A Systematic Review of Treatments For Music

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A Systematic Review of Treatments for Music Performance

Anxiety
Article in Anxiety, Stress, and Coping · September 2005

DOI: 10.1080/10615800500167258
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Anxiety, Stress, and Coping,
September 2005; 18(3): 183 /208
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)
Abstract
A 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 treatments
and other therapies. Issues such as the number of studies in each treatment modality, their sample
sizes and the methodological quality of most of the studies reviewed precluded firm conclusions about
the effectiveness of any of the treatments assessed for music performance anxiety. The field is in
urgent need of larger scale, methodologically rigorous studies to assist the large minority of musicians
who 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:
D.Kenny@fhs.usyd.edu.au
ISSN 1061-5806 print/ISSN 1477-2205 online # 2005 Taylor & Francis

DOI: 10.1080/10615800500167258
184 D. T. Kenny
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 account
for 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.
Barlow’s (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
vulnerabilities thatcan accountfor the development of ananxietyor mood disorder.These are a:
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 threat
perceived by the performer, is the defining feature of social phobia. Those perceiving most
Treatment review of music performance anxiety 185
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 low
trait 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 threat
by 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 performer’s 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 a
person 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 published
and unpublished primary studies in the area of MPA interventions as the precision of the
186 D. T. Kenny
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 pre–and 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 body’s 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 Nubé
(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,
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. Cohen’s d is a measure of the distance between the means (of experimental and
control 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 Cohen’s 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 Cohen’s 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
Cohen’s d. Where a simple two group design was employed, the means and standard
deviations of the experimental and control groups were used to calculate Cohen’s 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). The
behavior 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.
Kendrick’s 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
188 D. T. Kenny
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, Reitman’s 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.
Table I. Summary of Behavioral Interventions for Music Performance Anxiety
Author Year Country Subject Subject Study Treatment Control Outcome Results Effect size Conclusions
No type design measures (Cohen’s
d)
Deen 1999 (PhD USA 39 Music *2 (Groups) /2 Awareness/ No tape Performance p B/.005 .56 Treatment group,
dissertation) students (Time) repeated breathing anxiety inventory but not controls,
measures design exercise (6 (PAI) showed significant
*Randomly weeks practice Performance NS NS decrease in
assigned to with a tape) quality rating scale performance anxiety
groups. *PAI measured (PAI).
pre-treatment and
post jury
examination.
Grishman 1989 (PhD USA 41 (51% Advanced *2 (Groups) /2 Modified Waiting list Performance NS NS Treatment group,
dissertation) female) music (Time) repeated jacobsonian anxiety response relative to controls,
students and measures design progressive Q (PARQ) STAI-T showed
professionals *Randomly muscular STAI-S NS NS improvements on
assigned to relaxation Symptom p B/.05 .64 STAI-S, symptoms,
groups within (6 /2 hr questionnaire p B/.05 .72 MPAQ, and baseline
instrument sessions over Music performance HR.
Treatment review of music performance anxiety

