CHAPTER 36
Optimizing physical and
psychological health in
performing musicians
Dianna T. Kenny and Bronwen Ackermann
Introduction
Performing musicians face a number of physi-
cal, social and psychological challenges that
must be mastered if their musical career is to be
both rewarding and sustainable. However,
musicians are at high risk of physical and psy-
chological strain and injury in the execution of
their art. Physical and psychological stressors
exert reciprocal and synergistic effects on the
musician, and careful analysis of the intrinsic
characteristics of the performer and the extrin-
sic demands on the musician must be made in
order to develop appropriate interventions. In
this chapter we provide an overview of the risks
and challenges facing musicians with the aim of
developing awareness and understanding of
how to prevent and manage these challenges.
The chapter is divided into two sections: physi-
cal challenges and psychological challenges,
focusing on music performance anxiety. In each
section, we outline the key issues and then pro-
vide an overview of evidence-based treatment.
Physical health issues
Musicians are like athletes because both require
superior sensorimotor integration (Alternmuller
et al. 2000), neuro-musculoskeletal skill and
many hours of training and practice to achieve
mastery (Tubiana 2000). Several large epide-
miological studies have shown high physical
injury rates among musicians (Manchester 2006).
Performer-related risk factors for injury include
poor posture, poor physical condition, inade-
quate instrument set-up, long hours of playing,
insufficient rest breaks and inefficient move-
ment patterns (or poor technique) (Ackermann
and Adams 2004a).
Although musicians may suffer injury from
non-performance related causes such as lifting
and carrying awkward or heavy instruments and
suitcases (when on tour), demanding work
schedules, sitting on poorly designed orchestral
chairs, temperature variations (Manchester
2006), demanding repertoire and poor visibility
of music scores (Horvath 2002), the majority of
musicians’ injuries are over-use injuries
(Dawson et al. 1998) with soft-tissue symptoms
predominating (Pascarelli and Hsu 2001).
Musicians of all ages and levels of skill are vul-
nerable to injury, but the risk increases as hours
of playing increases. The neck, upper limbs and
lower back (Fjellman-Wiklund et al. 2003) are
vulnerable with upper limb over-use injuries
comprising 75–85 per cent of all injuries (Slade
et al. 1999). Strains of the muscle–tendon unit
predominate, with other common problems
including inflammatory disorders such as teno-
synovitis, arthritic problems and hypermobility
(also called double-jointedness) i.e. joints that
stretch more than normal (Dawson 2002).
People with hypermobile joints may be more
easily injured and may be more at risk of develop-
ing problems from muscle over-use, as muscles
must work harder to control joint movement.

Injury types vary according to instrument
type, gender (Engquist et al. 2004), years of
performing, repertoire, hours of practice and
age (Warrrington et al. 2002). Older musicians
more typically develop degenerative conditions
(i.e. conditions that have a gradual deterioration
in the structure of a body part with a consequent
loss of the part’s ability to function) while younger
musicians suffer more from performance-
related musculoskeletal pain (Warrington
et al. 2002).
Effective training for any athletic pursuit,
including music performance, involves a fine
balance between working hard enough to con-
tinually improve performance, while simultane-
ously resting enough to avoid incurring an
over-use injury, a task assisted by specifically
designed cross-training programmes (Marieb
2001). Muscle fatigue, which may arise from
central (brain) or peripheral (muscle) fatigue
(Gandevia 2001) due to over-practising without
adequate rest breaks (Ackermann and Adams
2004a) may be a factor in developing altered
movement patterns that can be a precursor to
injury. Exercise aimed at conditioning muscles
may reduce the effect of muscle fatigue by
increasing muscle cross-sectional area and cre-
ating neural adaptations that lead to an improved
ability to recruit motor units (Herbert 1993).
