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Journal of Consulting and Clinical Psychology 1982, Vol. 50, No.

3, 353-362

Copyright 1982 by the American Psychological Association, Inc. 0022-006X/82/5003-0353$00,75

Cognitive and Behavioral Therapy for Musical-Performance Anxiety


Margaret J. Kendrick, Kenneth D. Craig, David M, Lawson, and Park O. Davidson University of British Columbia, Vancouver, Canada

\ The present study compared the efficiency of cognitive-behavioral therapy, emphasizing self-instruction and attention-focusing techniques, with behavior rehearsal and with a waiting-list control in the treatment of debilitating musicalperformance anxiety. Clients were S3 pianists who experienced extreme anxiety in performing situations. Therapy sessions were conducted over a 3-week period with clients who met three times in small groups for l'/2 to 2 hours on each occasion and who also completed homework assignments. Self-report, behavioral, and physiological indexes of anxiety were collected at baseline, treatment termination, and follow-up intervals, Multivariate analyses indicated that both the cognitive-behavioral therapy and behavior-rehearsal programs were effective in reducing musical-performance anxiety in comparison to the control condition at the follow-up assessment, although there were no differences among groups at treatment termination. The cognitive therapy was more effective than the behavior-rehearsal program on several measures. Cognitive mediators of therapeutic change were examined and are discussed.

A burgeoning interest in patterns of thought as determinants of problematic behavior has prompted the development of innovative cognitive-behavioral interventions designed to change faulty styles of thinking (Beck, Rush, Shaw, & Emery, 1979; Mahoney, 1974; Meichenbaum, 1977). While all therapies relying on verbal communication have recognized the importance of cognitive processes, early formulations led to interpretative psychotherapies that have not been found effective (Rachman & Wilson, 1980). In contrast, recent theoretical accounts of behavior change have proposed cognitive mediational processes more directly related to observable behavior. For example, Bandura (1977) proposed that behavioral intervention procedures change defensive behavior by altering perceptions of self ^efficacy. Similarly, Meichenbaum (1977) concluded that therapeutic interventions are effective to the extent that they alter*covert self-instructions. Significantly, recent reviews have concluded that there is growing
Requests for reprints should be sent to Kenneth D. Craig, Department of Psychology, University of British Columbia, 2075 Wesbrook Mall, Vancouver, British Columbia, Canada V6T 1W5.

support in clinical-outcome research for incorporating techniques based on cognitive processes in what has become known as cognitive-behavior therapy (Foreyt & Rathjen, 1978). Performance anxiety represents a particularly appropriate therapeutic target for cognitive-behavior therapy. High levels of performance anxiety have been associated with excessive task-irrelevant ideation in evaluative situations. In these circumstances, test-anxious persons (a) worry about their performance and how well others are doing; (b) ruminate over alternative responses; (c) become preoccupied with feelings of inadequacy, anticipation of punishment, loss of status and self-esteem; and (d) become distracted by heightened somatic and autonomic arousal (Mandler & Sarason1, 1952; Marlett & Watson, 1968; Sarason, 1975, 1978; Wine, 1971). In fact, several investigators found that excessive emotional reactions were less likely to interfere with the performance of high test-anxious persons than was worrying over the performance (Doctor & Altman, 1969; Morris & Liebert, 1970; Wine, 1971). Musical-performance anxiety was selected as the therapeutic target for the pres-

