musical performance anxiety adapting psychotjerapy techniques

[Part Two in a Series of Three Hypothetical Case Studies Involving VoiceStudents with Musical Performance Anxiety]

IN A CONTINUED EFFORT to better understand and confront musicalperformance anxiety (MPA), this article is the second in a series of threecase studies seeking to nd the solution to stage fright concerns of threehypothetical students. Each case takes into account the student at handand his or her challenges, considers how the mental health/medical profes-sions treat patients with similar but more extreme symptoms, and translatesthose tactics into practical methods for use in the voice studio. Please note thatonly mental health/medical professionals should attempt to make clinicaldiagnoses, and any student with severe symptoms should be referred to thestudents primary care physician, a psychologist, or a psychiatrist.

Previously we discussed the theoretical case of Suzie, the high schoolsophomore with aspirations of Broadway grandeur, but who experiencedstage fright when singing. By considering the clinical treatment of phobias andtranslating those insights into studio techniques, we created a plan for help-ing her overcome her MPA through the use of desensitization. The second hypo-thetical student also suffers from performance anxiety, but while some causesand symptoms are similar, others are signicantly different.

HYPOTHETICAL STUDENT #2

Katherine is a mother of three teenage children, the wife of a minister, andin her early forties. She has been studying with you for several months sincethe time her music minister suggested voice lessons because she wants tosing solos in church. In addition to needing signicant technical work, she isalso very nervous about performing in the large interdenominational churchwhere her husband is one of the pastors. Katherine is a hardworking student.She practices more than she is asked. She memorizes most of her music withina week of starting it, although she has continued to procrastinate for many weekson the more challenging Italian selection you assigned to her. Katherine isalso frustrated because she believes she is not progressing quickly enoughtechnically. You notice that every time she makes even a small mistake it

March/April 2011 445

Musical Performance Anxiety: AdaptingPsychotherapy Techniques of CognitiveRestructuring to the Voice Studio, Part 2Heather Winter Hunnicutt and A. Scott Winter

Journal of Singing, March/April 2011Volume 67, No. 4, pp. 445450Copyright 2011National Association of Teachers of Singing

THE PRIVATE STUDIOCarl Swanson, Associate Editor

Heather Winter Hunnicutt

A. Scott Winter

437-476_JOS_MarApr11_depts_E (LC) 2/3/11 5:00 PM Page 445

throws her off for the rest of her lesson. When you makea well meaning and diplomatic suggestion for improve-ment, she seems to take it as a personal insult that hersinging was not awless in the rst place. During vocalisesshe politely refuses to try anything with which she doesnot think she will be immediately successful. Additionally,she seems always to be stressed.

Musical Performance Anxiety, Trait Anxiety,Gender, and Perfectionism

Stage fright occurs when the body senses a danger (theperformance situation), then summons its ght or ightresponse. This sends adrenaline throughout the body,changes natural blood ow and results in a multitude ofsymptoms from heart palpitations to butteries in thestomach. The three levels to which performance anxietyis experienced are, not surprisingly, mild, moderate, andsevere. Of those with performance anxiety, some expe-rience mild symptoms (increased energy from the adren-aline and a natural and helpful response from the body),most experience moderate symptoms, and some expe-rience severe symptoms (manifestations so signicantthat they disrupt or terminate a performance; thesesingers should always be referred to a mental health ormedical professional). There are also three classes ofsymptoms, including physical (sweaty palms, height-ened respiratory rate), cognitive (negative thoughts, cat-astrophizing), and behavioral (avoiding practicing,canceling lessons). It is unusual for a performer to expe-rience only one type of symptomatology; most singerswill have moderate physical, cognitive, and behavioralsymptoms.

Certain factors have a tendency to make any singernervous: lack of preparation, not enough experienceperforming, being in less than ideal health or voice, newor unfamiliar surroundings, and certainly an impendingperformance of particularly high importance. There arealso certain demographic and personality traits partic-ularly relevant to this and similar cases that heightenperformance anxiety for individuals who possess them.These include having high trait anxiety, female gender,and perfectionism.

