The science behind the problem Many musicians, including horn players, struggle with music performance anxiety (MPA). Through the years,wehave heard from many professionals about their individual approaches to dealing with it; however, The Horn Call has not publishedareviewofthescientificliteratureonthistopic. Dr. Julie Nagel [1], in her recent review of psychological approaches for treating MPA, observes that organic medical conditionsandthesymptomstheyevokemaybeexacerbatedby psychological factors, complicating both treatment and re-covery. She suggests that therapeutic strategies for treating many disorders require acknowledging this, and develop-ing a more holistic approach that includes psychological ap-proaches. In a previous article on embouchure dystonia (Embou-chure Dystonia: Hope for the Future? The Horn Call, Vol. 41 No. 3, May 2011), I commented on dystonias apparent associa-tionwithanxiety.Thoughthescientificcommunityisreluctanttoattributeanxietyasacausefordystonia,theassociationhasbeenmade[2,3].Itisbeyondthescopeofthisarticletoexploretheanxiety/dystoniaconnection;however,examiningperfor-manceanxietyappliestoallmusicians. This article describes the nature of MPA and samples the current literature for some general principles to understand and cope with it.

The sympathetic nervous system When we are placed in circumstances we perceive as threatening, we have a built-in mechanism for coping: a branch of our autonomic (automatic) nervous system known as the sympatheticnervoussystemthatpreparesustofightorflee.Our heart beats faster and stronger, the pupils of our eyes di-late, our airways become more open, our muscles tense, and even our salivary glands begin to secrete more viscous saliva that can give us that dreaded dry mouth feeling. While these are changes that prepare us to deal effectively with physical threats, they are counter-productive in performing artists. The fact is, our sympathetic nervous system responds to something that poses no real physical threat to us with physiologic adap-tations that are not helpful. Why? The issue is not whether a set of circumstances (audiences, adjudicators, audition panels, recording) really pose a physi-cal threat, but whether they are perceived by the individual as threatening.Whatdoesthescientificliteraturesayaboutthosefactors that lead us to inaccurate perceptions of threat? Do we acquire them naturally (by nature), do circumstances in our early development as musicians breed them (by nurture), or is it some combination? What does science say about approaches that are effective in preventing and/or dealing with debilitat-ing MPA? Does it even propose ways to channel this nervous energy in a positive way?

The dimensions of the problem Paul Salmon [4], in a review of the psychological literature, identifiesthreegeneralstatementsaboutthenatureofMPA.First, MPA includes a loosely correlated constellation of cogni-tive, behavioral, and physiological variables. Fearful thoughts, overt behaviors to perceived threats, and the activation of the sympathetic nervous system all work together to produce MPA to varying degrees. Second, the physiological arousal compo-nent of MPA relates to the degree to which this sympathetic nervous system activation has, through conditioning, become disproportionate to the real threat. Salmon makes a point that some degree of arousal is appropriate or even optimal, but that itistheexcessivenessoftheresponsethatcreatestheproblem.Finally, the anticipation of an event that is stressful can cause asmuchormoreanxietythantheeventitself;fearfulthoughtsofwhatcouldgowrongcanexacerbatesymptoms. In their study on 238 musicians, Lehrer and others [5] mea-suredstateandtraitanxiety,andidentifiedsomekeyfactorsthatrelatetomeasuresofMPA.Stateanxietyreferstositua-tionsthatarehighlyspecifictoaparticularpointintimesuchasagivenmusicalperformance.Trait anxiety indicates thedegreetowhichapersonexperiencesanxietyacrossawidevariety of situations, which tends to be more generalizable and enduring part of an individuals personality and require a more general psychotherapeutic approach in treatment. Leh-rer had his subjects complete several psychological tests: the State/TraitAnxiety Inventory [6],amodificationof theFa-cilitating/DebilitatingTestAnxietyQuestionnaire[7],andtheMusicPerformanceAnxietyQuestionnaire[5](whichismadeupof32itemstoidentifysourcesofMPAasexperienceddur-ing a concert, along with coping strategies that are employed). Fromthesemeasures,fivepersonalityfactorssurfacedthatpositivelycorrelatewithtraitanxiety: 1)planningforcopingwithanxiety 2) judgmental attitudes about ones performance 3)worryaboutanxietyanditseffectsonperformance 4) concern with the reactions of others to performance 5) concern with distraction during the performance Lehrer et alalsosuggestthatfactor3(worryaboutanxietyand its effects on performance) has the most consistent rela-tionshipwithstateanxietyandwithitemsontheMPAQthatrelatedtodebilitatinganxiety.Factor1(planningforcopingwithanxiety)hadtheweakestrelationship.Fromtheseresults,it appears thatmanymusicianswho experienceMPAmaybenefitfrompsychologicaltreatmentgearedtowardchangingwhat may be deeply rooted personality characteristics. This is inadditiontodevelopingspecificstrategiesforcopingwiththeanxietyincurredduringmusicalperformance[1]