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ent investigation because it represents a relatively unexamined but seriously debilitating problem that functionally impairs large numbers of people. Some degree of musicalperformance anxiety is experienced by most musicians, both amateur and professional, during their musical careers. If excessive, it can lead to inefficient use of musical skills and sufficiently adverse performing experiences to discourage students from further study of music (Appel, 1976). A prima facie case can be made for important qualitative distinctions between the demands made on performing musicians and other forms of evaluative performance. The musician must be in absolute control of motor coordination involving the finest muscle action, has to trust memory, and at the same time must feel and project the music to sophisticated audiences with authority and conviction (Deri, 1962). Several attempts to reduce musical-performance anxiety have been reported, using relaxation training, "insight therapy," musical analysis, systematic desensitization, and systematic rational restructuring (Appel, 1976; Goldstein, 1975; Lund, 1972; Wardle, 1975). The evaluation of strategies that explicitly focus upon cognitive mediators of performance anxiety among musicians has only just begun. Moreover, development of additional cognitively based techniques is warranted in view of the findings (Kendrick, Craig, Lawson, & Davidson, Note 1) that high-anxious performers were more selfpreoccupied and self-deprecating than lowanxious performers. A cognitive technique that can be readily adapted to the problems of performing musicians has been developed by Meichenbaum (1977). In the method of self-instructional training, clients are taught the constructive skills of becoming aware of negative thoughts and substituting positive and task-oriented self-statements for them. Accordingly, a self-management attentional training program that also incorporated modeling instruction and homework assignments was developed for evaluation in the present study. An advantage of focusing on musical-performance anxiety is that ^t affords an op-

portunity to compare a cognitive-behavioral program with behavior rehearsal, a technique that has been widely used by the musical community to cope with anxiety about forthcoming performances. Although behavior rehearsal is a component of empirically validated treatment procedures such as participant modeling (Bandura, 1971) and assertiveness training (McFall & Twentyman, 1973), when used alone it has not been effective consistently (Bellack & Hersen, 1977; Johnson, Tyler, Thompson, & Jones, 1971; Paul, 1966). In the present study, a behavior-rehearsal program was developed based on empirical findings, theoretical expectations, and current practice in the musical community (Kendrick, 1979). It included the following: (a) a nonthreatening, friendly audience, (b) positive feedback and nonpunitive reactions following performances, (c) hierarchical presentation of anxiety-producing performance situtions, and (d) assuredsuccess experiences during early behaviorrehearsal performances. The question remained whether the addition of the attention-focusing, self-instructional treatment would lead to additional therapeutic benefits. It has been suggested that cognitive-behavioral treatment combinations might be effective across a greater domain of subjective, behavioral, and physiological measures and that they may result in greater maintenance of treatment effects (Mahoney & Arnkoff, 1978). Thus, the criterion adopted for deciding whether the cognitive-behavioral program should be advocated for general application to performanceanxious musicians was whether it enhanced the benefits of the empirically refined behavior-rehearsal technique. Measurement of performance anxiety and treatment outcome was based upon a multidimensional formulation of anxiety (Lang, 1977) that acknowledges that subjective, physiological, and behavioral indexes of anxiety commonly vary independently and may be differentially affected by treatment. Measures in each modality were obtained during a solo performance before an audience prior to treatment and at treatment termination. At a 5-week in vivo follow-up, self-report measures were obtained, and significant oth-

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ers who were members of the audience provided ratings of both visual signs of anxiety and quality of performance. Method Subjects
Fifty-three pianists ranging in age from 12 to S3 years (M = 18.83, SD = 7.61) were selected from volunteers referred by music teachers throughout the metropolitan Vancouver area. To be selected for participation, the subjects had to be identified by their teachers as having extreme musical-performance anxiety, and the subjects had to report debilitating anxiety on at least 5 of the IS items on the Report of Confidence as a Performer Scale (Appel, 1974) that indicate the occurrence of disruptive anxiety during musical performance (M = 9.42, SD = 2.99). Only three volunteers were rejected as subjects because they did not satisfy the latter criterion. There were 48 females and 5 males, a distribution that is representative of the proportion of females to males studying piano (Reubart, Note 2). Grade levels of musical accomplishment ranged from 3 to 12 (M = 8.06, SD = 2.18) according to the scale used by the Royal Conservatory of Music in Toronto.

Apparatus
Two performance assessments were conducted in a music studio on the University of British Columbia campus using a grand piano. A Sonymatic portable camera and videorecorder were used to record performances. A 21-inch (5.3 cm) television set provided playback for rating purposes. Heart rate was recorded via Beckman electrodes attached to the neck and lower left rib cage, and the signal was transmitted through an EKEG Industries telemetric system to a 7P4A tachograph on a Grass Model 7 polygraph. The audio track of the modeling sequence was recorded on a cassette tape for use with a Singer Caramate II SP projector.