family. 3 wks) anxiety p B/.05 .74
questionnaire
(MPAQ)
HR
*Measured pre and p B/.05 .85
post-treatment
Kendrick 1982 Canada 53 (91% Student *3 (Groups) /3 Behavior 1. CBT STAI-S NS NS Both treatment
et al. female) pianists (Time) repeated rehearsal (3 (self-instruction, Subjective Stress NS NS groups showed more
with MPA measures design weekly sessions attention- Scale improvement than
*Randomly of 1.5 /2 hrs focusing Expectation of B/.05 .62 /1.21 controls on PASS
assigned to each/ techniques) (3 Personal Efficacy and performance
groups. homework) weekly sessions Personal Efficacy quality. CBT group
of 1.5 /2 hrs scale for showed more
each/ Musicians improvement than
homework) Performance Scale behavior rehearsal
2. Waiting list for Musicians group and controls
Performance B/.05 .25 /.83 on Expectations of
Anxiety Self-State- Personal
ment Scale (PASS) Efficacy. CBT
Visual signs of showed greater
anxiety B/.05 1.24 /1.99 improvement than
Performance 1.20 /1.51 behavioral group
quality B/.05 who showed more
*Measured pre and improvement than
post-treatment FU. controls on visual
signs of anxiety.
189
190
Table I (Continued )
D. T. Kenny
d)
Mansber- 1988 USA 19 (63% Music *Simple 2 group Deep muscle No contact Self-assessed state p B/.05 1.03 Treatment group
ger (M. Music female) students comparison relaxation (3/ anxiety scale showed higher level
Dissertation) *Did not 90 min weekly (SASAS) and strength of
specifically state sessions) Level of perceived p B/.05 1.03 self-efficacy and low-
whether or not self-efficacy er SASAS scores
group assignment Strength of than controls.
was random perceived self- p B/.05 1.24
efficacy
Performance
quality NS NS
*All measures
taken after
treatment, before
juried performance
only
Reitman 1997 (PhD USA 18 (72% Music *3 (Groups) /2 1. Verbal Waiting list sEMG NS NS
dissertation) female) students (Time) repeated coping HR NS NS
with MPA measures design systematic STAI NS NS
*Randomly desensitization Performance NS NS
assigned to 2. Music Anxiety Response
groups. assisted coping Questionnaire
desensitization (PARQ)
(8 /75 min
weekly group
sessions)
Wardle 1969 USA 30 Music *3 (Groups) /2 1. Systematic Orientation Heart rate (HR) p B/.05 Insufficient Treatment groups
students (Time) repeated desensitisation session Walkins-Famham NS date showed reduction in
(Brass measures design (7 /40min *Randomly Performance Scale provided HR from pre- to
players) sessions) assigned to Behavioral NS post-test, controls
2. Insight- groups observation showed an increase.
relaxation (7/ Performance p B/.05 HR reduction greater
40 min ratings by judges Insufficient in insight group than
sessions) *Measured pre and NS date desensitization
post-treatment provided group. Treatment
NS groups showed
reduction in
instrumental
behaviors indicating
anxiety compared to
controls.
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 for
improvement 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, it
is 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/biofeedback
intervention, but this study was conducted with music students who had not specifically
192
D. T. Kenny
Table II. Summary of Cognitive Interventions for Music Performance Anxiety
d)
Patson 1996 Australia 17 (71% Opera *3 (Groups)/2 Cognitive 1. Physiological Vocal and visual NS NS No pre- or
(M.Music female) students (Time) repeated strategies (e.g. strategies (8/ manifestations of post-test
dissertation) measures design positive .5 hr sessions performance significant
*Did not self-talk etc.) over 9 days) anxiety differences for
specifically say 2. Control *Measured pre any group.
if group group (8 /.5 hr and post-
assignment walks over 9 treatment.
was random. days)
Table III. Summary of Cognitive-behavioral Interventions for Music Performance Anxiety
Author Year Country Subject Subject Study design Treatment Control Outcome mea- Results Effect size Conclusions
No type sures (Cohen’s d
Lowest;
highest)
Harris 1987 USA 17 (47% Students *2 (Groups) /3 6 /2 hr weekly Waiting list PAI p B/.001 1.25; 1.65 Treatment group, but not
female) with (Time) repeated sessions STAI-S p B/.05 .40 controls, showed lower PAI
MPA measures involving STAI-T NS NS and STAI-S, at post-test
design cognitive Test Anxiety NS NS than pretest. Treatment
*Did not self-Instruction, Inventory (TAI) group showed pre to post
specifically say if relaxation Anxiety rating p B/.01 improvement in
assignment to training, from teacher 1.31 teacher anxiety ratings (not
groups was imagery & *Measured pre reported for
random. behavioral and post- controls)
rehearsal treatment and at Improvements in PAI and
3 mth follow-up teacher rating, but not
STAI-S, were maintained at
follow-up in treatment
group.
Kendrick 1982 Canada 53 (91% Students *3 (Groups) /3 CBT (self- 1. Behavior STAI NS NS Both treatment groups

