Editor’s note: This is part of a series of stories exploring what Gordon professors are up to in between semesters.
Most people might not think about the intricate muscles around a musician’s mouth as he or she plays the trumpet or French horn. But when those muscles—known as the embouchure—aren’t working the way they’re supposed to, well, suddenly music takes on a scientific and medical dimension.
Enter Peter W. Iltis, professor of kinesiology and horn, who in February 2012 published an article on music performance anxiety for the journal of the International Horn Society (IHS). Based on research he’s done over the past several years around movement and muscle disorders in musicians, Iltis (who is also the medical and scientific editor for IHS’s The Horn Call) connected his findings to the level of anxiety musicians often face when they perform. The result? Iltis got a call from world renowned horn player and ‘fearless’ performance coach, Jeff Nelsen, who is also a full professor at the prestigious Jacob School of Music at Indiana University and speaker at the TED Talks in July 2011.
Nelson read Iltis‘s article, invited him to Indiana for a week in July, and the two—along with a select group of colleagues—discussed how they might work together, bringing science to the art of musical performance. Now Iltis will serve as a consultant to Nelson for future coaching sessions, a video series and possible workshops. Below is the article he wrote for the February 2012 edition of The Horn Call:
“Music Performance Anxiety: The Science behind the Problem”
Many musicians struggle with music performance anxiety (MPA), including horn players. Through the years in The Horn Call, we have heard from many professionals about their own individual approaches to dealing with it. However, a review of the scientific literature on this topic has not been published in our journal to date. In her recent review of psychological approaches for treating MPA, Dr. Julie Nagel observes that organic medical conditions and the symptoms they evoke may be exacerbated by psychological factors, complicating both treatment and recovery. She suggests that therapeutic strategies for treating many disorders require acknowledging this, and developing a more holistic approach that includes psychological approaches. While my focus in this article is on MPA itself, in a recent article on embouchure dystonia, I commented on its apparent association with anxiety. Though the scientific community is reticent to attribute anxiety as a cause for dystonia, the association has been made [2, 3], and an understanding of factors related to and methods for dealing with MPA is warranted. It is beyond the scope of this article to fully explore the anxiety/dystonia connection. However, examining MPA separately has application for all musicians. This article describes the nature of MPA, and examines samplings from the current literature to provide some general principles for understanding and coping with this condition.
The sympathetic nervous system and music performance anxiety
When we are placed in circumstances we perceive as threatening, we have a built-in mechanism for coping. It is a branch of our autonomic (automatic) nervous system known as the sympathetic nervous system. This is that part of our body’s automatic control system that prepares us to “fight or flee”. Our heart beats faster and stronger, the pupils of our eyes dilate, 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 to the performing artist attempting to play a musical instrument. The fact is, our sympathetic nervous system has responded to something that poses no real physical threat to us with physiologic adaptations that are not helpful. Why?The issue is not whether a set of circumstances (audiences, adjudicators, audition panels, recording) really pose a physical threat, but whether they are perceived by the individual as threatening. Thus, it is helpful to closely examine what the scientific literature has to say about those factors that lead us to these inaccurate perceptions of threat. Do we acquire them naturally (by nature), do circumstances in our early development as musicians breed these inappropriate responses (by nurture), or is it some combination of these factors? Either way, it is informative to see what science has to say about MPA and approaches that are effective in preventing and/or dealing with MPA that is considered debilitating. There may even be ways to channel this nervous energy in a positive way.
The dimensions of music performance anxiety
In an excellent review article of the psychological literature by Paul Salmon , he identifies three general statements about the nature of MPA. First, Salmon states that MPA comprises a loosely correlated constellation of cognitive, behavioral, and physiological variables. In short, 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 component 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 it is the excessiveness of the response that creates the problem. Finally, the anticipation of an event that is stressful can cause as much or more anxiety than the event itself. That is, fearful thoughts of what could go wrong can exacerbate symptoms.
In their study on 238 musicians, Lehrer and others  measured state and trait anxiety, and identified some key factors that relate to measures of MPA. State anxiety refers to situations that are highly specific to a particular point in time such as what one might experience for a given musical performance. Trait anxiety indicates the degree to which a person experiences anxiety across a wide variety of situations. This form of anxiety tends to be more generalizable and a more enduring part of an individual’s personality, and requires a more general psychotherapeutic approach in treatment. Lehrer had his subjects complete several psychological tests including the State/Trait Anxiety Inventory , a modification of the Facilitating/Debilitating Test Anxiety Questionnaire  as well as the Music Performance Anxiety Questionnaire . This latter questionnaire is made of 32 items that identify sources of MPA as experienced during a concert, along with coping strategies that are employed.