Therapist
The therapist for both treatment groups is a Registered Psychologist in the Province of British Columbia and held an Associateship of the Royal Conservatory of Music (ARCT) in Toronto in piano performance.

Measures
Self-report. Three self-report instruments were administered to subjects immediately before they entered the studio for a performance: the State Anxiety Inventory (Spielberger, Gorsuch, & Lushene, 1970), the Subjective Stress Scale (Neufeld & Davidson, 1972), and the Expectations of Personal Efficacy Scale for Musicians (Kendrick et al., Note 1). The latter scale assesses the magnitude, strength, and generality of pianists' expectations of being able to complete a number of musical tasks with anxiety under control. Immediately after each performance, the Perfor-

mance Anxiety Self-Statement Scale (Kendrick et al., Note 1) was completed. This scale assesses pianists' positive and negative thoughts before, during, and after a performance. Negative thoughts included those that were self-depreciating and pessimistic, whereas positive thoughts included favorable self-references and taskoriented instructions. A single summative score was derived by adding the total score for positive thoughts to the total inverse score for negative thoughts. This sum was justified by a significant negative correlation between the positive and negative scores (r - -.30, p < .04). To assess possible differences in expectations of treatment effectiveness, subjects were queried after each session whether the program appeared logical to them, how' confident they were that the program would eliminate their fear of performing, and whether they would recommend the program to a friend who was extremely anxious about performing. Earlier studies (Kendrick et al., Note 1), including item analyses and tests of consensual, concurrent, and construct validity, as well as measures of test-retest reliability and internal consistency, had indicated that the Performance Anxiety Self-Statement Scale and Expectations of Personal Efficacy Scale for Musicians satisfied conventional criteria for reliability and validity. Behavioral. Two behavioral measures were derived from each performance. The first, an error count, was based on Appel's (1976) conclusion that performanceerror count was the most sensitive indicator of performance anxiety in musicians. It was provided by two pianists who held university degrees in music and ARCTs in piano performance. They worked independently from copies of the musical score and audio tape recordings and were blind as to experimental group and order of performance. Each subject's two performances were presented consecutively in counterbalanced order. Error types were classified as those of pitch, omission, rhythm, tempo, dynamics, and touch, using explicit definitions. Raters listened to each performance three times: the first to note a mistake of any type on the score, the second to identify the type of error, and the third to confirm the decision. Each performance provided a total error score. A time-sampling checklist of behavioral signs of performance anxiety was also developed that resulted in a set of seven categories: knees tremble, lifts shoulders, stiff back and neck, hands tremble, stiff arms, face deadpan, moistens lips. Two raters (both musicians) worked independently from video recordings without the sound and scored the target responses as having occurred or not occurred in each of three 20-sec intervals at the beginning, middle, and end of the performance. The two performances were presented in counterbalanced order with raters blind as to group membership and performance order. Physiological. Mathews (1971) reported that skin resistance and cardiovascular responses, particularly heart rate, demonstrated the most consistent changes to desensitization and related therapies. Heart rate transmitted through a telemetering system was selected for the present study because the measurement devices would interfere minimally with actual musical perfor-