52 The Horn Call February 2012

Medical and Scientific IssuesMusic Performance Anxiety

by Peter Iltis, Series Editor

What shapes our anxiety about musical performance?

In his review, Salmon [4] states that aspiring musi-cianspursueahighlysophisticatedcraftunderextremestressassociated with the physical and psychological demands of performing, as well as with the tenuous nature of music as a profession. He observes that because of these stresses, some musiciansmayfindtheirintendedfluidexpressionofmusicturnedintoaself-conscious,anxiety-filledchallenge.Wheredoes this come from? Is it there from the very beginning of ourmusicalexperiences,orisitsomethingthatwecultivatethrough the decades we spend learning our art? While cer-tainly personality traits may predispose us to developing MPA, some writers and researchers feel strongly that much of this angst is learned over many years. Nagel[1]identifiestwouniquefactorsthatmusicianscon-tend with that make the development of MPA in music differ-entfromtheanxietyexperiencedinotherprofessions.First,instrumental music lessons often begin very early in life (90% of professionals begin before the age of 12), and throughout the formative years, individuals go through intense musical training and lessons interacting with teachers who often serve as what Nagel refers to as metaphorical parental surrogates; i.e.,individualswhohaveaprofoundinfluenceonpersonalitydevelopment and social adjustment. The potential for develop-ing MPA issues is obvious. Second, the job market for musicians is limited, and unem-ployment in the arts is rampant. According to Nagel, in 2009, artists left the workforce in higher percentages than any other profession. Thus, the nearly life-long pursuit of a tenuous ca-reer involvingan investmentofpersonalego,finances,andtimecancreateanidealbreedinggroundforanxiety.Inmanycases,thisanxietygetstosuchadebilitatinglevelthatcareersmust be abandoned. As a personal comment, I would interject thattotheextentanxietymayamplifyphysicalproblemssuchasthoseexperiencedbyembouchuredystoniasufferers(andtomyknowledge,thisisyettobescientificallyconfirmed),un-derstanding approaches to managing MPA could be important.

What can be done? Self-help books in the popular literature address ways of dealing with MPA. Two that come to mind are The Inner Game of Music by Barry Green [8], and Effortless Mastery by pianist Kenny Werner [9]. These books have numerous suggestions for coping that in many cases appear to be well-founded, and I recommend a cautious and critical reading of them; however, what have clinical medicine and science revealed? Nagels review [1] includes some helpful ideas. Dr. Nagel is an award-winning clinical psychologist and psychoanalyst in private practice in Ann Arbor, Michigan. He is a graduate of the Juilliard School, the University of Michigan, and the Michi-gan Psychoanalytic Institute, and has authored numerous pa-pers on this topic. Nagels first observation is that any one approach fortreating music MPA will not necessarily be applicable to all cases. Though specific therapiesmay havemany varieties,she restricts her comments to two major categories of clinical treatment: 1) cognitive behavior therapy (CBT) and 2) psycho-

The Horn Call February 2012 53

Symposium Reports

dynamic theory-based therapy. In addition, Nagel observes that these approaches are often supplemented by the use of drugs such as beta blockers. While the use of medically-su-pervised beta blocking agents is designed to offset the inap-propriatesympatheticnervoussystemresponsesthatanxietyfosters, (i.e., treating the symptoms), the psychological thera-pies are aimed at altering the thought processes that spawn these symptoms (i.e. treating the supposed cause). It is beyond the scope of this article to deal with beta blocker use.