Trait anxiety refers to ones baseline level of general-ized anxiety without any particular stressor. It is likelygenetically determined and modied by the individualsenvironment. The body has a natural alarm system deep

within the temporal lobe of the brain called the amyg-dala. Scientists believe the amygdala of people with hightrait anxiety is far more reactive than those with lowtrait anxiety. Because the individual with high trait anx-iety experiences elevated baseline anxiety level, thespikes from the baseline (produced by the stress of aperformance, for example) are increased that much more.Therefore, when stressed, individuals with high traitanxiety will have substantially higher performance anx-iety as well. Trait anxiety is measured clinically by theState Trait Anxiety Inventory (STAI), and there is sub-stantial research using the STAI that demonstrates thisvery strong correlation between trait anxiety and MPA.1

There is also signicant data to show that women havesubstantially more generalized anxiety than men.2 This,as discussed above, translates into women also exhibit-ing more musical performance anxiety in both preva-lence and the intensity of symptoms.3 Womens increasedsusceptibility to anxiety is due to a combination of bio-logical factors and social stresses. Biologically, scans ofbrain activity indicate that a womans ght or ightresponse activates more than a mans when stressed.Louann Brizendine, author of The Female Brain, says ofthis phenomenon: Because of her highly responsivestress trigger, a woman becomes anxious much morequickly than a man does. This trait evolved to allow herto respond quickly to protect her children.4 Additionally,men have higher serotonin levels in the brain and sci-entists speculate that this dampens emotional reactiv-ity, making men less susceptible to anxiety. Socially,women are expected to maintain an incredible balanc-ing act twenty-four hours a day, seven days a week: career,often raising children and being a wife, nurturing otherrelationships with friends and family, maintaining ayouthful and attractive appearance, and keeping a con-sistently clean and maintained home. Women tend toapproach these challenges with a sense of having littlecontrol, being more emotionally invested than men, tak-ing even small failures personally and internalizing per-sonal struggles.5

Another personality trait with a high correlation toMPA is perfectionism.6 This, like gender differences,is connected to higher levels of generalized anxiety.Individuals with perfectionist tendencies regularly sub-mit themselves to extreme stress when they are unableto accomplish the plethora of unattainable goals they

446 Journal of Singing

Heather Winter Hunnicutt and A. Scott Winter


have set. This constant state of reaching for perfectionleads to higher generalized anxiety which, in turn, leadsto more MPA.

Assessment of the Students Problem

Returning to your student, by both observing and talk-ing with her you notice that Katherine is a woman withperfectionist tendencies and a lot of generalized anxi-ety. When it comes to singing by herself, you would con-sider her performance anxiety to be on the high side ofmoderate. She talks about some physical symptoms shegets, including sweaty palms, stomach discomfort rightbefore singing, and feeling like she is out of breath. Yourecognize behavioral symptoms, such as unwillingnessto try certain vocalises and procrastination on the moredifficult repertoire piece. Mostly, however, Katherinetalks about what happens in her head. When she eventhinks about singing a solo for the church she reportsthe following thoughts: They are going to laugh at me,If I dont sing well, it will reect poorly on my husband,Im going to forget all the words, If I make a mistakeI am never going to do this again, and They may besmiling at me but are secretly thinking I have a terriblevoice, among others. The complex factors contributingto Katherines anxiety need to be considered in how you,as her voice, teacher can help her. To learn from the men-tal health profession, we look at how a therapist wouldtreat obsessive compulsive disorder.

Cues from the Mental Health Profession:Treatment of Obsessive Compulsive Disorder

Katherines symptoms are not severe enough to qual-ify as obsessive compulsive disorder (OCD). However,we may gain valuable insight into ways of dealing withKatherines anxiety from what professionals do in thetreatment of OCD. Lets take a look at what constitutesOCD and how it might be treated. OCD involves recur-rent intrusive thoughts, impulses, or images that gowell beyond worrying about real-life problems. It alsotypically includes repetitive behaviors such as exces-sive handwashing, ordering, or checking. These thoughtsand behaviors produce marked distress and, while theindividual is usually able to recognize that these thoughtsand behaviors are over the top, they have great diffi-culty in resisting them. Compulsive behaviors can bevery time consuming or otherwise impractical, but

become entrenched as they serve to reduce the anxi-ety associated with intrusive thoughts (obsessions).Unfortunately the behaviors can also severely limit theindividuals ability to normally interact with the restof the world.

