Look Inward: Music Performance Anxiety

Welcome (or welcome back!). It's been a while since I sat down to pen a blog, and it wasn't due to disinterest. My last post was in January 2021, and shortly after that, I had to devote all of my time and energy to complete and defend my dissertation (and I did!). I was touched by the notes I received from readers throughout this time, especially regarding my post, Look Inward: Imposter Phenomenon. Now, I'm back in a place to starting writing again. This next blog discusses another topic that invites us to look inward to talk about something central to my research for my first year of doctoral studies.

Let’s talk about Music Performance Anxiety (MPA). For starters, yes, this is a real thing. MPA is recognized by psychologists as a subtype of social anxiety disorder, occurring along a continuous severity scale ranging from normal stress and anxiety intrinsic to being a musician to severely disabling symptoms of terror close to panic. While researchers disagree on the percent of prevalence among professional musicians, the range has been anywhere from 20–70%. I should note that there are two main reasons for inconsistent prevalence studies: 1) researchers don’t have access to a large sample size of professional musicians, such as an entire professional orchestra or chorus; 2) psychologists have yet to come to a consensus on a standard instrument to measure MPA. Anecdotally, I posted a poll on my Instagram page asking a simple question: "Have you heard of Music Performance Anxiety (MPA)?" 60% said "Yes" and 40% said "No" out of 354 votes. It's clear more awareness is needed here, so let's dive in.

Disclosure: This blog does not constitute medical or therapeutic advice. Please seek professional help if you find yourself in crisis. If you do not know where to go to seek help, contact me, and I'll refer you to resources. Trigger warning: we will be discussing anxiety.

The Research

More compelling research is done with university or college-level musicians where scientists can easily access large sample sizes. MPA prevalence among college and university music majors is concerning and multiple studies have yielded confirmatory results:

34% of students consider MPA a debilitating problem, and 65% of students said they believe their institution does not provide the support needed to cope better with MPA. Some may argue that some level of anxiety is to be expected when anyone must publicly perform. They are correct. There is a level of healthy, and perhaps, obligatory stress and anxiety intrinsic to the profession. And so, for quite a few years, researchers and mental health professionals brushed the alarming studies of MPA under the rug.

That is, until 2018.

The guiding thought up until 2018 from researchers was that MPA is not a real problem because it’s short-lived and something to be expected. Musicians get a little nervous leading up to a performance, but then they go home after the performance and then they are fine. Right?

Wrong. Really, really wrong.

A team of researchers published a groundbreaking study on MPA in the peer-reviewed scientific journal called Psychoneuroendocrinology. For those pronouncing that word multiple times in their head like a Hooked on Phonics lesson, I’ve got you. Psychoneuroendocrinology is the clinical study of hormone fluctuations and their relationship to human behavior. It draws heavily on the established research in psychiatry and endocrinology, where there are already many intersectionalities. It’s a relatively new field of study that has already proven incredibly useful in understanding disorders such as postpartum depression, for example. Back to the study.

These researchers studied a group of college music students. Instead of relying on qualitative indicators, these students had to regularly submit saliva samples under extremely rigorous sample control procedures. These samples were collected six times daily for seven days leading up to and after a concert day—that is a lot of saliva! The researchers then measured salivary cortisol (sC) and alpha-amylase (sAA)—prime biomarkers of stress and anxiety—over time. The results were staggering and challenged numerous prior assumptions and research findings. The findings contradict the researchers' predictions, who admittedly ran this study to affirm previous research from the psychoneuroendocrinology perspective. Here’s a comprehensible version of the main conclusions:

For those with MPA, the neuroendocrine effects of a musical performance go far beyond the concert day. Stress recovery appeared to require days beyond the designed research study.
Those with MPA had increased cortisol levels several days leading up to a performance that extreme physical exertion cannot even match.
Even a short solo performance of five minutes caused heightened salivary cortisol and alpha-amylase that prolong for several days.
Since musicians are often going from one performance to the next, musicians rarely have the opportunity to recover to baseline levels, so the salivary cortisol and alpha-amylase remain in a heightened or additive state.

This, among other findings in this study, led the researchers to pen this stunning conclusion:

“Considering that university music students perform regularly and plan to perform at the professional level, the prolonged post-performance neuroendocrine activation in this population could represent a relevant factor with well-being, health, and career-related implications. Particularly critical could be periods with several performances close to each other. Insufficient recovery associated with sustained psychobiological stress responses may lead to a generalized pathogenic state and may ultimately lead to a number of disorders… Music performances should preferably be separated by several days to avoid carry-over effects.”

This study opened the flood gates to additional research, which quickly deepened our understanding of MPA. For starters, researchers have increasingly called for the end of beta-adrenoceptor blocking medications, or “beta-blockers,” due to the number of adverse effects it can cause for musicians who rely on airflow (e.g., singers or wind players). Multiple studies have shown that simply incorporating a few deep breaths before a performance is equally as effective as beta-blockers without adverse effects. Additionally, recent research has demonstrated that there is a clinically insignificant difference between ensemble musicians and solo musicians. Both groups have sustained levels of salivary cortisol and alpha-amylase. There is, however, a clinically significant difference in the recovery time: soloists have prolonged levels of stress biomarkers for several days whereas ensemble musicians see a rather steep decline to base levels of stress biomarkers within a few days.