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KENDRICK, CRAIG, LAWSON, AND DAVIDSON record positive and negative thoughts, and rate anxiety level and performance quality. The second session involved the following: (a) a review of the rationale and discussion of the home assignment; (b) two slide-tape cognitive-modeling sequences of pianists in examination and competition situations; (c) discussion of anxieties in evaluative situations; (d) the therapist playing a piece of music and verbalizing thoughts aloud; (e) all subjects doing this same task; (f) homework instructions asking for performance in front of a small group; and (g) practicing a piece of music at home while pretending to perform for someone, verbalizing thoughts out loud, and challenging negative thoughts and replacing them with positive, task-focused ones. The third session involved: (a) a review of the rationale and discussion of the home assignment; (b) development of lists of positive self-statements, (c) a cognitive-modeling sequence of a pianist in solo recital; (d) performance of two pieces of music with the subjects sharing their thoughts; and (e) imaginary rehearsal thoughts while the therapist described the process they went through in musical competition, and (f) home assignments paralleling the earlier tasks but also asking subjects to take themselves through two imaginary sequences (examination and recital) and to actually perform as part of the sequence. A standardized treatment manual provided the basis for both treatment approaches (Kendrick, 1979). Behavior rehearsal. Each of the two small groups (eight subjects per group) met once a week for 3 consecutive weeks for 1 '/i to 2 hours. The first session began with a discussion of performance anxiety. Subjects described their experiences, including anxiety-inducing moments and ways in which they had attempted to cope. The therapist then described models of the origins of performance anxiety and a treatment rationale for undertaking repeated practice before an audience. Support for repeated rehearsal was provided by quotations from well-known musicians and eminent musicologists, After the therapist modeled playing a piece of music, subjects were asked to do so. The response from other group members was positive and encouraging, and the general atmosphere was friendly and supportive. A home assignment to perform for family members was then described. Subjects also were asked to rate their anxiety and the quality of their performances at home. Sessions 2 and 3 were very similar. At the end of each session, a similar home assignment was given with encouragement to enlarge audience size and include nonfamily members among those listening.

mance. Seven 10-sec samples were selected from the continuous recording of telemetered heart rate beginning after entry into the studio and ending immediately after the performance.

Procedure
Subjects were randomly assigned to groups: attentional training (N = 19), behavior rehearsal (TV = 16), and waiting-list control (N= 18). Assessment began immediately for control subjects. They were not informed they were in a waiting-list control, but were told that scheduling requirements would necessitate a substantial delay (aproximately 8 weeks) in sessions. Assessment sessions. A pretreatment baseline assessment session provided demographic, self-report, behavioral, and physiological data. The major requirement during this session was that subjects were to perform a self-selected piece of music of 3 to 5 minutes duration that they had earlier mastered in a nonperforming situation. Upon arrival at the studio, details of the session were provided and electrocardiogram (EKG) electrodes were attached. Questionnaires were also completed. In the studio, subjects were seated and performed when ready. The second performance assessment at the termination of treatment paralleled the first. Provision was also made during the second performance assessment for the subjects to provide follow-up information. They were given a package with instructions asking them to select as demanding a performing situation as possible. The instructions indicated that adjudicated performance at an examination, music festival, or a concert would be preferred. The package also contained questionnaires similar to those used during the two performance assessments. To provide ratings by someone other than the performer, each subject was asked to solicit in advance performance ratings from a member of the audience who had heard them play frequently in recent months. These subject-solicited observers provided evaluations of visual signs of anxiety and quality of performance at the time of the follow-up performance. Treatment sessions: Attentional training. Each of two groups (10 subjects in one group and 9 in the other) met for 1V4 to 2 hours one evening for each of 3 consecutive weeks. Negative and task-irrelevant thoughts during piano performance were solicited first as subjects viewed videotapes of their baseline performance. This segment was followed by presentation of a treatment rationale relating negative thinking to performance anxiety, poor performance, and the potential for "vicious circles." The technique of challenging negative thoughts followed by substituting and attending only to taskoriented and positive thoughts was recommended. Four types of positive self-statements were described: comforting, task focusing, technique oriented, and self-rewarding. A slide-tape, cognitive-modeling sequence of a pianist performing for a group of friends was then shown and discussed. A coping model, who shared but overcame the subject's fear, was portrayed. At the end of the session, home-assignment instructions identical to those given to the behavior-rehearsal group, but including an attentional-training component, were provided. Subjects were to perform for family members,

Results Group Comparability One-way between-group analyses of variance (ANOVAS) yielded no initial differences among groups (p > .05) on age, level of musical proficiency (grade), reported performance anxiety, number of months of preparation, number of performances or length

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of the test piece, and practice of the test piece after the pretest and prior to the follow-up assessment. Prior to intervention, the group as a whole displayed substantial evidence of subjective anxiety, physiological arousal, and frequent performance errors (see Table 1). Because several outcome measures were employed to evaluate treatment effectiveness, multivariate analyses of variance (MANOVAS) were used to assess group comparability during

baseline assessment (see Table 1). The obtained F value was significant, approximate F(12, 80) = 2.37, p< .01, indicating pretreatment differences among experimental conditions. To identify the source of the significant effect among the individual measures, univariate ANOVAS were performed. These indicated significant effects for expectations of personal efficacy, F(2, 45) = 4,39, p < .02, and near significant effects for performance-error count (p<.15) and heart

