evaluative juries," just as anxiety inereases for individuals facing examinations."* In a recent study specifically ad- dressing the issue of risk perception and anticipatory anx iety, Butler and Mathews! explored ways in which students’ predictions oftheir performance on upcoming examinations varied asthe event drew nearer. They found a clear trend toward predicting more negative outcomes as the exams approached (despite, presumably, increases in preparatory study), and moreover found chat students became more certain that they—but noe thee classmates—would do poorly This effect was especially pronounced in subjects prone to heonie, enduring “trait” anxiety. When not carried to an extreme, anticipatory anxiety 6 Medical Problems of Performing Arcsts «can facilitate performance because it provides an oppor tunity €o practice coping with the anticipated stresor. In a study of sports parachutist, for example, Fenz and Ep- seein2” found chat fear ratings peaked well before a jump for the most experienced jumpers, and reached levels litle different from those of novices, whose maxital feat tended to occur when the jump was imminent. The experience of peak fear in advanced of a jump served as a cue for various adaptive behaviors, such as checking one’s parachute, re- hearsing jump instructions, and visualizing the jump itself. Active coping with fear at this point in time presumably aided in mastery of the jump situation itself. Epstein?? uses such evidence as illustrative of an effective coping mech anism, which has come to be referred to a5 stress inocu lation, in which anxiety-evoking images of a stressful event, such as a fortheoming recital, are imagined in derail, fol lowed by ether active preparatory activity of visualization of effective coping behavior. A recent study by Salmon, Schrodt, and Wright" re- ported evidence that relatively experienced musicians like- Wise experience greatest anxiety i advance of, rather than during, their performances. Results of both studies suggest that i is therapeutically helpful (1) to accept anticipatory anxiety as a natural concomitant of performing; and (2) to tse the consequent tension ro mobilize preparatory activity ‘The capacity to imagine in great detail and generate coping responses to foreseeable difficulties is a sound pedagogical idea, even though it may seem counter-intuitive to per formers who prefer not to think about situations they may have to cope with on stage. Avoiding thinking about an upcoming performance because it evokes twinges of anxiety deprives one of a useful preparatory strategy employed by many seasoned performers. Furthermore, such avoidance ray be accompanied by a misleading, impoverished con- ception of performing which maximises the perception of threat and danger, a pattern more generally associated with phobic behavior. Evidence suggests that infrequent ex posure to anxiety-provoking situations causes tension to increase in a manner disproportionate tothe actual degree of risk, an effect termed incubation. It is possible, of course, to err too much in the other direction, continually exposing oneself to anxiety-provok ing situations. Such “counterphobic™ behavior, by virtue cof mere frequency, does not guarantee a eduction in anx- iety, and may intensify it, a illustrated ina study by Lader, Gelder, and Marks*” in which attempts to habituate highly anxious subjects to test sounds through repeated exposure resulted in an increase in skin conductance and, presumably, anxiety. Moreover, there ate certainly instances when Avoiding thinking about an upcoming performance because it evokes twinges of anxiety deprives one of a useful prepa- ratory strategy employed by many sea- soned performers.avoidance of stresful situations is a helpful coping strat- eay"*—everyone needs to “get away” from things once in awhile. An effective arrangement for keeping anticipatory anxiety from becoming too intense isto strive fora balance oflive performances, imaginal exercises, and the cultivation cof both musical and stress-coping skills There are indications that predisposition to anxious anticipation may reflect certain enduring psychological trait Spielberger®” has developed a widely used anxiety inventory (che Strate-Trait Anxiety Inventory, or STAN) which dis- tinguishes between “trait” and “state” anxiety (see Spiel- berger etal.” for a review of these concepts), Trait anxiety refers to a predisposition to chronic anxiety and worry about the future, whereas state anxiety involves a more circum- scribed response to specific situations. Individuals high in trait anxiety are typically troubled by self-doubts and are more likely to perceive danger where none is objectively present than are individuals low on this variable In a related vein, there are indications that some indi- viduals are chronically fearful of becoming anxious, and are prone to react excessively fearfully to sensations of physi- logical arousal.