Consider, for example, patients who are so perfec-tionistic that their entire sense of self-worth is depend-ent on being perfect. While they may do an outstandingjob at some things, they may also have serious problemswith procrastination, as it is simply impossible to be per-fect all the time. They may also nd it terrifying to dosomething which they dont feel perfect at (e.g., mak-ing a presentation at work). Intrusive thoughts in thisindividual might include Im no good at my job, Peoplewill see me as a fraud, or Ill never succeed. Thesethoughts produce intense anxiety. In order to cope withthe anxiety our patient develops various compulsionsor rituals (e.g., doing a perfect job of something irrele-vant like counting) to bind that anxiety.

What can be done for our patient? In all likelihoodhe or she will be treated with a combination of medica-tions and psychotherapy. Medications used for treatingOCD are typically ones that increase serotonin activityin the brain, such as Prozac (uoxetine), Zoloft (sertra-line), or Anafranil (chloripramine). These same drugs arealso frequently used as antidepressants. Medications,however, rarely are sufficient to combat this very chal-lenging condition, and psychotherapy would focus onthe dysfunctional thoughts and behaviors (compulsions,self-handicapping behaviors like the procrastination,and feared situations). The rst thing that needs to beaddressed is a recognition of the problemthe ob sessivepreoccupation with perfection, the intrusive thoughts,nonproductive compulsive behaviors, procrastination,and avoidance of a wide variety of important activitiesare real problems that limit our patients ability to suc-ceed in life. He or she will also need to recognize thathis or her self-sense of value has been too narrowlydened. The patient has value as a person even if notperfect. Likewise, a therapist would want to work onovercoming the obsessions and compulsions, and lastlywill want the patient to reengage in normal activities.To accomplish these goals, his therapist would likelyemploy cognitive behavior therapy (CBT).

In this case, therapy would likely involve two majorCBT tools: exposure therapy/response prevention and


The Private Studio


cognitive restructuring. Briey, exposure therapy involveshaving the patient face anxiety provoking situations thatwould have been otherwise avoided because of the illness(similar to the systematic desensitization discussed inpart one of this series), while response prevention entailsblocking the compulsions/rituals our patient has beenusing to avoid anxiety. CBT posits that events lead tothoughts which are then instrumental in producing emo-tions and behaviors. Emotions and behaviors can like-wise inuence thoughts so there is a dynamic interplaythat can be harnessed using cognitive restructuring.According to CBT there are conscious thoughts, automaticthoughts, and schemas (core beliefs). In the above exam-ple, the intrusive thoughts are automatic thoughts, whilethe belief that our patient has to be perfect is a schema.Automatic thoughts and schemas can be good, bad, orneutral. Pathology arises, however, when they are dys-functional (as with our patient).

Cognitive restructuring would involve our patient ana-lyzing the automatic thoughts and schemas and refram-ing them so that they are accurately stated, rather thanreecting the stinking thinking that propagated theanxious emotions and led to the compulsive behaviors.Each of these dysfunctional cognitions needs to be eval-uated and reframed in the patients mind to one that isaccurate, realistic, and hence far less anxiety provoking.For example, reframing the patients dysfunctional cog-nition, Im no good at my job, would lead to a state-ment acknowledging that, while not perfect, the patientdoes a good job by any reasonable standard. The corebelief (schema) of having to be perfect to be a worthyperson needs to be reframed to something like beingperfect is not only unrealistic but unnecessary in orderto be a valuable person. There will be many dysfunc-tional cognitions that will have to be addressedfarmore than those listed. By working through each of thesedysfunctional thoughts, the emotions and behaviors thatthey drive will in turn be affected in a positive way. It isimportant to note that the therapist cannot simply sug-gest a new way of framing the dysfunctional thoughts;in order to be effective the reframing must be the patients.The strategies listed above would be accomplished in agradual, nonthreatening fashion with the patient inti-mately involved in brainstorming the needed changesas well as the pace of the therapy. Now lets turn ourattention back to Katherines MPA.

Translating Clinical Treatment of ObsessiveCompulsive Disorder to Studio Techniques forPerformance Anxiety

Katherine does not have severe symptoms, but if she didshe would need referral to a mental health professionalor a physician rather than work with a voice teacher.Her less serious symptoms, therefore, require a simplerand more casual approach than the OCD patient underthe care of a therapist. She probably does not need anyserotonin enhancing medications or beta blockers, thoughonly a visit to her physician could determine that. Theexposure therapy would be analogous to a form of desen-sitization as discussed in part one of this series. Theresponse prevention requires only that when Katherinestendency to freeze up after a mistake surfaces, you reas-sure and put her immediately back on the horse with-out allowing her time to obsess about it. What we willconsider in more detail from OCD treatment is recog-nition of the problem, and a less formal, more casualuse of cognitive restructuring that we simply call rea-sonable rethinking.