Table 1 Means and Standard Deviations of Outcome Measures


Group"

AT (n = 16)
Measure STAI

BR ( = 16)
SD SD

WLC (n = 16)
M
SD

M
49.56 38,38 34.69
2.27 1.18

Pre
Post Follow-up

10.22 8.88 8.75

49.69 41.63 39.00


2.97 1.44 1.52

* 14.25 11.81 10.20

52.88 43.44 45.19


2.46 2.09 2.34

11.75 11.87 13,53

SSS Pre
Post Follow-up PASSS

1.36 1.09

.92
200.94 255.63 265.69 34.50 40.50 44.88
11.37 * 9.37

.81
64.70 50.99 43.92
9.39 9.71 7.90 6.69 5.20
21.12 15.62

1.35 1.35 1.06


49.41 60.58 58.77 10.49 9.76 9.51

1.52 1.44 1.50

Pre
Post Follow-up EPES

203.00 228.50 241.88 28.56 34.50 35,44


8.62 8.64

193.13 215.19 184.63


24.31 27.19 29.88

63.95 46.85 64.74


9.40 12.19 9.59 4.60 4.58

Pre
Post Follow-up

PEC Pre
Post Follow-up

5.02 5.29

7.60 7.51

HRM Pre
Post . Follow-up

109.26 102.75

15.48 14.32

123.93 118.41

19.40 16.25

117.54 109:42

VSA Pre
Post Follow-up


2.38

.62 1.00

1.38 1.56

.96

1.53 1.72

.06

QP Pre
Post Follow-up

1.94

1.15

-.19

Note, AT ** attentional training; BR = behavior rehearsal; WCL = waiting list control; STAI = State Anxiety Inventory; SSS = Subjective Stress Scale; PASSS = Performance Anxiety Self-Statement Scale (total score); EPES = Expectations of Personal Efficacy Scale (total score); PEC = performance-error count; HRM = mean heart rate; VSA = improvement in visual signs of anxiety; QP = improvement in quality of playing. * The sample size was reduced to an N of 48 for the purposes of MANOVA statistical analyses. Data were incomplete on one subject.

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Table 2 Interrater Reliabilities in Percentages


Variable Performance-error count Visual signs of anxiety Group Pretreatment Posttreatment

AT BR WLC AT BR WLC

87.3 88.0 94.2 82.1 84.0 97.6

90.2 92.3 95.2 81.6 96.9 85.2


behavior re-

Note. AT = attentional training; BR hearsal; WLC = waiting-list control.

rate (p < .10). As a conservative approach for subsequent analyses, these three variables were used as covariates. The ANOVAS on answers to questions relating to expectations of treatment effectiveness revealed no group differences. Therefore, differential treatment effects could not be attributed to expectancy factors. Reliabilities Interrater reliabilities for observer-judged dependent measures appear in Table 2. These represent the smaller total divided by the larger one and multiplied by 100. Following Kazdin and Straw's (1976) convention that agreement should fall between 80% and 100%, agreement for the two variables of performance-error count and visual signs of anxiety was quite acceptable. Treatment Effects To evaluate differential treatment effects, two one-way between-group multivariate analyses of covariance (MANCOVAS) were performed separately on six post- and six follow-up measures, with pretreatment expectations of personal efficacy, performanceerror count, and heart rate as covariates. As performance-error count and heart-rate measures were not taken at follow-up, two other measures were used instead: behavioral ratings of visual signs of anxiety and quality of playing as assessed by significant others. At follow-up, therefore, only the pre-