From these measures, five personality factors surfaced from the results that positively correlate with trait anxiety: 1) planning for coping with anxiety, 2) judgmental attitudes about one’s performance, 3) worry about anxiety and its effects on performance, 4) concern with the reactions of others to performance, and 5) concern with distraction during the performance. Lehrer et al  also suggest that factor 3, worry about anxiety and its effects on performance, has the most consistent relationship with state anxiety and with items on the MPAQ that related to debilitating anxiety. Factor 1, planning for coping with anxiety, had the weakest relationship to debilitating MPA. From these results, it appears that many musicians who experience MPA may benefit from psychological treatment geared toward changing what may be deeply rooted personality characteristics. This is in addition to developing specific strategies for coping with the anxiety incurred during musical performance 
What shapes our anxiety about musical performance?
In his review, Salmon  states that “… aspiring musicians pursue a highly sophisticated craft under extreme stress associated with the physical and psychological demands of performing, as well as with the tenuous nature of music as a profession”. He continues by observing that because of these stresses, some musicians may find their intended fluid expression of music turned into a self-conscious, anxiety-filled challenge. Where does this come from? Is it there from the very beginning of our musical experiences, or is it something that we cultivate through the decades we spend learning our art? While there are certainly personality traits that may predispose us to developing MPA, some writers and researchers feel strongly that much of this angst is learned over many years.
Nagel  identifies two unique factors that musicians contend with that make the development of MPA in music different from the anxiety experienced in other professions. First, instrumental music lessons often begin very early in life (90% of professionals begin before the age of 12), and throughout the formative years of life, individuals go through intense musical training and lessons interacting with teachers who often serve as what Nagel refers to as “metaphorical parental surrogates”; individuals who have a profound influence upon personality development and social adjustment. The potential for developing MPA issues is obvious. Second, the job market for musicians is limited, and unemployment 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 career involving an investment of personal ego, finances, and time can create an ideal breeding ground for anxiety. In many cases, this anxiety gets to such a debilitating level that careers must be abandoned. As a personal comment, I would interject that to the extent anxiety may amplify physical problems such as those experienced by embouchure dystonia suffe rs (and to my knowledge, this is yet to be scientifically confirmed), understanding approaches to managing MPA could be very important.
What can be done? What are the various recommended approaches?
There are many self-help books available in the popular literature addressing ways of dealing with MPA. Two that come to mind are The Inner Game of Music, by Barry Green , and Effortless Mastery by pianist Kenny Werner . These books have numerous suggestions for ways of coping that in many cases appear to be well-founded, and I recommend a cautious and critical reading of them to anyone interested. However, what have clinical medicine and science revealed that may be of use to us?
Dr. Julie Nagel’s review, “Treatment of Music Performance Anxiety via Psychological Approaches” recently published in the journal, Medical Problems of Performing Artists  includes some helpful ideas. Dr. Nagel is an award-winning Clinical Psychologist and Psychoanalyst in private practice in Ann Arbor, Michigan, is a graduate of the Juilliard School, the University of Michigan, and the Michigan Psychoanalytic Institute, and has authored numerous papers on this topic.
Dr. Nagel’s first observation is that any one approach for treating music MPA will not necessarily be applicable to all cases. Though specific therapies may have many varieties, she restricts her comments to two major categories of clinical treatment: 1) cognitive behavior therapy (CBT) and 2) psychodynamic theory-based therapy. In addition, Dr. Nagel observes that these treatment approaches are often supplemented by the use of drugs such as beta blockers. While the use of medically-supervised beta blocking agents is designed to offset the inappropriate sympathetic nervous system responses that anxiety fosters, (i.e. treating the symptoms), the psychological therapies 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, so I hereafter restrict my comments to CBT and psychodynamic therapy.
Cognitive Behavior Therapy (CBT)
Vital to the cognitive behavior therapy approach is acceptance of the idea that “… performance anxiety is conceptualized as a learned behavior that can be modified or extinguished through various techniques of controlling the external environment through rewards and punishments”. Described first by Beck , CBT intervention assumes that our thoughts (cognitions) have a controlling influence on our behaviors, and conversely, that how we behave influences our thoughts. Thus, MPA is thought of as the problem rather than the symptom of underlying psychological issues that foster anxiety. This will later be contrasted with psychodynamic approaches.
CBT, in the context of treating MPA, works to modify inappropriate thoughts that lead to anxiety in order to prevent discomfort during performance. In a study by Kendrick et al , something called cognitive restructuring was employed over three, two-hour training sessions to elicit anxiety reduction in fifty-three highly anxious pianists. This technique involves a 5 step process: 1) monitoring one’s 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, and 5) incorporating them into performance-related activities. Those who have read The Inner Game of Music may recognize some of these ideas. Compared to pianists in a control group receiving no treatment, pianists who employed cognitive restructuring showed significantly reduced anxiety, and were more confident in their ability to effect positive change. Sweeney and Horan  conducted a similar study that in addition to CBT also employed relaxation techniques. The authors suggest that both relaxation and CBT therapy leads to reduced anxiety scores greater than control subjects, but the combination of both relaxation and CBT appears to be no more effective than either by itself.