Acknowledging the existence of a problem may bequite simple. It could be as simple as you asking her,Does it frustrate you when the piece is not perfect?and she responds with tears or other obvious negativeaffect. Or, perhaps she may not even recognize that herperfectionism (analogous to the schema/core beliefmentioned above) and negative self-talk (analogous toautomatic/intrusive thoughts) are getting in the way ofher singing success, and you will have to initiate a con-versation about it by asking her to explain further howshe justies those negative thoughts. By discussing itand adding perspective, it likely will become clear toher that this is self-defeating and therefore somethingthat needs to change.

In terms of reasonable rethinking, it is crucially impor-tant that Katherine be the one to replace the negativethoughts with something that is reasonable and accu-rate to her. Your job is to point out when a negativethought is unrealistic and self-defeating, and then todraw out of her what a reasonable restatement of thefacts would be. For example, when she admits to think-ing, Theyre going to laugh at me, you respond with, Doyou really believe they are going to laugh at you? Wouldyou laugh at somebody if you were in the congregationand they made a mistake? Even if you make a mistake,




most of these people probably wouldnt even notice itand any that did certainly would not laugh at you.Katherine, one hopes, will reply that it is unlikely thatanyone would actually laugh at her if her performanceis less than perfect. If she does not agree, you continueto try to draw such an acknowledgement from her.

When someone has one of these automatic thoughts,there is usually a miniscule crumb of truth that waswarped by the students unreasonable perfectionism,and the voice instructor must recognize that crumbrather than discount it. The restatement in an accurateway needs to be Katherines restatement in order forher reasonable rethinking to have any power. For thevoice teacher to simply restate it from his or her own per-spective, or not admit the possibility of some negativereaction would not resonate at a psychological levelfor the student. Ideally, Katherine is eventually able torecognize self-defeating thoughts when they come, andreasonably rethinking them for herself, instead say-ing I am well prepared and ready. I might make a mis-take, but the congregation will still like and respectme, and its OK to not be perfect. By dealing with theintrusive thoughts, this also indirectly confronts thecore perfectionism. In some cases, however, it may beimportant that she explicitly acknowledge in her ownwords that perfection is not attainable, and requiringit is self-defeating.

Final Thoughts

In the discussion above, a parallel was drawn betweenKatherines perfectionism and the far more serious psy-chiatric condition known as obsessive compulsive dis-order. We reviewed some key cognitive behavior therapystrategies used in treating the patient with OCD. Theseincluded exposure, response prevention, and cognitiverestructuring. The pedagogic equivalent of exposure inthe voice studio involves gradually exposing the stu-dent to the feared activities in a safe environment (i. e.,desensitization, as discussed in part one of the series).Fortunately Katherine didnt require any response pre-vention other than requiring her to go on with her les-son instead of allowing her to freeze up following whatshe perceived as a mistake. Finally, our primary focuswas on having Katherine acknowledge the problem andthe translation of cognitive restructuring into reason-able rethinking, an educational tool to help her over-

come the negative thought patterns that contributed toher musical performance anxiety. In the final install-ment of this series, we will discuss Jos, a junior inhigh school whose musical performance anxiety stemsfrom problems with focus, discipline, and self-esteem.

NOTES

1. Susanne Gorges, Georg W. Alpers, and Paul Pauli, MusicalPerformance Anxiety as a Form of Social Anxiety?, Inter -national Symposium on Performance Science (Porto, Portugal:2007); Wendy J. Cox and Justin Kenardy, Performance Anxiety,Social Phobia, and Setting Effects in Instrumental MusicStudents, Journal of Anxiety Disorders 7, no. 1 (January-February 1993): 4960; Dianna T. Kenny, Pamela Davis, andJenni Oates, Music Performance Anxiety and OccupationalStress Amongst Opera Chorus Artists and Their Relationshipwith State and Trait Anxiety and Perfectionism, Journal ofAnxiety Disorders 18, no. 6 (January 2004): 757777; Paul M.Lehrer, Nina S. Goldman, and Erik F. Strommen, A PrincipalComponents Assessment of Performance Anxiety AmongMusicians, Medical Problems of Performing Artists 5, no. 12(March 1990): 1218; Marnie Liston, Alexandra A. M. Frost,and Philip B. Mohr, The Prediction of Musical PerformanceAnxiety, Medical Problems of Performing Artists 18, no. 3(September 2003): 120125.