Types of injuries
Muscle/tendon injuries
Muscles are the primary source of force needed
for the performance of motor skills such as
instrumental playing. An occupational over-use
injury may result from insufficient muscle toler-
ance to cope with the quality, quantity and rate
of task demands (Hagberg et al. 1997). Dynamic
postures are less likely to cause pain than static
postures due to the short rests that occur
between the bursts of activity of muscles
involved in dynamic movements (Vergara and
Page 2002). Some strategies for musicians within
task-constraints are possible for small-scale
movements that can allow these dynamic
motions to occur (Rolland 1974). Pablo Casals
intentionally practised relaxing between phrases,
no matter how difficult the material, to mini-
mize the build up of adverse muscle tension
(Ma 1986).
Physical health issues · 391
Joint injuries
Joint injuries in musicians are degenerative,
likely to be related to repetitive use, but more
specifically to regional overload. For example,
the right thumb of a clarinettist carries the whole
weight of the instrument and shows early degen-
erative changes (Chesky et al. 2000). Ergonomic
devices such as a neck strap to carry the weight
of the clarinet may effectively reduce strain on
the thumb, although long-term effects of trans-
mitting this load through the neck are unclear
(Chesky et al. 2000).
Nerve compression disorders
Nerve compression syndromes in musicians are
related to the demands and nature of musicians’
work, such as sustained awkward positions, sus-
tained muscle contraction pressure, or the com-
pression arising from having to support the
instrument itself (Spinner and Amadio 2000).
Common nerve-entrapment disorders include
symptoms from compression of the ulna nerve
at the elbow, the median nerve at the wrist, cer-
vical radiculopathies, occasional digital neu-
ropathies and symptomatic thoracic outlet
syndrome (Schuele and Lederman 2004).
Central nervous system disorders
The most common performance-related condi-
tion of the central nervous system (CNS) affect-
ing musicians is focal dystonia, a movement
dysfunction syndrome thought to be due to dis-
ruptions between central sensory processing
and motor output (Chen and Hallett 1998).
Focal dystonias involve abnormal, often twist-
ing movements that tend to affect performers in
a similar way, with the left ring finger the main
reported site of the dysfunction in violinists
(Hochberg and Hochberg 2000). While a defini-
tive cause remains unclear, the amount of move-
ment repetition is a major factor in developing
dystonias (Hochberg and Hochberg 2000), and
these are potentially more potent if abnormal bio-
mechanical factors are present (Wilson 2000).
Treatment
Treatment, assessment and management proce-
dures are still largely based on clinical experi-
ence rather than scientific research (Schuele and
Lederman 2004). A primary goal of treatment is
392 · CHAPTER 36 Optimizing physical and psychological health in performing musicians
not only relief of symptoms but restoration of
function, addressing both local and general
effects of an injury (Herring and Kibler 1998).
Psychological factors may be involved in the
genesis or maintenance of physical problems.
Spahn et al. (2001) found significant rates (25%)
of somatization and somatoform disorders in
musicians presenting to hand surgery clinics.
Most of their sample (75%) did not attribute
their current physical problems to psychosocial
factors, even though there was no identified
organic cause for their physical problems. The
authors concluded that psychosomatic aspects
play a decisive role in somatic problems of musi-
cians and that these should be addressed
in treatment to avoid unwarranted medical
interventions.
Rest and rehabilitation
There is no benefit from prolonged rest for soft
tissue injuries in the majority of cases (Nash
et al. 2004). Scott (1997) defines the term rest
for soft tissue injuries with the mnemonic
‘Resume Exercise below Soreness Threshold’,
and emphasizes the importance of continuing
to play in a reduced and careful fashion wher-
ever possible without causing aggravation of the
injury. Guidelines for rehabilitating sports over-
use injuries stress the importance of relative rest,
where overall fitness is maintained even in the
acute stage of an injury while rehabilitating the
injured part back to performance requirements
(Herring and Kibler 1998). Relative rest can be
achieved if necessary with the assistance of
splints or ergonomic aids.
Poor muscle balance around the shoulder gir-
dle is frequently considered to be a cause of upper
limb symptoms in the musician, and restoring
a good balance of muscle condition as well as
strengthening postural muscles in this area is an
important part of rehabilitation (Chamagne 2000).