et al. female) pianists (Time) repeated instruction, rehearsal-3 Subjective Stress NS NS showed more improvement
with measures attention- weekly sessions Scale than controls on PASS and
MPA design focusing of 1.5-2 hrs Expectations of B/.05 .62; 1.21 performance quality. CBT
*Randomly techniques) (3 each/ Personal Efficacy group showed more
assigned to weekly sessions homework Scale for improvement than behavior
groups. of 1.5-2 hr 2. Waiting list Musicians rehearsal group and
each/ Performance B/.05 .25;.83 controls on
homework) Anxiety Expectations of
Self-Statement Personal Efficacy. CBT
Scale (PASS) showed greater
Visual signs of B/.05 1.24;1.99 improvement than
anxiety behavioral group who
Performance B/.05 1.20;1.51 showed more
quality improvement than controls
on visual signs of anxiety.
Roland 1993 Australia 25 (88% Student *3 (Groups) /3 1. Self None Perfor- STAI-S p B/.05 1.37;1.72 Combination group showed
(PhD female) pianists (Time) repeated instruction (SI) mance quality Musical p B/.05 1.13;1.64 for pre-post and pre-FU
Dissertation) measures 2. Progressive Measured at Performance combination improvement on MPASS,
design muscle relaxa- pre-test racital Anxiety Self- group; .77 SI showed pre-post
*Randomly tion(R) (1 wk before Statement Scale for SI group improvement only. R
assigned to 3. Combination treatment), (MPASS) p B/.05 .46;1.01 showed
groups treatment (6 /1 post-test recital Performance pre-post and pre-FU
hr weekly (1 wk after quality improvement on
sessions; 2hr treatment), and *Measured at performance quality, not
sessions for 6 wk pre-test recital (1 significant for other groups.
193
combin.) follow-up. wk before
treatment),
194
Table III (Continued )
Author Year Country Subject Subject Study design Treatment Control Outcome mea- Results Effect size Conclusions
No type sures (Cohen’s d
D. T. Kenny
Lowest;
highest)
post-test recital
(1 wk after
treatment), and 6
33 (88% *3 (Groups) wk follow-up. Standard and modified
female) Music /3 (Time) STAI-S B/.05 Insufficient CBT groups didn’t differ
students repeated data on any outcome variables.
with measures Waiting list provided for when treatment groups
MPA design 1. Standard combined were combined they were
*Randomly CBT treatment superior to controls on
assigned to 2. Modified groups STAI, MPASS, SE, but not
groups. CBT (included MPASS B/.05 Insufficient PQ, at post and FU, Both
pre- data treatment groups differed to
performance provided for controls on anticipatory HR
routine & visual combined (controls lower
rehearsal etc.) Self-efficacy scale B/.001 treatment surprisingly); standard
(4 /2 hr weekly Performance groups CBT group also differed to
sessions) quality Insufficient controls on HR during
HR NS data performance (controls
*Measured at provided for lower surprisingly); no diffs
pre-test recital B/.05 combined between treatment groups.
(1 wk before treatment
