A META-ANALYSIS OF NONPHARMACOLOGIC PSYCHOTHERAPIES FOR MUSIC PERFORMANCE ANXIETY.pdf

A META-ANALYSIS OF
NONPHARMACOLOGIC PSYCHOTHERAPIES FOR
MUSIC PERFORMANCE ANXIETY
by
Laurie Goren
A Dissertation Submitted to the Faculty of
the California Institute of Integral Studies
in Partial Fulfillment of the Requirements for the Degree of
Doctor of Psychology in Clinical Psychology
California Institute of Integral Studies
San Francisco, CA
2014

CERTIFICATE OF APPROVAL
I certify that I have read A META-ANALYSIS OF
NONPHARMACOLOGIC PSYCHOTHERAPIES FOR MUSIC
PERFORMANCE ANXIETY by Laurie Goren, and that in my opinion this work
meets the criteria for approving a dissertation submitted in partial fulfillment of
the requirements for the Doctor of Psychology in Clinical Psychology at the
California Institute of Integral Studies.
Katie McGovern, Ph.D., Chair
Professor of Clinical Psychology
M. D. Gall, Ph.D.
Emeritus Professor of Education
University of Oregon

iv
Laurie Goren
California Institute of Integral Studies, 2014
Katie McGovern, Ph.D., Committee Chair
A META-ANALYSIS OF NONPHARMACOLOGIC PSYCHOTHERAPIES
FOR MUSIC PERFORMANCE ANXIETY
ABSTRACT
Music performance anxiety (MPA) is a common problem in musicians of
all ages, genders, socio-economic backgrounds, and levels of performance
experience. The intensity of symptoms associated with the condition range from
mild to debilitating. Even at lower levels, chronic MPA is associated with stress-
related illnesses and maladaptive coping behaviors, such as self-medication with
licit (cigarettes and alcohol) and illicit or off-label drugs. Acute MPA is known to
destroy musical careers.
Faced with the pervasiveness and potential gravity of MPA, clinicians
have developed a number of nonpharmacologic treatment protocols, some of
which have been studied for efficacy. Most of the outcome studies have reported
pairwise comparisons (experimental versus control) of measures taken of small
samples of performing musicians. The robustness of the treatment was determined
by tests of statistical significance of observed differences on outcome measures or
by the calculation of effect size.
Previous narrative reviews of outcome studies have provided summary
descriptions of their characteristics and findings. However, these analyses do not

v
provide quantitative evidence of the efficacy of different treatments for
ameliorating MPA.
Since it was first employed in psychological research by Smith and Glass
in 1977, meta-analysis has become the gold standard for synthesizing quantitative
research findings across studies.. The method involves integration of standardized
treatment effect estimates from different studies. It can provide comparisons of
the effectiveness of subgroups of therapies (approaches), characterize a
therapeutic approach in terms of an outcome profile, and determine whether a
particular psychotherapeutic intervention is effective. The present review is the
first to use meta-analysis to integrate the findings of research studies in the
literature on nonpharmacologic psychotherapies for MPA and to compare their
effectiveness.
An exhaustive search of the literature identified 46 efficacy studies. Of
these, 29 met the criteria for inclusion in the meta-analysis. The accumulated data
represents autonomic, self-report, and observational measures of MPA for 852
advanced music students and professional musicians. Each measure was coded for
type (autonomic, self-report or observational) and for therapeutic approach
(cognitive, behavioral, complementary and alternative, and combined). Analysis
of the synthesized data indicated statistically significant therapeutic effects of
each therapeutic approach. Additionally, when the approaches were compared, the
class of psychotherapies that was made of combinations of two or more types of
interventions (combined) showed the strongest treatment effect.

vi
Among the implications of these findings is the plurality of good choices
for an individual suffering with MPA. The development of programs to raise
awareness of the prevalence of music performance anxiety and available
treatments is recommended. For researchers, greater standardization in
methodology and periodic meta-analysis is encouraged.