Recent scholarship has also debunked another myth within the music profession—that MPA diminishes as you become older and more experienced. False. They just develop unhealthy coping habits (read: gin) and, sadly, more mental health comorbidities. Also, without attributional retraining (more on that later), more experienced musicians tend to perpetuate the same unhealthy mindset regarding MPA which jeopardizes the wellbeing of younger musicians. Most concerning among recent scholarship is that MPA is strongly associated with other mental health comorbidities such as depression, anxiety, and obsessive-compulsive disorder. In other words, addressing MPA can mitigate other mental health concerns quite significantly.

The increase in research on MPA has also transformed from questioning whether MPA is an actual thing worth studying to questioning what causes it and how it’s treated amongst musicians.

Cause & Treatment

At the root of MPA is the fear of negative evaluation. This has been a common theme in much of my research and it draws from self-preservation theory.

This theory asserts that our desire to preserve our social self is fundamental to human motivation. So, when we are put in environments conceived as socially evaluative (ahem, a performance), we perceive it as threatening to our social self because of numerous factors:

A high level of performance is essential to our musical self-identity.
Music performance requires a display of high-level cognitive and sensorimotor skills coupled with aesthetic and interpretative abilities.
Our performance is evaluated by others.
There are numerous factors outside of our circle of control or influence.

This fourth factor is essential because for those with severe forms of MPA, the go-to treatment was cognitive behavioral therapy (CBT), which focuses on regulating our thoughts, feelings, and actions. However, a significant cause of MPA is our inability to control or influence certain factors such as audience response, critical reviews, etc. This has also led researchers to turn to a different and demonstrably effective treatment for MPA: acceptance and commitment therapy (ACT).

Rather than striving for mastery or control of one’s symptoms (a goal of conventional CBT), ACT promotes mindfulness and acceptance of one’s emotional distress. According to ACT, a primary cause of psychological stress is when we repeatedly engage in well-intended behaviors to reduce or eliminate unwanted internal experiences. Also known as “experiential avoidance,” this is a defining feature for all anxiety disorders, including MPA. To be clear, the explicit goal of ACT treatment is not to remove MPA symptoms. However, paradoxically, symptom reduction does occur with ACT treatment.

Another treatment option is attributional retraining (sometimes called attributional reframing). This is something that can be done independently or under the guidance of a mental health professional. Essentially, MPA thrives off maladaptive thinking. Most common among musicians are thoughts that a good performance is attributed to luck or external factors (again, things out of our control) whereas a bad performance is attributed to their ability. MPA also thrives off poor acknowledgment of effort. This has huge implications for musicians and teachers of musicians. [For more information on Attribution Theory, check out my blog on Imposter Phenomenon].

Coping Strategies

Let’s say you aren’t privileged enough to call your local neighborhood ACT practitioner.

There are other clinically or empirically established strategies that help people cope with or reduce MPA symptoms. These strategies have implications for both musicians and teachers of musicians:

For musicians:

Focus on the joy of process rather than the joy of a singular moment of performing.
Acknowledge that you are not in control of many factors in a performance, and that’s okay.
Accept that there will always be a bit of stress and anxiety when it comes to performing and that, if it feels debilitatingly high, seek professional help.
Build-in recovery time in between performances to bring your biomarker stress levels down. Maybe take on one less gig in December…
Be mindful of perseverative cognition (PC). Constantly replaying previous instances of when a performance went wrong does not serve you well. Past events have already happened and are beyond your control. Accept the past and embrace the present.
Deep breathing is clinically as effective as beta-blockers. Three slow and deep breaths before walking on stage will help.

For teachers:

Always praise the process, not the performance. Acknowledge hard work and effort over “natural talent” or “natural ability” (insert giant air quotes because the thought of innate ability is continually challenged in research).
Feedback—good or bad—should primarily be delivered privately.
Drop the perfectionism.
Reconsider how you schedule your performances. Back-to-back performances should be avoided if possible. If it’s impossible to avoid (read: it is possible to avoid), build in recovery or reflective time into your rehearsals. If you have three performances on a Friday, Saturday, and Sunday, maybe cancel Monday's rehearsal to give your students some recovery time.
Scaffold the performance setting. Instead of rehearsing for a performance, make every rehearsal incorporate minor performance aspects—even something as small as inviting an administrator or colleague to step in and listen.
Talk about times you’ve felt nervous performing. Acknowledge that MPA is a real thing.

For anyone thinking that this is not a big deal, let this be the main reason why this is worth addressing: Researchers concluded that successful coping with or treatment of MPA improved music performance quality by an average of 40% as measured by the Music Performance Quality (MPQ) Rating Form. That’s a significant improvement! Maybe that means spending a little less time on your scales in the practice room and instead focusing on your mental wellbeing.

As we all prepare to enter the concert halls again, we should be mindful that MPA may be even more pronounced as it’s been quite some time since many of us have performed in front of others. If you have the privilege of leading an ensemble, please consider how much good you could do by simply acknowledging MPA. Knowing more about MPA and recognizing its pervasive nature within our profession might help us all thrive just a bit more. For years in my training, I thought I just hated performing. Looking back, I hated MPA and suffered from it significantly. I wish I had known about it sooner because maybe I could have taken actionable steps to address it. The good news is that now you know, and now you can do something about it—one day, one breath at a time. So, what are you waiting for?