treatment), groups NS
post-test recital Insufficient
(1 wk after data
treatment), and provided for
5 wk follow-up. combined
treatment
groups
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 high
level 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 their
anxiety 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 group
music therapy intervention as compared to attentional control subjects (all effect sizes /2).
196
Table IV. Summary of Combined Interventions for Music Performance Anxiety
Author Year Country Subject Subject Study design Treatment Control Outcome measures Results Effect size Conclusions
D. T. Kenny
No type (Cohen’s)
Brodsky 1997 Israel/ 54 (50% Professional *3(Groups) /3 1. Counselling None General Health NS NS Few differences
& UK females symphony (Time) repeated 2. Counselling/ Questionnaire between treatments.
Sloboda approx.) orchestra measures design relaxation/ (GHQ-28) Together the
musicians *Subjects listening to music STAI B/.005 Insufficient treatments led to pre
matched before 3. Counselling/ data to post
being randomly relaxation/ music provided improvements in
assigned to one and music- Derogatis Stress NS NS anxiety, depression,
of three generated Profile (DSP) anger, fatigue,
interventions vibration POMS B/.0005 Insufficient confusion,
sensations data psychological stress,
provided work overload, work
Maslach Burnout NS NS relations, performer’s
Inventory stress. *Stats poorly
Appraisal of Music B/.05 Insufficient done in this study.
Performer’s Stress data
(AMPS) provided
Music Performance NS NS
Stress Survey (MPSS)
*Measured pre and
post-treatment, and 2
month FU.
Clark & 1991 USA 29 Musicians *4 (Groups) /2 1. CBT/Placebo Placebo Subjective anxiety pB/.05 .29 CBT groups showed
Agras (including (Time) (P) medication during musical (CBPT/P v greater pre to post
full-time repeated 2. CBT/ performance Placebo) fall in music &
prof) with measures Buspirone Subjective anxiety pB/.05 .62 (CBT/ speech anxiety than
social design 3. Buspirone during speech P v Placebo) non CBT groups.
phobia *Randomly (CBT /5 weekly Heart rate during NS NS Placebo groups
(with regard assigned to meetings) [Busp / musical performance showed a greater pre
to perfor- groups. 5mg tab, up to Heart rate during NS NS to post fall in
mance *Double blind 12/day, for 6 speech Self-Statement
situations). study. weeks] Self Statement pB/.05 .40;1.05 Questionnaire than
Questionnaire buspirone groups.
Personal report of pB/.05 .86;2.36 CBT groups showed
confidence as greater pre to post
performer fall in performer
Musical performance pB/.05 1.64 confidence at 1 mth
*all measured pre and follow-up than non
post treatment CBT groups.
(Personal report of CBT/placebo
confidence also 1mth group showed
follow-up) greater post to FU
improvement on
performer
confidence than each
Table IV (Continued )
No type (Cohen’s)
of the other 3 groups.