vii
ACKNOWLEDGEMENTS
Last year, Diana Nyad performed the astounding feat of swimming the
ocean from Cuba to Florida. Upon arriving, exhausted and barely able to walk,
she said “this may look like a solitary achievement, but it took a team.” I can say
the same. Like Ms. Nyad, I relied on a support network of extraordinary people to
complete this research project.
I wish to convey my deep thanks
. . . to committee members Katie McGovern and M. D. “Mark” Gall for
their encouragement, thoughtful consideration, and belief in this project.
. . . to Professors Ed Connor and Ryan Howell for their generous
assistance with the meta-analysis.
. . . to Robert Patterson, for championing my dream in innumerable ways,
both essential and delightful.
. . . to my daughter, Whitney Spector, for her loving witness and
encouragement.
. . . to my dearest of friends, Jan Lytjen, Tienne Beaulieu, Anthony
Wright, and Bill Storms for being there for me in so many ways.
. . . to Patrick O’Kelly, Christine Lorenz, and Gerard Aknouny for their
timely and essential help.
. . . to Lucette Doessegger for strength and inspiration.
. . . to Beth Miller, Pam Birrell, Susan Dubin-McNeil, Hiram Elliott,
Nancy Freitas Lambert, and to Benjamin Tong and colleagues at the California
Institute of Integral Studies for their sage guidance.

viii
. . . to fellow students Bayla Travis, Ana Berezovskaya, and Robyn El-
Bardai for their encouragement and much-appreciated collegial support.
. . . and, of course, to my parents, Alvin Goren and Audrey Riddell Goren
for providing the musical, intellectual, and socially-conscious environment in
which I was raised.

ix
TABLE OF CONTENTS
ABSTRACT........................................................................................................... iv
ACKNOWLEDGEMENTS.................................................................................. vii
CHAPTER 1: INTRODUCTION........................................................................... 1
Developing Treatments........................................................................................... 3
Studying Treatments............................................................................................... 4
Reviewing Treatments ............................................................................................ 6
Historical Context of the Problem .......................................................................... 7
Significance............................................................................................................. 9
Research Questions............................................................................................... 10
Approach............................................................................................................... 10
Major Constructs................................................................................................... 10
Music Performance Anxiety ..................................................................... 10
Debilitating Music Performance Anxiety................................................. 11
Performance Anxiety ................................................................................ 11
Social Anxiety Disorder............................................................................ 11
Delimitations and Scope ....................................................................................... 11
CHAPTER 2: LITERATURE REVIEW.............................................................. 13
Models of Anxiety ................................................................................................ 13
State Versus Trait Anxiety........................................................................ 13
Yerkes-Dodson Law ................................................................................. 13
Catastrophe Theory................................................................................... 14
Music Performance Anxiety in the DSM.............................................................. 15

x
Performance Anxiety ............................................................................................ 20
Music Performance Anxiety ................................................................................. 21
Psychotherapeutic Treatment.................................................................... 27
Efficacy Studies ........................................................................................ 28
Reviews of Efficacy Studies..................................................................... 28
Conclusion ............................................................................................................ 30
CHAPTER 3: METHODS.................................................................................... 32
Search Strategy ..................................................................................................... 32
Selection Criteria .................................................................................................. 33
Data Analysis........................................................................................................ 38
Data Extraction ..................................................................................................... 39
Categorization of Data.............................................................................. 41
Data Entry................................................................................................. 42
Meta-Analysis........................................................................................... 44
Step 1: Effect calculation.............................................................. 44
Step 2: Combination of effects. .................................................... 44
CHAPTER 4: RESULTS...................................................................................... 46
Review of Effect Sizes.......................................................................................... 46
Behavioral Therapies ................................................................................ 48
Complementary and Alternative Therapies .............................................. 50
Cognitive Therapies.................................................................................. 52
Combined Therapies................................................................................. 53
Conclusion ............................................................................................................ 56

xi
CHAPTER 5: DISCUSSION................................................................................ 58
Limitations............................................................................................................ 59
Recommendations for Future Research................................................................ 60
Clinical Implications............................................................................................. 61
REFERENCES ..................................................................................................... 62
APPENDIX A: STUDIES IN THE META-ANALYSIS..................................... 77
APPENDIX B: SELF-REPORT MEASURES IN THE META-ANALYSIS ..... 80
APPENDIX C: DESCRIPTIVE STATISTICS FOR EACH OUTCOME IN THE
META-ANALYSIS.............................................................................................. 82
APPENDIX D: RANDOM-EFFECTS ANALYSES OF INDEPENDENT
OUTCOMES ........................................................................................................ 92