Cognitive Behavior Therapy (CBT) Vital to the cognitive behavior therapy approach is accep-tanceoftheideathatperformanceanxietyisconceptual-izedasalearnedbehaviorthatcanbemodifiedorextinguishedthroughvarioustechniquesofcontrollingtheexternalenvi-ronment through rewards and punishments[1]. Described firstbyBeck[10],CBTinterventionassumesthatourthoughts(cognitions)haveacontrollinginfluenceonourbehaviors,andconversely,thathowwebehaveinfluencesourthoughts.Thus,MPA is thought of as the problem rather than the symptom of underlyingpsychologicalissuesthatfosteranxiety.Thiswillbe contrasted with psychodynamic approaches. CBT,inthecontextoftreatingMPA,workstomodifyinap-propriatethoughtsthatleadtoanxietyinordertopreventdis-comfort during performance. In a study by Kendrick et al [11], something called cognitive restructuring was employed over three,two-hourtrainingsessionstoelicitanxietyreductionin53highlyanxiouspianists.Thistechniqueinvolvesafive-stepprocess: 1) monitoring ones thoughts 2) considering how these troublesome thoughts contribute to dysfunctional symptoms 3) developing helpful counter-thoughts or coping strategies 4) rehearsing those strategies in practice 5) incorporating the strategies into performance- related activities Those who have read The Inner Game of Music may rec-ognize some of these ideas. Compared to pianists in a control group receiving no treatment, pianists who employed cogni-tiverestructuringshowedsignificantlyreducedanxietyandweremoreconfidentintheirabilitytoeffectpositivechange.Sweeney and Horan [12] conducted a similar study that in ad-ditiontoCBTalsoemployedrelaxationtechniques.Theau-thors suggest thatboth relaxationandCBT therapy lead toreducedanxietyscoresgreaterthancontrolsubjects,butthecombinationofbothrelaxationandCBTappearstobenomoreeffective than either by itself. More literature is available than can be reviewed in this article; forexample,Nagel [1]citesat leastfivestudies thatshowed CBT to be effective in reducing MPA to varying de-grees. The point is to emphasize that CBT has been shown to be effective and might be considered by those dealing with MPA.Formoreinformationonthespecificsofthistechnique,I refer you to both the Nagel and Salmon papers [1, 4] and to the March 1990 issue of Medical Problems of Performing Artists.

54 The Horn Call February 2012

Thinkofanxietyaseagerness/excitementpositive energy Visualizeperformingwhenoffstage Thinkofyourinstrumentasyourfriend Breathedeeplyandslowly Expecttofeelanxious Visualizeacomfortingimageorplace Acceptyourself Enjoyyourself

Table2.StructuredApproachesforTreatingPerformanceAnxiety

Thinkinpositivetermsaboutyourperformingand challenge negative self-statements Analyzesomeunderlyingreasonsforyouraffectsand anxietythatarenotspecificallyperformancerelated Accepttheideathatseekingprofessionalhelpis a strength Exercise Yoga,meditation Diet(limitcaffeine) Biofeedback Medication Cognitivebehaviortherapy In-depthpsychotherapy/psychoanalytictreatment