CBT/placebo
group showed more
improvement over
time in musical
performance than
placebo alone group.
CBT/placebo
group showed
improvement from
pre to post on the
self-statement
questionnaire
compared to
buspirone alone
group.
Nagel et 1989 USA 20 (60% Music *2 (Groups) /2 Progressive muscle Waiting list Performance Anxiety B/.001 1.51 Significant greater
al. female) students (Time) relaxation, Inventory (PAI) pre to post reduction

with MPA repeated cognitive therapy, STAI-T B/.05 0.40 in performance
measures design biofeedback STAI-S NS NS anxiety and trait
*Randomly training (6 weekly Test Anxiety Inventory NS NS anxiety in treatment
assigned to group sessions/6 Autonomic Perception NS NS than control group.
groups. weekly Questionnaire (APQ)
biofeedback Rational Behavior NS NS
sessions) Inventory (RBI)
*Measured pre and
post-treatment
Niemann 1993 USA 18 (78% Music *2 (Groups) /2 6/35 min Waiting list STAI-S and T pB/.01 Insufficient Significant pre to
et al. female) students (Time) biofeedback data post improvements
with MPA repeated sessions/6/1 hr provided were found on
measures design group meetings Facilitating/ pB/.01 anxiety scales.
*Assignment to (training in coping debilitating anxiety
groups based on strategies; muscle scales *Measured pre
study schedule relaxation, and post-treatment
of students. breathing
awareness,
imagery) &
coinciding practice
of the strategies
with sedative
music during
individual
biofeedback
197
training.
198
Table IV (Continued )
No type (Cohen’s)
D. T. Kenny
Sweeney 1982 USA 49 (49% Music *5 (Groups) /2 1. Cue-controlled 1. Standard Achievement Anxiety NS NS CCR and CR alone,
& Horan female) students (Time) relaxation (CCR) treatmen Test Scale (AATS) but not combined,
with MPA repeated 2. Cognitive t(ST) Musical Performance B/.05 1.27;1.62 led to lower pulse
measures design restructuring (CR) control Competence (MPC) rate than ST control;
*Matched by 3. CCR/CR (All (Musical Behavioral Index of B/.05 .88;1.000 no diff between
pretest scores had 6 weekly Analysis Anxiety (BIA) treatments. All 3
then randomly sessions of 60 min Training) Pulse rate B/.05 .24;.86 treatments were
assigned to each) 2. Waiting Piano Performance B/.05 1.58;2.000 superior to ST
groups. list Anxiety Scale (PPAS) control (and did not
Anxiety Differential B/.05 1.56;1.75 differ from each
(AD) other) on PPAS, AD,
*Measured pre and MPC (except CR),
post-treatment and BIA (except
CCR).
Sweeney- 1997 (D.Ed. USA 30 (43% Music *2 (Groups) /2 Diaphragmatic No training STAI-T and S but NS NS No significant diffs
Burton Dissertation) female) students (Time) breathing, results reported only between treatment
repeated progressive muscle for S. and control groups
measures design relaxation, Adjudicator NS NS with regard to
*Did not autogenic training, Performance Rating pre-post changes in
specifically say biofeedback. Form TAI or music
if group *Measured pre and performance.
assignment was post-treatment.
random.
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 further
consideration 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 individual’s 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, and
experience 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 MPA
and 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 was
weakened 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, Stanton’s 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 natural
alignment of head, neck and spine that has associated with it qualities of balance, strength
200 D. T. Kenny
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 one’s 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 the
opposite 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 Nubé (1991) have published comprehensive reviews of the impact of
beta-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 those
musicians who report primarily somatic manifestations of their anxiety (e.g. palpitations,
Table V. Summary of Other Interventions for Music Performance Anxiety
No type (Cohen’s d)
Chang 2001 USA 20 (75% Music *Post-test only Meditation 1. Meditation Performance Anxiety pB/.05 .41 No significant diffs
female) students control group (8 weekly 2. No Inventory (PAI) between treatment and
in piano, design 1.25 hr treatment Cognitive Interference NS NS control groups with
violin and *Randomly as- sessions) Control Questionnaire (CIQ) regard to pre-post
voice signed to Concert Performance- NS NS changes in STAI or
groups. Heart rate and blood music performance.
pressure
McKinney 1984 USA 32 male Music 2 (Groups) Biofeedback No training Peripheral skin NS NS Biofeedback group
students /2 (Time) training control temperature (PST) showed greater pre to
in wind repeated (2 /15 min post increase in WFPS
instru- measures sessions/wk STAI-S NS NS than control group. No
ments design for 5 weeks) significant differences
*Did not Watkins-Famham pB/.05 .83 between biofeedback and
specifically Performance Scale control groups with
state whether (WFPS) regard to pre-post
group Performance rating by NS NS changes in PST, STAI-S
assignment three judges (PRJ) or PRJ.