xii
LIST OF TABLES
Table 1: Social Anxiety Diagnostic Criteria......................................................... 19
Table 2: Studies Selected for Meta-Analysis......................................................... 35
Table 3: Previously Reviewed Studies Excluded From Meta-Analysis ................ 37
Table 4: Additional Studies Determined to Be Ineligible for Meta-Analysis........ 38
Table 5: Meta-Analysis Data Elements................................................................. 43
Table 6: Analysis of Random Groupings of Independent Outcomes .................... 47
Table 7: Behavioral Therapies Treatment Effects ................................................ 49
Table 8: Complementary and Alternative Interventions Treatment Effects.......... 51
Table 9: Cognitive Therapies Treatment Effects .................................................. 52
Table 10: Combined Therapies Treatment Effects................................................ 54
Table C1: Treated Pre-Post Means Reported....................................................... 82
Table C2: Control Pre-Post Means Reported....................................................... 85
Table C3: Not Controlled Pre-Post Means Reported........................................... 89
Table C4: Controlled, Post-Only Reported .......................................................... 91
Table C5: Controlled, Pre-Post Difference Reported........................................... 91
Table D1: Random Grouping 1............................................................................. 92

xiii
Table D9: Random Grouping 9........................................................................... 100
Table D10: Random Grouping 10....................................................................... 101

1
CHAPTER 1: INTRODUCTION
Music performance anxiety (MPA) is a complex psycho-physiological
event (e.g., Neiss, 1988; van Fenema et al., 2013; Zinn, McCain, & Zinn, 2000).
Its most salient features are negative cognitions, uncomfortable physiological
symptoms, and musical performance as the instigator of these cognitions and
symptoms. At low levels of intensity, MPA generally is manageable with a
healthy lifestyle (exercise, fresh air, good nutrition, and sufficient sleep) and
adequate preparation in the requisite performance skills. At high levels of MPA,
however, these practices may fail to protect the musician from a breakdown in the
memory, concentration, muscular agility, and breathing essential for musical
performance. Unfortunately, high levels of MPA are likely to occur with high-
risk performances, such as orchestral solos, auditions, and advancement juries,
when the standard of performance nears perfection. Breakdowns in performance
during these events can be traumatic and injurious to a musician’s career and
confidence in subsequent performances (Barlow, 2000; Derakshan, Smythe, &
Eysenck, 2009; Wan & Huon, 2005). Anxiety experienced in anticipation of MPA
(fear of fear) can intensify MPA and lead to timid performance or abandonment
of opportunities for subsequent musical performance (Papageorgi, Hallam, &
Welch, 2007; Powell, 2004).
Even at levels that do not interfere with performance, chronic MPA can
threaten the health and careers of its sufferers (Clark, 1989). For example, chronic
MPA has been found to lead to unhealthy coping methods, such as excessive use
of tobacco, alcohol, and illicit or off-label drugs among professional musicians of

2
classical music (Fishbein & Middlestadt, 1988; Steptoe, 2001) and of popular
music (Miller & Quigley, 2011; Raeburn, 2000).
MPA is a common problem experienced by most musicians at one time or
another (Kenny, 2011; Lederman, 1999; Reitman, 2001). Great classical
performers such as Vladimir Horowitz (Rosenthal, 2000), Glenn Gould
(Simmonds & Southcott, 2012), and Pablo Casals (Plaut, 1988; Salmon, 1990)
had years of triumphant performances, but are known to have suffered from MPA.
Popular vocal musicians such as Barbra Streisand (ABC News, 2005), Carly
Simon (Simmons & Southcott, 2012), and Linda Ronstadt (2013) have admitted
that debilitating symptoms of MPA caused them to avoid live performance.
From these artists’ experiences, it is reasonable to conclude that MPA
does not necessarily result from lack of skill, talent, or experience. However, it is
not uncommon for musicians to associate MPA with a lack of character. Take, for
example, this quote from the Music Educator’s Journal:
Here is the cure for stage fright. If you have strength of mind and a
conscientious determination, you can walk onto the stage for a solo with
almost the same certainty you have in practicing. There is the added and
thrilling incentive now of an audience. By imagining what you may fancy
to be their opinion of you—which does not matter anyway—you have a
new angle: giving emotional joy, spiritual nobility, or dramatic
stimulation. With an honest artistic outlook stage fright goes out the
window. In its place you have the pleasure of adding something to the
lives of your listeners. (Dunham, 1953, p. 46)
While inspirational in tone, this statement implies that musicians whose MPA is
out of control lack “strength of mind”, “conscientious determination,” or “honest
artistic outlook.” Perhaps for this reason there is a culture of denial in music
schools and professional orchestras that forbids open discussion of MPA. In