° Termed “anxiety sensitivity,” this di- mension is related both to a general expectancy set anticipating risk and danger as well as to a negative re- sponse to anxiety symptomatology. An assessment scale, the Anxiety Sensitivity Index, based on this model"? has recently been developed, and appears to represent a prom- ising avenue of research in assessing underlying predspo- sitions to MPA. Aside from an individual's predisposition to anxiety or fear of it, more broadly defined personal belies appear to play a role in maintaining a fearful, defensive orientation. ‘A recent study by Tobacyk and Downs” investigated the relationship between MPA reported by music student dur ing juries and more general measures of personal threat and irrational beliefs. “Degree of personal threat” was defined within the context of Kelly’ personal construct theory,” which holds chat anxiety is linked to experiences that force a significant reappraisal of oneself and one’s competencies ‘An important musical jury, the outcome of which might have implications for a musician’s career, is an example of an experience likely to force such a reappraisal Irational beliefs, central to Ellis’ cognitive model of psychopathol- gy, reflect erroneous assumptions (e.g., “I must be per- fect”) about oneself and the world which, when violated, sive rise to anxiety. Tobacyk and Downs found that both measures were predictive, to a significant degree, of the atnount of situational anxiety experienced by the musicians at the time of theit end-of-semester juries. Specifically, subjects for whom juries represented high threat levels and who harbored unrealistic beliefs reported greatest levels of situational anxiety. Individuals prone to anticipatory anxiety are frequently deficient in what Bandura’ has termed self-efficacy. Self- efficacy refers to how capable an individual thinks he or she is in dealing with stressful or demanding situations. Unlike more global measures of distress such as trait anxiety, Subjects for whom juries represented high threat levels and who harbored unreal- istic beliefs reported greatest levels of sit- uational anxiety. self-efficacy is a construct that appears to be helpful in predicting behavior in a wide range of specific, stressful situations,® especially when they involve a social context likely to evoke “public se-consciousness.”!* Ifa situation, is appraised as manageable (that is. if the individual pos- sesses the necessary coping skills), it is approached with confidence. If not, selfdoubts and anxiety commonly re- sult The type of inner dialogue, or “self-talk,” individuals engage in when confronting stressful situations appears to be related to the concept of self-efficacy. A study by Steptoe and Fidler” provided some evidence for a relationship be- tween musicians’ self-talk and self-report measures of MPA, such that statements that neither minimized stresses on the cone hand nor reflected catastrophic thoughts about the risks of performing in public, were associated with lowest overall levels of anxiety. Such self-talk tended to emphasize real istic appraisals of performance situations, such as the inev- inability of occasional mistakes, the generally tolerant nature ‘of audiences, and the need to concentrate on technical and interpretive aspects of the music. That such cognitions were ‘more common among experienced than relatively inexpe- rienced musicians suggests that they ae likely to have been incorporated into a general attitude about one’s perfor- mance skills that conveys a sense of confidence and com- petence. Subjects prone to intense MPA were much more likely either to report catastrophic cognitions ("I chink I'm going to faine”; “I'm almost sure to make a dreadful mistake, and that will ruin everything”), or to adopt a rather blasé attitude ("Ie's just another concert. "). Additional corroboration for evidence of anxious self tall in musicians is reported by Lehrer,* who identified a cluster of worrisome thoughts frequently reported by per- formers. Included were fears of becoming anxious, concern about potential distractions and memory slips, anticipation of disapproval from others, and anxieties over one’s per- formance abilities, Many performers are troubled by anxiety-provoking thoughts such as those enumerated here during the time of their performances, even after years of training and expe- rience. Moreover, there isa tendency to use such thoughts as the basis for predictions about how an upcoming per- formance is likely to turn out. There is some indication that “defensive pessimism’"—fearing the worst, then being pleased when things turn out less catastrophicaly than you predicted—may prove adaptive at times:"" however, all too frequently, becoming preoccupied with dite predictions about an upcoming performance has a way of creating sel-uling prophecies that are the hallmark of the chronically anxious performer. March 1990 7Becoming preoccupied with dire predic- tions about an upcoming performance has a way of creating self-fulfilling prophecies. 4, Psychotherapeutie interventions for MPA. appear to be successful to the degree that they address specific com- ponents (cognitive, physiological, behavioral) of the over- all profile of anxicty. ‘The treatment of MPA has begun to receive some at- tention in the clinical research literature, primarily in terms ‘of studies evaluating interventions aimed at the cognitive, behavioral, and paysiological components of the chre-fac- tor model of anxiety discussed earlier. Two studies in par ticular, one by Kendrick et al.*8 and a second by Sweeney and Horan, are notable for theit careful design and meth- ‘oxdology, and consequently each is described in some detail Both compare the relative effectiveness of variants of "cog nitive restructuring” with either relaxation or behavioral rehearsal procedures. Cognitive restructuring® refers in gen- eral to a procedure for (1) monitoring one’s thoughts: (2) exploring the dysfunctional qualities of troublesome thoughts; (3) developing effective counter-responsess (4) reheansing the new responses; and (5) incorporating them into task-relevant activities.” Kendrick et al.