Retraining
Retraining is used for the treatment of both neu-
rological and musculoskeletal conditions occur-
ring in musicians. Some treatment approaches
for focal dystonia include splinting with specific
exercises (Candia et al. 1999), postural and
movement retraining strategies (Chamagne
2000), proprioceptive and sensory retraining
techniques (Ackermann and Adams 2005), and
the slow-down exercise regime involving task-
specific music drills (Sakai 2006). Movement
patterns can be re-trained by restoring good mus-
cle balance and functioning of the arm as a whole
kinetic chain unit to correct any underlying
mechanical inefficiencies (Dreyer and Boden
1999).
Manual therapy
Trigger point therapy may be useful for soft tis-
sue problems, particularly when palpation of
active trigger points reproduces the musicians’
symptoms (Davies 2002). Joint mobilization
techniques of the cervical spine, thoracic spine,
forearm, wrist and hand are necessary to restore
full functional range of movement for musicians
following an injury (Kember 1998).
Prevention of playing-related
injuries
Prevention is the best form of management for
occupational over-use injuries (Melhorn 1998).
Key factors in injury prevention include aware-
ness of correct postural requirements, technique
and biomechanics involved in playing one’s
instrument, and maintaining overall good physical
condition that is achieved by warming up, stretch-
ing (Zaza 1994) and strength and endurance
training (Marieb 2001).
Posture
Correct posture minimizes stress applied to each
joint. Poor posture, defined as a ‘faulty relation-
ship of the various segments of the body, pro-
ducing increased stress on supporting structures’
(Aaras et al. 2001), is a major risk for injury
because musicians have to maintain awkward,
relatively static postures over extended time
periods (Brandfonbrener 2000). Musicians must
maintain their posture within physiological
boundaries, even with asymmetrical instru-
ments such as the violin and flute, with good
proximal muscle support and weight balance to
avoid injury and to allow optimal fine control of
movements during performance (Tubiana et al.
1989). The musical instrument should be con-
sidered as an extension of the musicians’ body
(Dommerholt 2000).
Ideal sitting posture alignment occurs with hips
and knees at 90° of flexion, with a 10° backward

inclination of a supportive back on the chair
(Kendall et al. 1993), or a level seat and a back-
rest set back 20° to minimize lumbar loadings
(Bonney and Corlett 2002). Sitting should also
be balanced between sides by weight-bearing
evenly on both sides, as excessive weight-bear-
ing on one side may lead to lateral stresses on
the lumbar discs (Cailliet 1990).
Technique, biomechanics and
physical condition
Within a technique or movement pattern on a
musical instrument, early more rigid move-
ments are replaced by efficient movements
within anatomical and task constraints as the
skill is mastered (Sparrow and Newell 1998).
Musicians working under pressure may be so
focused on achieving a musical goal that a dis-
tortion of technique or posture occurs, and
these aberrations may then become established
in the motor programme, causing a subcon-
scious alteration in technique (Wilson 2000).
These physical adaptations do not represent the
players’ normal technique and may lead to
maladaptive changes including muscle misuse
or more serious neurological disorders such as
focal dystonia (Wilson 2000). Excessive muscle
tension also accompanies mechanical inefficiencies
in performance (Ma 1986).
Warming up and stretching
Regular stretching improves flexibility (Wilkinson
1992), and musicians benefit from instrument-
specific stretching programmes (Markison 1998).
Stretching should be performed regularly to
maintain adequate range for performance
demands (Norris 1993). Stretching prior to per-
formance only may not be sufficient to mini-
mize injury risk (Pope et al. 2000). General
warming-up and cooling-down routines are
recommended (Markison 1998). Players using
instrumental warm-up strategies may protect
themselves against the development of a
playing-related injury (Zaza and Farewell 1997).
Strength or endurance conditioning
Poor physical condition is a predisposing factor
to playing-related injuries (Ackermann and
Adams 2004a). Instrument-specific strength
and endurance training is effective in reducing
injury frequency and intensity as well as reducing
Psychological health issues · 393
the perceived exertion associated with practis-
ing their instrument (Ackermann et al. 2002).
In contrast, participating in unsupervised gen-
eral sports was not found to provide any benefits
in terms of injury prevention for musicians (van
Hees 1997).