3
competitive environments, it can be unwise to show vulnerabilities and risk giving
psychological advantage to a competitor. Researchers have managed to deal with this
culture of denial by promising anonymity when they survey members of musical
organizations. Among studies of professional orchestral musicians, the findings
range from 16% reporting MPA in a survey of 2,212 respondents from 47
American orchestras (Fishbein & Middlestadt, 1988, p. 6) to 96% reporting MPA
in a survey of 204 respondents from 19 Canadian orchestras (Bartel & Thompson,
1994, p. 72). The reason for this wide range in MPA incidence may be the
differing definitions of MPA used in these studies. Fishbein and Middlestadt
focused on acute MPA, whereas Bartel and Thompson focused on “performance
related stress,” which probably includes lower levels of MPA. In spite of efforts
to clarify the construct of MPA, discrepancies in its use occur throughout the
literature.
Developing Treatments
Some clinicians faced with clients suffering from MPA have tried to apply
standard treatment protocols for more general anxieties, such as social anxiety
disorder, with varying degrees of success. Other clinicians base their therapeutic
approach on the way they understand the etiology of their client’s distress. A
psychodynamic therapist might formulate therapy for an MPA client in terms of a
diagnosis of neuroticism involving such features as perfectionism, self-doubt, and
a tendency to anticipate negative results (Nagel, 1993; Steptoe & Fidler, 1987). A
cognitive-behavioral therapist might plan a therapeutic approach based on the
DSM-V subtype of Social Anxiety Disorder (SAD), in which the emphasis is on

4
comparison of oneself against others. Cognitive-behavioral approaches (attention
redirection training, relaxation, anxiety management, and systematic
desensitization) may be indicated (Bögels et al., 2010).
In today’s clinical practice, a clinician’s therapeutic orientation is not
considered a sufficient basis for selecting a treatment for any psychological
disorder, including MPA. Clinicians now must look to research to provide
evidence that can guide their selection of treatment options for their clients.
Studying Treatments
The empirical study of psychotherapeutic treatments for MPA is
consistent with this movement in Psychology towards evidence-based practice.
The 1993 APA Division 12 (Clinical Psychology) Task Force on Promotion and
Dissemination of Psychological Procedures promoted “empirically-validated
treatments” as being in line with medicine and psychiatry’s movement towards
evidence-based practice and as “essential” for the survival of the profession of
Clinical Psychology.
Brodsky (1996) responded to the task force with a critical review of
current research practices on music performance anxiety. He found that
researchers had not built consensus on the meaning of the construct of MPA. He
also found that the experimental studies on MPA treatments involved inadequate
sampling, weak screening criteria, and unreliable and invalid assessment
procedures.
Nonetheless, the need to validate clinical treatments for psychological
disorders was mandated by the 2005 APA Presidential Task Force on Evidence-