was random.
Montello 1990 USA Exp1: 17 Freelance *2 (Groups) Group music Waiting list Personal Report of pB/.01 2.61 Therapy group showed
et al. musicians /2 (Time) therapy (12 Confidence as a greater increase in PRCP
with MPA repeated weekly 1.5 hr Performer (PRCP) pB/.05 0.67 than both control groups.
measures sessions) STAI-T Therapy group,
design compared to attentional
*Randomly as- *Measured pre and controls, became more
signed to post-treatment. musical, less stressed,
groups. and less self-involved
Exp2: 24 Freelance *3 (Groups) Group music 1. Waiting list PRCP STAI-T pB/.001 2.46 during performance from
(53% musicians /2 (Time) therapy (12 2. Attentional Narcissistic NS NS pre to post. Therapy
female) with MPA repeated weekly 1.5 hr control (this Personality Inventory pB/.05 0.16 (cited group moved
measured sessions) group met (NPI) in article) significantly towards nor-
design weekly with Performance pB/.001 2.29 malcy on the NPI (from
*Randomly as- therapist to musicality pre to post) compared to
signed to complete psych Performance stress pB/.001 2.10 attentional controls but
groups. tests and symptoms not waiting list controls.
discuss musical Performance pB/.001 2.47
topics) self-involvement
*Measured pre and
post-treatment
Richard 1992 (D.Ed. USA 21 Music *3(Groups) 1. Eriksonian Waiting list Musical Performance NS NS Significant pre to post
Dissertation) students /2(Time) Resource Stress Inventory improvement on STAI-S
with MPA repeated Retrieval (4 (MPSI) and PRCP for Eriksonian
measures /45 min STAI-S NS NS group. No significant
201
design weekly Personal Report of NS NS group/time
*Randomly sessions) Confidence as a interactions.
202
Table V (Continued )
No type (Cohen’s d)
D. T. Kenny
assigned to 2. Cue- Performer (PRCP) NS NS
groups. controlled Cognitive strategies
relaxation assessment
(6 /45 min Performance NS NS
weekly competence
sessions)
Stanton 1994 Australia 40 Music *2(Groups) Hypnotherapy Discussion Performance Anxiety pB/.01 1.26 (Pre v Significant reduction in
students /3(Time) (2 /50min with lecturer Inventory (PAI) Post) PAI following treatment,
with MPA repeated sessions 1 (matched for 1.98 (Post v but not control. Further
measures week apart) session length) *Measured pre, post FU) significant reduction in
design and 6 months later treatment group at 6
*Paired on ba- month follow-up.
sis of PAI
scores then
randomly
assigned to
groups within
each pair.
Valentine 1995 UK 25(84% Music *2 (Groups) Alexander No lessons Heart rate pB/.05 Insufficient Controls showed greater
et al female) students /4 (Time) Technique in AT Musical quality pB/.05 data increase in heart rate
repeated (15 lessons) Technical quality pB/.05 provided variance from audition to
measures Nowlis Mood pB/.05 0.25 recital than treatment
design Adjective Checklist 0.13 group. Treatment group
*Randomly as- Music Performance pB/.06 Insufficient showed pre to post class
signed to Anxiety data improvement in musical
groups Self-Statement Scale provided and technical quality,
*Most measures taken Insufficient controls showed
at audition, in class data opposite.
prior to treatment, provided Treatment group showed
in class following pre to post increase in
treatment, and at final active and warm-hearted
recital. scales of Nowlis, controls
showed decline.
Treatment group showed
greater pre to post
decrease in anxiety scale
of Nowlis than controls.
Treatment group showed
increase in positive
attitude to performance
(MPASS) from pre to
post, controls showed
decline.
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).
Nubé (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; Lidén & 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 Nubé (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 of
medication on intonation in string players while Pearson and Simpson (1978), (as cited in
Nubé, 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 prior
to 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 be
quite different.
204 D. T. Kenny
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 associated
with 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 pieces
played 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 performance
while 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 from
the 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 for
music performance anxiety, although it is premature to make such an assertion in view of
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. Behavior
rehearsal, 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 shown
to 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 or
more treatment modalities, and which investigate the effectiveness of combined treatments.
206 D. T. Kenny
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 the
crucial 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 employed
consistently 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.
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A Systematic Review of Treatments for Music Performance

Article in Anxiety, Stress, and Coping · September 2005

Dianna Theadora Kenny

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A Systematic Review of Treatments for Music

A Systematic Review of Treatments for Music Performance Anxiety

ISSN 1061-5806 print/ISSN 1477-2205 online # 2005 Taylor & Francis

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

Treatment review of music performance anxiety

Treatment review of music performance anxiety

of the other 3 groups.

Treatment review of music performance anxiety

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

Treatment review of music performance anxiety

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

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