treatment measure of expectations of personal efficacy was used as a covariate. Means and standard deviations appear in Table 1. The resulting F value for the postmeasures was not significant, approximate F(12, 74) = < 1, p > .05; however, the F value for the follow-up measures was significant, approximate F(12, 78) = 3.05, p < .01. Thus, groups did not differ at treatment termination, but did 5 weeks after the termination of treatment. To isolate the source of treatment effects at follow-up on individual measures, six univariate analyses of covariance were computed on the six follow-up measures with pretreatment expectations of personal efficacy as a covariate. With the exception of the State Anxiety Inventory and the Subjective Stress Scale, all measures were significant (p < .01). Paired group differences for each measure were examined with Newman-Keuls Tests. These revealed that on the Performance Anxiety Self-Statement Scale and the quality of playing rating, the attentional training and behavioral-rehearsal groups were superior to the waiting-list control (p < .05), although they did not differ from each other. Univariate analyses of positive and negative self-statements at follow-up indicated a reduction in the incidence of negative thoughts rather than an increase in positive thoughts. A significant effect for treatments and analyses of paired group differences indicated that the two treatments had yielded fewer (p < .05) negative thoughts than the controls, but they did not differ from each other. On the Expectations of Personal Efficacy Scale, attentional training was superior to behavior-rehearsal and waiting-list control conditions (p < .05), with no significant difference between the latter two. On the visual-signs-of-anxiety rating, the attentionaltraining, behavior-rehearsal, and waitinglist-control groups differed significantly from each other in that order of effectiveness (p < .05). Supplementary analyses examined whether the number of completed home assignments was related to therapeutic outcome. Subjects had been instructed to monitor their use of the techniques. The

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Both the cognitively based treatment program and the behavior-rehearsal program proved effective in reducing musical-performance anxiety, in contrast to a waiting-list Posttreatment Measures as Predictors of control condition. On the measures of indiOutcome vidual components of anxiety at follow-up, Table 3 provides Pearson product^mo- both attentional training and behavior rement correlation coefficients of relationships hearsal were more effective than no treatamong measures taken at posttreatment and ment in reducing visual signs of anxiety, in at follow-up. Of particular interest were the improving the quality of playing, and in two cognitive mediational variables, self-talk yielding salutary changes in self-talk. Attenand self-efficacy, as predictors of follow-up tional training was superior to behavior rebehavior. The expectations-of-personal-effi- hearsal in reducing visual signs of anxiety cacy measure at posttreatment was posi- and in enhancing expectations of personal tively correlated with improvements in visual efficacy. signs of anxiety at follow-up (/ = .34, Differences among groups were not evi/x.Ol), and quality of playing (r-,29, dent at the end of the brief treatment prop < .05). Positive thinking at posttreatment grams, perhaps reflecting an emphasis was associated with greater improvement in on producing changes in performance in visual signs of anxiety (r = .25, p < .05), but the natural environment. Self-management was not significantly related to quality of therapeutic programs commonly lead to conplaying. Although performance-error count tinued improvement subsequent to treatment at posttreatment was not related to either termination because clients persist in exerof the behavioral measures at follow-up, vi- cising newly acquired skills (Kanfer, 1979). sual signs of anxiety at posttreatment were In the present study, it was fortunate that inversely related to improvement in visual in vivo follow-up generalization measures signs of anxiety at follow-up (r = .40, were collected from the musicians and sigp < .001). Thus, the cognitive measures ap- nificant others during a performance in the peared to predict follow-up performance bet- community. The fact that observers knew ter than behavioral measures at treatment that the subjects were involved in treatment termination. may have biased their ratings in favorable Tables
Posttreatment Measures as Predictors of Outcome fn = 48) Group Measure STAI SSS PASSS EPES PEC HRM Follow-up STAI .77*** .51*** -.53*** -.59*** .07 .12

attentional-training group reported completing 95% of their assignments, and the behavior-rehearsal group completed 75% of the assignments. The number of completed assignments did not correlate with therapeutic outcome (p > .10).

Discussion Treatment Outcome

SSS
.54*** .51*** -.25* -.58*** -.29 .12

PASSS
-.30* -.39** .56*** .36** .09 -.28*

EPES -.38** -.36** .31* .81*** .08 -.07

VSA
.33** .44*** -.25* -.34** -.35 .22

QP
.26* .40** -.15 -.29* -.24 .15

STAI = State Anxiety Inventory; SSS = Subjective Stress Scale; PASSS = Performance Anxiety Self-Statement Scale (total score); EPES = Expectations of Personal Efficacy Scale (total score); PEC = performance-error count; HRM = mean heart rate; VSA = visual signs of anxiety; QP = quality of playing. * p < .05, one-tailed. **p < .01, one-tailed, ***p < .001, one-tailed.