5
Based Practice, which stated that “the scientific method is a way of thinking and
observing systematically, and it is the best tool we have for learning about what
works for whom” (p. 18).
Schnurr (2007) elucidated methodological issues in psychotherapy
outcome research with the goal of moving the profession of clinical psychology
towards better evidence-based practices. In contrast to pharmaceutical trials,
Schnurr found that it is very difficult to control psychotherapeutic factors
involved in the patient-provider relationship, the provider’s skill, and fidelity to
the treatment protocol. It is also impossible in a psychotherapy study to blind
patients and providers to which treatment the patient is receiving. Furthermore,
Schnurr declared “there is no true placebo in a psychotherapy study” (p. 779).
Schnurr urges the development of standards for experimental design that take
these differences into consideration.
In 2008, the CONSORT (Consolidated Standards of Reporting Trials), a
major effort by the American College of Physicians to improve experimental
trials, was expanded to include nonpharmacologic treatment interventions
including psychotherapies (Boutron, Moher, Altman, Schulz, & Ravaud, 2008).
These standards are designed to guide researchers in the design, report, and
comparison of randomized controlled trials (RCTs). To date, Wells, Outhred,
Heathers, Quintana, and Kemp (2012) is the only experimental study on treatment
for MPA that has referenced these standards.
Most empirical studies on nonpharmacologic treatments for MPA are
randomized and controlled. They represent a variety of approaches, including

6
behavioral therapies (e.g., exposure/desensitization and relaxation), cognitive
therapies (e.g., guided imagery), complementary and alternative therapies
(hypnosis, yoga, meditation, biofeedback, and music therapy), and combinations
or “multi-modal” therapies.
Treatment outcome research thus far has not addressed the complete
spectrum of MPA experiences and appears to present a one-size-fits-all approach
to treatment (Nagel, 2004). The research populations generally have been
performing musicians who are capable of managing their MPA well enough to
continue their academic program or career. Consequently, experiments have
focused on stress management techniques for mid-range discomfort. It is possible
that findings from these studies may help manage musicians who suffer from
manifestations of chronic MPA, such as stress-related illnesses and maladaptive
coping behaviors. However, effective psychotherapy for this population might
require treatment of mental illness, personality disorders, or trauma.
Reviewing Treatments
Three systematic narrative reviews (Brugués, 2011; Kenny, 2005;
McGinnis & Milling, 2005) have provided summaries of the characteristics and
findings of most of the empirical studies published so far. However, these
analyses did not compare the efficacies of different treatments nor did they
answer the question of whether there is evidence that psychotherapy works to
ameliorate MPA.
Since meta-analysis was first employed in psychological research by
Smith and Glass in 1977, it has become the gold standard of research synthesis in

7
psychology and related fields. The method involves integration of standardized
treatment effect estimates from different studies. It offers the advantages of
increasing statistical power and improving the precision of small effect sizes. It
can provide comparisons of the effectiveness of subgroups of therapies,
characterize a therapeutic approach in terms of an outcome profile, and determine
whether a particular psychotherapeutic intervention is effective. The present
review is the first to use meta-analysis to integrate statistical findings about the
relative efficacy of various nonpharmacologic psychotherapies for MPA.
Meta-analysis was used in the hope that it will guide MPA researchers to
use stronger research designs and better interventions and to assist clinicians in
choosing appropriate psychotherapeutic interventions for their musician clients.
Historical Context of the Problem
While MPA has been a part of human experience for a very long time, it is
a relatively new area of focus for psychological and medical research. Until about
30 years ago, most of the research on MPA’s causes, effects, and mitigations have
been conducted in the field of Music Education, where it was most often referred
to as stage fright (e.g., Dunham, 1953; Gruenberg, 1919; Lehrer, 1987; Martin,
1964).
Research on stage fright has helped guide the development of didactic
practices that support a student’s process of mastering timidity and emergence as
a performer. These practices include methods designed to strengthen focus,
nurture delight in challenge and mastery, encourage healthy practice habits, and