Ergonomic aids and advice
Various ergonomic interventions aimed at
reducing physical load include hand splint
adaptations for the trombone to assist with
reach difficulties (Quarrier and Norris 2001),
development of polymer drumsticks with
reduced vibration characteristics (Zaza et al.
2000), a neck strap to carry the weight of the
clarinet and bassoon may effectively reduce strain
on the thumb (Chesky et al. 2000), and many
other designs such as angle-headed flutes, key
extensions on wind instruments, and remodel-
ling of viola or guitar bodies (Norris 2000).
Instruction on good lifting technique is important
for musicians who may injure their lower back
as a result of carrying heavy or awkward-shaped
instruments (Fjellman-Wiklund et al. 2003).
Psychological health issues
Stressors experienced by musicians
Sternbach (1995) described the working condi-
tions of professional musicians as generating a
‘total stress quotient’ that far exceeds that
observed in other professions. Like elite athletes,
performing artists must maintain their skills at
peak form, endure many hours of solitary,
repetitive practice, constantly self-evaluate their
performances and subject their public perform-
ances to close scrutiny. They are required to
work in a pattern akin to shift work, be available
to travel to performance venues, leave their
families while on tour, adjust to changing time
zones, live at close quarters with colleagues and
peers, and cope with financial insecurity. For
these reasons, it can be difficult to differentiate
between the occupational and physical stressors
discussed in the previous section and psycho-
logical problems that can arise in individual
musicians that may require individualized
psychological intervention.
Frequently reported psychosocial issues while
on tour or working on contract with interstate
394 · CHAPTER 36 Optimizing physical and psychological health in performing musicians
and overseas orchestras include loneliness,
homesickness, sexual frustration and relation-
ship breakdown. Occupational issues include
language barriers, unfamiliar backstage arrange-
ments at concert venues and variable quality of
dressing rooms. In addition to these psychologi-
cal and occupational stressors, there is the physical
stress associated with moving instruments and
luggage, setting up on different stages, adjusting
to differently shaped chairs at every venue,
sleeping in different beds with different pillows,
coping with jet lag, general fatigue and lack of
sleep. New injuries or pains are frequently
reported by professional musicians on tour, as a
direct result of these factors (Ackermann 2002).
Individuals vary in their capacity to cope with
such stressful working conditions. However,
since not all performers suffer the same degree
of psychological distress or indeed report the
same levels of occupational stress, individual
differences in a range of psychological charac-
teristics are likely to account for variations in
the degree to which musicians experience symp-
toms. For example, the difficulty in coping may
be compounded for those who are also highly
anxious, who lack confidence in their abilities
and who engage in unhelpful strategies to deal
with their anxieties, such as the regular consump-
tion of alcohol, and licit (e.g. beta blockers) or
illicit (e.g. marijuana) drugs. Since music per-
formance anxiety is one of the most commonly
reported psychological stressors in musicians,
the remainder of this chapter will focus on music
performance anxiety, its manifestations, conse-
quences and treatment.
Anxiety in public performance
Performance anxiety is a group of disorders that
affect individuals in a range of performance set-
tings, such as examinations, competitions and
public speaking. Solo and orchestral instrumen-
talists (van Kemenade et al. 1995) and solo and
choral vocal artists (Kenny et al. 2004) all report
experiencing music performance anxiety. Music
performance anxiety is also observed in young
musicians (Kenny and Osborne 2006), and chil-
dren and adolescents show a similar constella-
tion of symptoms to college level music students
and professional musicians (Osborne et al. 2005).
Students of classical music report higher levels
of performance anxiety than students of Jazz
(Kaspersen and Gotestam 2002). Like all per-
formance anxieties, music performance anxiety
occurs on a continuum of severity from ‘normal
everyday healthy aspects of stress and anxiety
that are intrinsic to the profession’ (Brodsky
1996, p. 91) to the severely debilitating symp-
toms of stage fright.