2. American Psychiatric Association, Diagnostic and StatisticalManual of Mental Disorders, 4th ed. (Washington, DC:American Psychiatric Association, 1994); P. M. Lewinsohn,I. H. Gotlib, M. Lewinsohn, J. R. Seeley, and N. B. Allen,Gender Differences in Anxiety Disorders and AnxietySymptoms in Adolescents, Journal of Abnormal Psychology107, no. 1 (1998): 109117.

3. M. Fishbein, S. E. Middlestadt, V. Ottati, S. Straus, and A. Ellis,Medical Problems Among ICSOM Musicians: Overview of aNational Survey, Medical Problems of Performing Artists 3(1988): 18; Gorges, Alpers, and Pauli; J. L. Huston, FamilialAntecedents of Musical Performance Anxiety: A Comparisonwith Social Anxiety, Dissertation Abstracts International: SectionB: The Sciences & Engineering 62, no. 1-B (2001): 551; A. LeBlanc,Y. C. Jin, M. Obert, and C. Siivola, Effect of Audi ence on MusicPerformance Anxiety, Journal of Research in Music Education45, no. 3 (January 1997): 480496; Liston, Frost, and Mohr; M.S. Osborne and J. Franklin, Cognitive Processes in MusicPerformance Anxiety, Australian Journal of Psychology 54,no. 2 (2002): 8693; L. M. Sinden, Music Performance Anxiety:Contributions of Perfectionism, Coping Style, Self-Efficacy, andSelf-Esteem (PhD dissertation, Arizona State University,1999); Robert B. Wesner, Russell Noyes, and Thomas L. Davis,The Occurrence of Performance Anxiety Among Musicians,Journal of Affective Disorders 18 (1990): 177185.


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4. Louann Brizendine, The Female Brain (New York: MorganRoad Books, 2006).

5. Mental Health Information, Mental Health America, MentalHealth America, n.d. Web. 2 Jan 2010. www.nmha.org (accessedJanuary 2, 2010)

6. R. O. Frost and K. J. Henderson, Perfectionism and Reactionsto Athletic Competition, Journal of Sport and Exercise Psy -chology 13 (1991): 323335; Gorges, Alpers, and Pauli; DiannaT. Kenny and Margaret S. Osborne, Music PerformanceAnxiety: New Insights from Young Musicians, Advances inCognitive Psychology 2, no. 23 (2006): 103112; Liston, Frost,and Mohr; S. Mor, H. I. Day, G. L. Flett, and P. L. Hewitt,Perfectionism, Control, and Components of PerformanceAnxiety in Professional Artists, Cognitive Therapy and Research22, no. 3 (1984): 267280; Z. D. Yondem, Performance Anxiety,Dysfunctional Attitudes and Gender in University MusicStudents, Social Behavior and Personality: An InternationalJournal 35, no. 10 (2007): 14151426.

Dr. Heather Winter Hunnicutt is an Assistant Professor of Music,Coordinator of Vocal Studies, and Director of the Lyric Theatre Pro-gram at Georgetown College, and maintains a small private studio.She received her undergradate, masters, and doctoral degrees fromthe Indiana University Jacobs School of Music. Various research, teach-ing, and singing endeavors have taken her to Bangkok, Honolulu, Paris,Salzburg, Northern Ireland, and Munich, among others. She is an activemember of NATS and is the faculty advisor of the Georgetown CollegeChapter of SNATS.

Dr. Scott Winter is an Associate Professor of Psychiatry and a Clinical Assis-tant Professor of Internal Medicine at the University of North Texas HealthScience Center. He is also the Director of the Psychiatric Residency Train-ing Program for the JPS Health Network in Ft. Worth, Texas. He is a Dis-tinguished Fellow of the American Psychiatric Association, and is boardcertified in geriatric psychiatry, forensic psychiatry, and addiction medi-cine, in addition to general psychiatry. Dr. Winter has a special interest inthe area of music performance anxiety.




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musical performance anxiety adapting psychotjerapy techniques

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