‘® compared the efficacy of behavioral rehearsal with that of cognitively based “attention training” in reducing MPA in two treatment groups and a waiting- list control group, Fifty-three highly anxious pianists served as subjects, each of whom was randomly assigned to one of the three groups. Subjects in both treatment groups received a total of 6 hours training in two-hour sessions. In the attention training group, subjects made videotapes oftheir Performances for baseline purposes, then, employing a widely used cognitive assessment procedure,® reviewed the tapes as an aid in recollecting theit negative and task-irelevant thoughts. A treatment rationale for “cognitive restructur- ing" was then presented, linking negative thinking to anx iety and poor performances in the manner ofa self-defeating, Vicious eyele. Subjects were taught 0 (1) challenge the assumptions underlying their selfdefeating thoughts; and (2) substitute for them more task relevant and competency- enhancing thoughts. Four categories of adaptive selftatements were proposed (examples are in parentheses): (1) comforting ("I've leared the music thoroughly and am well prepared"); (2) task- focusing ("I need to concentrate on maintaining a constant tempo"); (3) technique-oriented ("Keep my shoulders and arms relaxed so my fingers will move freely"); (4) and self rewarding (“There—the opening section went wel!”), Subjects were also exposed to a slide/tape presentation showing a model actively overcoming hs ear of performing. Finally, subjects were given homework in the form of as- signments to perform for small groups of family and friends, after each of which they were to record their thoughts and rate both their anxiety and the overall quality of the pe 8 Medical Problems of Performing Ariss formance. Subjects in the behavioral rehearsal group were initially presented with a rationale emphasizing the impor- tance of repeated performances before an audience as a ‘means of reducing anxiety. The therapist modeled a per- formance, after which group members likewise played. As in the artention training group, subjects were instructed t0 engage in "practice performances” for family and friends, Dependent variables included a variety of cognitivelselé- report, behavioral, and physiological measures. Ar the time of treatment termination, no differences in reported anxiety "were apparent across groups. However, at the time of a five ‘week follow-up, both the behavioral rehearsal and attention training groups showed significantly greater anxiety reduc tion than did the waiting-lis contcol group. Furthermore, the cognitive intervention showed the added benefit (at follow-up) of increased self-efficacy, suggesting that indi- viduals in this group may have developed a more positive perspective on their capacity to cope with stress. ‘The study by Sweeney and Horan compared a wider range of treatment for MPA, including cue-controlled re Taxation (CCR), cognitive restructuring (CR), a combi nation of the two, musical score analysis, and a waiting list control condition, Subjects (totaling 43) in each con- dition received six hours of training over a six-week period. CCR involved first taining subjects in progressive muscle relaxation, and then teaching them to evoke a relaxed state with the cue work “relax.” In the CR condition, much as in the study by Kendrick et al., subjects learned to monitor and challenge anxiety-evoking cognitions and substitute more mastery-oriented responses. As in the Kendrick et al study, dependent measures were derived from cognitive (self report), behavioral, and physiological variables. Subjects learned to monitor and challenge anxiety-evoking cognitions and substitute more mastery-oriented responses. Significant positive treatment effects were reported for CCR training on measures of both state and trait anxiety, as well as on ratings of performance quality. In contrast, CCR was associated with a significant reduction in observable behavioral indices of anxiety. The effect of combining the ‘wo conditions did not appear to affect significantly the resultant degree of anxiety reduction, These results point to the feasibility of using different procedures to treat dif- fering manifestations of MPA. Significantly, no dependent ‘measures showed reductions in anxiety for the score analysis condition. This finding may have in part been due to screening procedures, which eliminated from participation subjects with learning/preparation problems who might have oth- erwise benefitted from such training. Several other comparative treatment outcome studies of MPA have likewise examined the relative effectiveness of varying combinations of physiological (relaxation-oriented), cognitive, and score analysis conditions. Lund comparedSDT, relaxation taining, and a problem-oriented “insight” condition with reference to @ no-treatment control group. A significant reduction in anxiety on follow-up testing was reported forall groups, but subjects in the “insight” con dition tended to maintain improvement better at follow- up testing. Subsequent to this study, Appel? compared the effectiveness of systematic desensitization (SDT), an anx iety reduction technique involving graded exposure to a feared situation, relative to score analysis