The phenomenology and
determinants of music
performance anxiety
Performance anxiety may occur as an isolated
disorder, affecting only one specific part of a per-
son’s life, such as public speaking, test-taking or
music performance. However, for a significant
minority of those suffering performance anxie-
ties, other comorbid disorders may be present,
the most common of which is generalized anxiety
disorder, which appears to co-occur in about one
third of those presenting with severe perform-
ance anxiety (Sanderson et al. 1990). Generalized
anxiety disorder is characterized by excessive,
uncontrollable and often irrational worry about
everyday concerns and is disproportionate to
the actual source of worry. People with general-
ized anxiety disorder may have a long history of
chronic worry and apprehension in most facets
of their lives, not just in performance situations
(American Psychological Association 2000).
Others may qualify for a diagnosis of social
phobia (social anxiety) if the performer demon-
strates significant impairment in interactions
with others as well as in the performance setting
and who otherwise meet the criteria for social
phobia presented in DSM-IV-TR (American
Psychological Association 2000). About 10–15%
of those with a social phobia also meet criteria
for clinical depression (Kessler et al. 1999). For a
subgroup of music performance anxiety suffer-
ers, there may be underlying psychological
conflicts that need to be identified and resolved
before the symptoms abate (Lazarus and
Abramovitz 2004).
Two distinct aspects of performance anxiety
have been identified—cognitive anxiety and
somatic anxiety (Martens et al. 1990). High cog-
nitive anxious individuals generally display a

consistent style of thinking about their perform-
ance that includes the following characteristics:
1 stronger negative expectancies before the
event
2 stronger negative bias in their retrospective
self-evaluations of performance
3 stronger expectation that their performance
will be judged negatively by their examiners/
audience
4 stronger concerns about the consequences of
a poor performance
5 heightened responsiveness to changes in reac-
tions of judges or audience
6 failure to derive comfort from evidence that
they have handled the situation skilfully
(Wallace and Alden 1997).
Somatic anxiety refers to the experiencing of a
cluster of physical symptoms during an anxiety-
provoking activity such as performing in front
of an audience. It is characterized by muscle
tension, agitation, and other phenomena such
as trembling, sweating, dry mouth, shallow
breathing and ‘buttlerflies in the stomach’ that
are associated with the ‘fright–fight–flight’
response, first described by Cannon (1915) and
subsequently by many researchers (Friedman
and Silver 2007). These symptoms occur as a
result of arousal of the sympathetic nervous sys-
tem via the release of the hormone epinephrine
(adrenaline) and to a lesser extent norepine-
phrine from the medulla of the adrenal glands
(Gleitman et al. 2004).
Music performance anxiety and
performance quality
Performance quality is determined by a number
of interacting factors, including the ability of the
performer and the level of achievement attained
as a musician (Fortune 2007), the degree to
which the performance repertoire has been
mastered (Wilson 2002), the fit between techni-
cal ability and task difficulty (Fehm and Schmidt
2006), the circumstances of the performance,
for example, whether the performance will be
evaluated by expert judges, audience character-
istics (Brotons 1994), and the type and severity
of anxiety experienced (Wang 2002).
Psychological health issues · 395
To date, Wilson (2002) has offered the most
comprehensive model of music performance
anxiety that incorporates the performer’s trait
anxiety, or their constitutional and learned
tendency to become anxious in response to
socially stressful situations; the degree of task
mastery achieved; and degree of situational
stress, such that high anxiety is more likely to be
experienced in situations where social or envi-
ronmental pressures are high. Performance anx-
iety may exert either an enhancing or detrimental
effect on performance depending upon the
interaction between these three factors (Fehm
and Schmidt 2006). For example, an individual
with high trait anxiety will perform best with an
easy, well-prepared piece in a relaxed environ-
ment, whereas an individual with low trait anxi-
ety will perform better if the piece is challenging
and performed in an evaluating environment,
such as an exam or competition.
Optimizing music performance
An optimal performance is determined by a com-
plex interaction between person characteristics,
task characteristics and performance setting.