There is much more literature than can be prudently reviewed in this article. For example, Nagel  cites at least five studies that showed CBT to be effective in reducing MPA to varying degrees. The point is to emphasize that CBT has been shown to be effective, and might be considered by those dealing with MPA. For more information on the specifics of this technique, I refer the reader to both the Nagel and Salmon review papers [1, 4] and the March 1990 issue of Medical Problems of Performing Artists.
Psychodynamic theory and performance anxiety
In some individuals, MPA is thought to be symptomatic of deeper, unconscious, unresolved conflicts that lie within the mind. For these people, CBT may not be effective in alleviating their troubles, and psychodynamic theory-based treatment (PTT) presents another option. Psychodynamic theory assumes that symptoms of anxiety are determined by multiple factors, and may be due to repressed issues that lie outside of an individual’s awareness. Further, performance anxiety maybe symptomatic of unresolved conflicts “… buried deeply in the unknowing, outside-of-awareness part of the mind” . It is thought that defending one’s ego at this sub-conscious level may increase anxiety and physical discomforts. (This is somewhat consonant with ideas put forth by Joaquin Fabra, the gentleman in Madrid, Spain who has shown some remarkable results working with musicians with focal dystonia. I refer you to a series of YouTube videos posted by David Scragg where Mr. Fabra is interviewed. I, too, have interviewed Mr. Fabra. He has some fascinating ideas.)
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-esteem, and PTT involves exploring one’s character and identity in an attempt to uncover where this anxiety comes from. Patients treated with PTT are helped to “access inner strengths, examine self-doubts and fantasies, and strengthen self-esteem in a number of ways that affect performance”. However, Nagel asserts that performance anxiety experienced early in musical training often carries over into adulthood and may be resistive to treatment. There is much more that could be said about psychodynamic theory, but for such detail, I refer the reader to Dr. Nagel’s review. The bottom line is that PTT has been shown to be an effective strategy in treating performance anxiety in general  that may be applied to MPA in specific, and is a complex technique that should be carried out under qualified professional psychotherapy.
Some practical suggestions from medicine and science
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 for horn players as well as for those whose privilege and responsibility it is to teach. Nagel provides two useful lists for our consideration that I provide below. The first relates to what she refers to as self-coaching and self-appraisal steps, while the second pertains to more formal approaches to treating MPA. These have been reproduced with permission of the publisher in an attempt to leave you with some simple ideas to keep in mind. Hopefully, you will find them helpful in your teaching and practice.
Table 1. Self-coaching and Self-appraisal for the Performance Anxious Musician Think about why you are performing
- Focus on what you are doing (rather than how others perceive you)
- Practice mindfully: repetition is useless unless you are concentrating
- Develop a plan for a “jam” in performance
- Practice all the way through your program so you can deal with lapses
- There is no such thing as a “perfect performance” or “perfect performer”
- Think of anxiety as “eagerness/excitement” – positive energy
- Visualize performing when off stage
- Think of your instrument as your friend
- Breathe deeply and slowly
- Expect to feel anxious
- Visualize a comforting image or place
- Accept yourself
- Enjoy yourself
Table 2. Structured Approaches for Treating Performance Anxiety
Think in positive terms about your performing and challenge negative self-statements
- Analyze some underlying reasons for your affects and anxiety that are not specifically performance related
- Accept the idea that seeking professional help is a strength
- Yoga, meditation
- Diet (limit caffeine)
- Cognitive behavior therapy
- In-depth psychotherapy/psychoanalytic treatment
1. Nagel, J.J., Treatment of music performance anxiety via psychological approaches: a review of selected 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. Med Probl Perform Art, 2010. 25(1): p. 3-9.
3. Jabusch, H.C., S.V. Muller, and E. Altenmuller, Anxiety in musicians with focal dystonia and those with chronic pain. Mov Disord, 2004. 19(10): p. 1169-75.
4. Salmon, P.G., A psychological perspective on musical performance anxiety: a review of the literature. Medical Problems of Performing Artists, 1990. 5(1): p. 2-11.
5. Lehrer, P.M., Goldman, N.S., Strommen, E.F., A principal components assessment of performance anxiety among musicians. 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.]. ed1983, Palo Alto, CA: Consulting Psychologists Press, Inc. iv, 36 p.
7. Alpert, R., and Haber, R.N., Anxiety in academic achievement situations. Journal of abnormal social psychology, 1960. 61: p. 207-215.
8. Green, B. and W.T. Gallwey, The inner game of music. 1st ed1986, Garden City, N.Y.: Anchor Press/Doubleday. x, 225 p.
9. Werner, K., Effortless Mastery: Liberating the Musician Within1996: 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., Cognitive and behavioral therapy for musical-performance anxiety. Journal of consulting and clinical psychology, 1982. 50(3): p. 353-62.
12. Sweeney, G.A., and Horan, J.J., Separate and combined effects of cue-controlled relaxation and cognitive restructuring in the treatment of musical performance anxiety. Journal of Counseling Psychology, 1982. 29: p. 486-497.
13. Shedler, J., The efficacy of psychodynamic psychotherapy. American Psychology, 2010. 65(2): p. 98-109.