and a no-teat- ‘ment control condition. In vivo performances were included in both conditions as part of each treatment, and both proved more effective than no treatment in reducing MPA, with SDT being most effective overall SDT was also one of the comparison conditions employed, in a dissertation study by McCune,“ who used an inter ‘esting improvisation training/cognitive skills building con- dition, in addition to a no-treatment control group. ‘Comparing pre- and post-treatment measures, subjects in the SDT group showed a significant reduction both in tech- nical errors and anxious verbal responses in excess of those attained by subjects in the other two groups. ‘The use of desensitization procedures finds additional support in a singlesubject case study by Norton et al,” alehough in this instance the technique was modified to have the client (a female pianist with chronic MPA, in- cluding memory lapses and motor tremor) imagine herself coping effectively with progressively more anxiery-provoking situations, rather than simply learning eo visualize such circumstances in a relaxed state. When she had successfully visualized herself actively coping with stressful performance situations, she began a series of “practice performances” before small audiences, prior to and during which she de- ployed the coping strategies taught earlier. Following teat ment, she was able to perform successfully in an important competition and several concert performances, reporting thar subjective anxiety, memory lapses, and eremulousness had all significantly diminished. Exploring another facet of MPA management tech- niques, Grishman” evaluated the efficacy of progressive muscle relaxation’? in reducing cognitive, behavioral, and physiological concomitants of MPA. Forty-one anxious in- strumentalists were randomly assigned to either a modified progressive relaxation training group or to a no-treatment control condition. Usinga variety of self-report, behavioral, ‘and physiological measures, the effects ofa six-sesion re- laxation training program on MPA measured in an in vivo performance situation were evaluated. Results of this study showed a strong therapeutic effect of relaxation training on cognitive indices of anxiety, as well as a more predictable reduction in baseline resting heart rate. Grishman's study is of particular interest because it pro- The promising effects of relaxation train- ing warrant further investigation in sub- sequent studies of MPA. vides some support for the hypothesis that the impact of modality-specifie treatment of MPA may extend co other ‘components of anxiety as well, in a manner consistent with Lang's three-factor model. Relaxation training, it would seem, is an especially likely candidate for such an effect, because ofits far-reaching effects. It is really quite difficult to be relaxed in a general sense while atthe same time feel physiologically and/or cognitively aroused. The promising effects of relaxation training warrant further investigation in subsequent studies of MPA. Those available to date have been succinctly reviewed by Lehrer,” and, in a broader perspective, by Woolfolk and Lehirer.!% SUMMARY Considerable evidence has heen amassed in recent years that MPA is a widespread bur treatable problem rhae re- sponds well to psychotherapeutic interventions directed at its cognitive, behavioral, and physiological concomitants.”” OF course, not every anxious musician meets the criteria for MPA set forth at the beginning of this article, and it is the task of the clinician to determine when perfor problems are due to MPA and when chey may be symap- tomatic of more deep-seated, pervasive difficulties. Rew- bart! has proposed a sensible, hierarchical intervention ‘model that warrants incorporation into clinical practices treating anxious musicians. He advocates beginning with symptomatic treatment, blending pedagogical and clinical procedures, progressing to more formal psychotherapeutic modalities if anxiety persists. For musicians troubled by MPA, further questions must be answered: Which aspects of the anxiety are creating the greatest distress? Is the state of arousal experienced during performances within an optimal, or at least acceptable, range? ‘Ate anticipatory tensions the real culprit, provoking avoidant behavior that limits preparation and leads to jus- tifiable anxiety onstage? Questions such as these are difficule to answer with any degree of certainty at present, due to che dearth of formal, ‘empirical studies of the nature and treatment of MPA. The studies reviewed here indicate that a stare has been made in this endeavor, but much of our understanding of MPA isstll derived from studies of other individuals equally prone to anxiety, but perhaps for different reasons and in different ways. Perhaps the recent inauguration of scholaely journals devoted to the needs and problems of performing artists will encourage additional research on a topic of vital im- portance to health care providers and performing artists alike. Acewouinanents The contributions of Paul and Phys Alpert Lehrer. Jey Jame, and David Payne tothe ideas developed inthis manuscript are tefl acknowledged March 19909REFERENCES 4 arn 5: Stage rit Cie, University of Chicago res, 1986, ‘Ammencan Payhiatric Asoxition: Diagnostic and Setsical anal ‘of Mental Dirder ded. Revised, Washington, D.C, American Bychatric Auctton, 1987 3. 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