These include adequate preparation, achievement
of task mastery such that the complex motor tasks
required to perform the task have been (over)
learnt to the point of being automatic (Oliveira
and Goodman 2004), familiarization with the
performance venue and adequate rehearsal with
other performers in the case of ensemble perform-
ance. When all of these characteristics occur at an
optimal level, the performer is said to be ‘in the
zone’ (Young and Pain 1999) or to have achieved
a state of ‘flow’ (Marr 2000). Another construct to
describe peak performance, borrowed from sport
psychology, is the ‘individualized zone of optimal
functioning’ (IZO) (Hanin 1986), that is, the per-
former has achieved the optimal level of pre-per-
formance anxiety that results in a peak
performance. ‘Optimal’ pre-performance anxiety
is a good predictor of performance quality (Turner
and Raglin 1991).
Although one would expect highly anxious
individuals to experience performance break-
down or impaired performance quality more
often than low-anxiety performers, this is not
usually the case (Strahan and Conger 1998).
396 · CHAPTER 36 Optimizing physical and psychological health in performing musicians
Even in situations where the highly anxious do
perform less well than the less anxious, social or
artistic performance catastrophes are rare. There
are a number of possible explanations for this.
First, people display highly individual ways of
responding to stressful situations. Very small
changes in context or task-expectancy can change
a person’s appraisal of a situation as anxiety-
provoking or not (Bandura 1991). Secondly,
those situations that could produce a catastro-
phe are indeed rare, even for highly anxious
individuals. Thirdly, highly anxious professional
performers are likely to engage in a number of
pre-performance compensatory activities, such
as over-learning, additional rehearsals, or visit-
ing the venue before the performance to ensure
that their performance can withstand the addi-
tional anxiety they know they will experience
during the performance (Kenny et al. 2004).
Treatments for music
performance anxiety
Many treatment programmes have been devel-
oped to assist the anxious or stressed musician.
However, most of the available treatments have
not been adequately assessed as to their effec-
tiveness. These include:
1 Prescription pharmacological interventions
such as antidepressants, benzodiazepines,
beta-adrenergic receptor blockers, and
busipone.
2 Meditative interventions (autogenic training,
(self-) hypnosis, meditation, yoga)
3 Physiological and physically based interven-
tions (aerobic exercise, Alexander technique,
biofeedback, Feldenkrais, massage)
4 Relaxation therapies e.g. progressive muscle
relaxation training
5 Cognitive and cognitive behavioural inter-
ventions: assertiveness training, attention-
focusing techniques, cognitive behaviour
therapy (cognitive restructuring), multimo-
dal behavioural therapy, coping skills train-
ing, exposure therapy, goal setting, lifestyle
changes (e.g. development of non-musical
hobbies and interests), imagery (distraction
and focused), mental rehearsal, stress inocu-
lation, systematic desensitization and system-
atic rehearsal
6 Music therapy (music enhanced relaxation
techniques; group therapy for musicians)
7 Psychotherapy (Nagel 2004).
Space permits only a brief overview, update
and summary of the most commonly used and
researched treatments and their effectiveness—
the cognitive and behavioural therapies. A
detailed review and analysis of other treatments
for performance anxiety can be found in Kenny
(2005).
Cognitive, behavioural and cognitive
behaviour therapies
Behaviour is determined by a combination of
thoughts, feelings and past and present behav-
iours (Turkington et al. 2006). Three groups of
therapies—behavioural (van de Wiel et al.
2007), cognitive (Willner, 2006) and cognitive
behavioural (Butler et al. 2006)—are all based
on the same principles, but use the available
therapeutic techniques in different amounts.
Behavioural therapies focus primarily on chang-
ing the dysfunctional behaviours that arise when
people feel anxious. One of the main targets of
behavioural therapies for anxiety disorders is
excessive muscle tension, which is treated with
deep muscle relaxation training (Conrad and
Roth 2007) and systematic desensitization
(Pagoto et al. 2006), a procedure in which the
person is encouraged to imagine the feared or
anxiety provoking situation in graded steps,
called the fear hierarchy, until they can visualize
the situation without experiencing the muscle
tension that used to accompany the visualiza-
tions. Once the fear hierarchy has been mastered
in the therapist’s office (imaginal desensitiza-
tion), people are encouraged to apply their new
skills in the actual, anxiety-provoking situation
(called in vivo desensitization) (Choy et al.