References1.Nagel,J.J.,Treatmentofmusicperformanceanxietyviapsychologicalapproaches:areviewofse-lected CBT and psychodynamic literature. Medical Problems of Performing Artists, 2010. 25(4): p. 141-8.2. Altenmuller, E. and H. C. Jabusch, Focal dystonia in musicians: phenomenology, pathophysiology, triggering factors, and treatment. Medical Problems of Performing Artists, 2010. 25(1): p. 3-9.3.Jabusch,H.C.,S.V.Muller,andE.Altenmuller,Anxietyinmusicianswithfocaldystoniaandthosewith chronic pain. Movement Disorders, 2004. 19(10): p. 1169-75.4.Salmon,P.G.,Apsychologicalperspectiveonmusicalperformanceanxiety:areviewofthelitera-ture. Medical Problems of Performing Artists, 1990. 5(1): p. 2-11.5. Lehrer, P. M., N. S. Goldman, and E. F. Strommen, A principal components assessment of perfor-manceanxietyamongmusicians.Medical Problems of Performing Artists, 1990. 5(1): p. 12-29.6. Spielberger, C. D. and R. L. Gorsuch, Manual for the State-Trait Anxiety Inventory (Form Y): (self-evaluation questionnaire). [Rev.]. ed 1983, Palo Alto CA: Consulting Psychologists Press, Inc. iv, 36 p.7.Alpert,R.,andHaber,R.N.,Anxietyinacademicachievementsituations.Journal of Abnormal Social Psychology, 1960. 61: p. 207-215.8. Green, B. and W. T. Gallwey, The Inner Game of Music. 1st ed. 1986, Garden City N.Y.: Anchor Press/Doubleday.9. Werner, K., Effortless Mastery: Liberating the Musician Within. 1996: Jamie Aebersold Jazz, Inc. 196.10. Beck, A.T., Thinking and Depression. Ii. Theory and Therapy. Archives of General Psychiatry, 1964. 10: p. 561-71.11. Kendrick, M. J., et al.,Cognitiveandbehavioraltherapyformusical-performanceanxiety. Journal of Consulting and Clinical Psychology, 1982. 50(3): p. 353-62.12.Sweeney,G.A.andJ.J.Horan,Separateandcombinedeffectsofcue-controlledrelaxationandcognitiverestructuringinthetreatmentofmusicalperformanceanxiety.Journal of Counseling Psychol-ogy, 1982. 29: p. 486-497.13.Shedler,J.,Theefficacyofpsychodynamicpsychotherapy. American Psychology, 2010. 65(2): p. 98-109.

Peter Iltis holds a PhD in Exercise Physiology from the Univer-sity of Kansas. He is Chair of the Department of Kinesiology at Gor-don College and Chair of the Advisory Board for the Gordon College Center for Balance, Mobility, and Wellness.

Psychodynamic Theory Treatment (PTT) In some individuals, MPA is thought to be symptomatic ofdeeper,unconscious,unresolvedconflictsthatliewithinthemind. For these people, CBT may not be effective in allevi-ating their troubles, and psychodynamic theory-based treat-ment (PTT) presents another option. Psychodynamic theory assumesthatsymptomsofanxietyaredeterminedbymultiplefactors and may be due to repressed issues that lie outside of anindividualsawareness.Further,performanceanxietymaybesymptomaticofunresolvedconflictsburieddeeplyinthe unknowing, outside-of-awareness part of the mind [1]. It is thought that defending ones ego at this subconscious level mayincreaseanxietyandphysicaldiscomforts.(Thisissome-what consonant with ideas put forth by Joaquin Fabra of Ma-drid, Spain, who has shown remarkable results working with musicians with focal dystonia.) These deep-rooted sources of tension may in fact be rooted in childhood, an observation that is particularly relevant for musicians who typically begin performing at very young ages. Additionally, these feelings may be closely related to self-es-teem,andPTTinvolvesexploringonescharacterandidentityinanattempttouncoverthesourceofthisanxiety.PatientstreatedwithPTTarehelpedtoaccessinnerstrengths,exam-ine self-doubts and fantasies, and strengthen self-esteem in a number of ways that affect performance[1]. However, Nagel assertsthatperformanceanxietyexperiencedearlyinmusicaltraining often carries over into adulthood and may be resis-tive to treatment. More could be said about psychodynamic theory, but for such detail, I refer you to Nagels review. The bottom line is that PTT has been shown to be an effective strat-egyintreatingperformanceanxietyingeneral[13]thatmaybeappliedtoMPAinspecific,andisacomplextechniquethatshouldbecarriedoutunderqualifiedprofessionalpsychotherapy.

Some practical suggestions While in some cases it may be advisable for a musician affected with MPA to seek professional counsel, I would like to share some practical implications as described by Dr. Nagel [1] for horn players as well as for teachers. Nagel provides two useful lists (below), reproduced with permission of the pub-lisher.Thefirstrelatestowhatshereferstoasself-coachingand self-appraisal, while the second pertains to more formal approachestotreatingMPA.Hopefully,youwillfindthemhelpful in your teaching and practice.Table 1. Self-coaching and Self-appraisal for the Performance-AnxiousMusician

Thinkaboutwhy you are performing Focusonwhatyouaredoing (rather than how others perceive you) Practicemindfully:repetitionisuselessunlessyouare concentratingDevelopaplanforajaminperformance Practiceallthewaythroughyourprogramsoyoucan deal with lapses Thereisnosuchthingasaperfectperformanceor perfect performer

Music Performance Anxiety

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