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KENDRICK, CRAIG, LAWSON, AND DAVIDSON

directions. However, this prior knowledge would not account for the reliable betweengroup differences observed in these ratings. Treatment Components While the labels attached to the treatment programs signified their most salient components, they were far more complex and shared components of verbal persuasion, modeling instruction, performance accomplishments, group influence, and homework assignments (Rosenthal, 1980). Cognitive therapy. The additional benefits of attentional training, beyond the success of behavior rehearsal, provided support for the position that dealing directly with maladaptive thoughts would complement behavioral techniques that do not intervene intentionally with cognitive mediators (Beck & Mahoney, 1979; Goldfried, Linehan, & Smith, 1978). The finding that therapeutic gains were largely associated with reductions in negative self-statements was consistent with findings on adjustment to aversive medical procedures (Kendall et al., 1979) and coping with heterosocial anxiety (Cacioppi, Glass, & Merluzzi, 1979). As expected, both treatments affected the behavioral measures of anxiety. Both therapies shared the use of behavior rehearsal before a small supportive audience. The technique was aimed at changing behavior, and it did help the performers to control body tension (e.g., stiff arms, shaking arms and legs) and to improve the quality of their playing. More surprising perhaps was the effectiveness of both attentional training and behavior rehearsal in increasing positive and decreasing negative thoughts about performance. Thus, the expected superiority of a cognitive intervention designed to alter selftalk was not supported. This finding may be consistent with Meichenbaum's (1977) theory of behavior change, which argues that diverse therapies can be equally effective to the extent that they alter clients' self-talk. Wilson (1978) has argued similarily that directly produced behavior change may be the most effective means of changing cognitive mechanisms mediating performance.

The attentional-training program did surpass behavior rehearsal in enhancing efficacy expectations. Bandura (1977) predicted that performance-based treatments would be supplemented by cognitive interventions in improving perceptions of self-efficacy. The effectiveness of the program may be attributed to success in having clients believe that they had serviceable coping skills available to them. Behavior rehearsal. The relatively good showing of behavior rehearsal would seem to support music teachers who fortuitously program their captive audiences to respond in a positive manner when helping anxious students. Measures. The variable impact of the treatment programs on dependent measures attested to the specificity of the effects of different treatment programs and the loose coupling of different kinds of measures of therapeutic targets. Neither treatment program affected self-reported anxiety, with effects restricted to reports of cognitive states and thoughts, behavioral expressions of anxiety, and quality of playing. Lick and Katkin (1976) noted that several studies have demonstrated that clients may make behavioral changes before evidencing reductions in cognitive distress, suggesting that further evaluations of self-reported anxiety would have been useful. In terms of predicting behavioral response to treatment, expectations of personal efficacy at posttreatment not only were positively correlated with improvement in visual signs of anxiety and quality of playing at follow-up but were also better predictors than measures of individual differences in performance accomplishments at treatment termination (cf. Bandura, 1982). Positive self-talk at posttreatment also was associated with a reduction in visual signs of anxiety but not with improved performance at follow-up. Implications for the Musical Community Music teachers could be advised that their student-rehearsal gatherings probably benefit students, provided that favorable concepts of audiences were fostered. Attentional

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training would complement this technique. Programs for music teachers incorporating attention-focusing therapeutic instructions and the cognitive-modeling slide-tape sequences appear to be feasible and to have cost-benefit advantages. It certainly would be easier to teach music teachers what they need to know about attentional training than to teach psychologists what they would need to know about music! Reference Notes
1. Kendrick, M. J., Craig, K. D., Lawson, D. M., & Davidson, P. O. Measures of cognitive mediators of musical performance anxiety. Unpublished manuscript, University of British Columbia, 1980. 2. Reubart, D. Personal communication, March 28, 1979.

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Received July 10, 1981

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