2007). This allows for behavioural exposure, i.e.
repeatedly practising the task in the feared situ-
ation until the associated anxiety is reduced to
manageable levels. For this to be effective, the
task must have been mastered so that the per-
former can ensure successful performance in
the more stressful situation (Rauch and
Foa 2006).
Cognitive therapy focuses on mental states
such as thoughts, feelings and images (Willner
2006). Dysfunctional cognitions, those that create
emotional distress or maladaptive responses,

can be the result of cognitive deficits (i.e. diffi-
culties with problem solving) (van Winkel et al.
2006), and/or errors or biases in information
processing (Joormann et al. 2007). Cognitive
therapy changes faulty thinking patterns that
give rise to maladaptive behaviours, such as exces-
sive muscle tension, avoidance of the feared sit-
uation, or impaired performance. In this therapy,
people learn a skill called cognitive restructur-
ing, a process whereby people replace negative,
unproductive, catastrophic thinking with more
rational, useful ways of understanding their
problem situations (Murphy et al. 2007). Based
on changed thinking patterns, people are often
able to reassess or reappraise their feared situa-
tions in ways that reduce the perceived threat.
Cognitive behavioural therapy (CBT) is a
combination of behavioural and cognitive inter-
ventions (Turkington et al. 2006). CBT uses
educational and psychological interventions
that are based on the idea that changing nega-
tive thinking patterns and behaviours can have a
powerful effect on a person’s emotions, which
in turn can change behaviour in situations in
which the negative emotions arose. Like all new
learning, CBT requires commitment, practice
and application in situations outside the therapy
office (Yovel and Safren 2007). CBT is focused
and directive, usually of short duration and is
action-oriented,—it relies on the client’s record-
keeping, active participation, application and
evaluation (Rees et al. 2005).
A more recent variant of CBT, multimodal
behavioural therapy (Lazarus and Abramovitz
2004) proposes a multimodal approach to
treatment that involves the assessment and
management of any combination of seven com-
ponents: behaviour, affect, sensations, imagery,
cognition, interpersonal relationships, and
drugs/biological factors. Research is needed to
assess whether this more comprehensive
approach will produce better results for the
anxious musician.
Prevention of music performance
anxiety
Parenting style is important in the prevention of
anxiety and depression in children (Barlow
2000). Parents who are responsive, unobtrusive,
not overly protective, and who give children
age-appropriate opportunities to exercise control
References · 397
over their environment foster a sense of control
and mastery in their children that provides
protection against the development of anxiety
(Gar et al. 2005).
Most forms of performance anxiety are diffi-
cult to treat and anxiety levels after treatment
rarely reduce to those of non-anxious people
(Kenny 2005). The best form of treatment is to
prevent its occurrence. Sound pedagogy, appro-
priate parental support and expectations, and
the learning of self-management strategies early
in one’s musical education can help to mitigate
the effects of entering a highly stressful profession.
Children should be offered frequent, low-
stress opportunities to perform almost from the
beginning of their musical training. These per-
formances should be presented in a positive,
non-judgemental way, so that young performers
can learn that performance is an integral, enjoy-
able and manageable part of their musical educa-
tion. Children should not be prematurely thrust
into competitive environments whose focus is
evaluation (such as auditions or competitions)
and when they are, students need to be well pre-
pared for the performance both musically and
psychologically. Repertoire should be well within
the technical capacity and interpretive abilities of
the student and the material should be well-
learned. Sensible pre-performance routines
should be established that attend to the perform-
er’s physical well-being (having adequate diet
and sleep), psychological well-being (developing
positive self-statements and realistic self-ap-
praisal capacity) and musical demands (adequate
practice, appropriate level of complexity, cogni-
tive and physical capacity commensurate with
the musical demands). These strategies will
enhance the student’s sense of competence and
control so that when confronted with critical
performances, a strong sense of a competent self
will guide a self-actualized performance.
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