8
habituate the student to the stage by providing plenty of performance
opportunities (Boucher & Ryan, 2011; Lund, 1972).
Music performance anxiety first appeared as a distinct topic of scientific
inquiry in the mid-1970s (Appel, 1976). The literature on MPA has been built
primarily on medical and psychological studies of the broader construct of
performance anxiety and on specific related performance anxieties, such as test
anxiety and sports performance anxiety. In 1986, the journal Medical Problems of
Performing Artists was launched. Among its early publications was a reprint of
the massive national survey study on orchestral musicians, known as the ICSOM
study (Fishbein & Middlestadt, 1988). This study shed light on the pervasiveness
and severity of music performance anxiety in that population. More importantly,
the survey provided legitimacy and momentum to the scientific effort to
understand the problem and find ways to treat it. Since the publication of the
ICSOM survey results, the study of music performance anxiety has made
substantial progress towards definition of terms and constructs.
A recent milestone in the promotion of MPA research is the addition of a
new specifier for Social Anxiety in the most current edition of the psychiatric
manual of standard diagnostic taxonomies, the DSM-5 (American Psychiatric
Association, 2013). Although the manual does not mention music performance
anxiety specifically, it lists musicians among those who suffer from performance
anxiety. The new diagnosis of Social Anxiety Disorder, performance only applies
to individuals who have “performance fears that are typically most impairing in
their professional lives (e.g., musicians, dancers, performers, athletes) . . . [and]

9
may also manifest in work, school, or academic settings in which regular public
presentations are required” (p. 203). This was an important step in the recognition
of MPA as a psychological problem worthy of further research.
A challenge in the study of MPA is gaining access to populations that
represent a full range of relevant experiences. Most research subjects have been
drawn from academic and professional performance organizations, such as bands,
choirs, orchestras, and musicians unions. These populations generally are
comprised of committed and skilled musicians who can manage their MPA well
enough to perform. In contrast, research on musicians with incapacitating
symptoms is done on a case-by-case basis, providing data from which it is
difficult to extrapolate general characteristics of the problem and efficacy of
treatment. Currently, the best estimate of the prevalence of debilitating MPA was
derived from studies on test anxiety. Powell (2004) conjectured that 2% of the
general population suffers debilitating performance symptoms of some kind (p.
806).
Significance
The present study is the first to apply meta-analysis to the data from
outcome studies on nonpharmacologic treatments for MPA. Prior to this, three
reviews of this empirical research were done in a traditional narrative manner.
Now that the field has matured to the point where there is agreement on the basic
construct of MPA and there is a sufficient number of published outcome studies, a
meaningful meta-analysis is possible, and that is the purpose of the present study.

10
Research Questions
The present study asks the following questions: Are nonpharmacologic
psychotherapies for MPA effective? Which of four classes of empirically-studied
nonpharmacologic psychotherapies is most effective in reducing MPA?
Approach
Efficacy studies of nonpharmacologic psychotherapeutic interventions for
MPA in adults were selected and relevant outcome data were extracted. These
data were then entered and coded in a meta-analysis database. The software,
Comprehensive Meta-Analysis, calculated standardized effect sizes. The effect
sizes for a variety of subgroupings of interventions were compared
Major Constructs
Music Performance Anxiety
The term music performance anxiety (MPA) refers to the very specific
form of anxiety associated with performing or preparing to perform music in front
of others. The most commonly cited definition is that proposed by Salmon (1990):
“the experience of persisting, distressful apprehension about and/or actual
impairment of, performance skills in a public context, to a degree unwarranted
given the individual’s musical aptitude, training, and level of preparation” (p. 3).
Symptoms can be characterized as autonomic (e.g., sweating, racing heart),
psychological (i.e., cognitive and emotional), and behavioral (e.g., musical
timidity, performance avoidance, loss of memory and technical ability). Music
performance anxiety can worsen as the musician experiences, remembers, or

11
imagines the disastrous effect of MPA on the quality of performance (Bögels et
al., 2010; Kirchner, 2003).
Debilitating Music Performance Anxiety
Debilitating music performance anxiety refers to a degree of music
performance anxiety that results in disastrous worsening of performance quality
or performance avoidance. This term contrasts with the term facilitating music
performance anxiety (Lehrer, Goldman, & Strommen, 1990) and other
manageable degrees of MPA.
Performance Anxiety
Performance anxiety is a general diagnostic term that applies to test
anxiety, sports performance anxiety, fear of public speaking, writer’s block,
dancing, acting, sexual performance and music performance anxieties.
Social Anxiety Disorder
Social Anxiety Disorder (SAD) is a standard clinical diagnostic term that
is defined by the DSM V (APA, 2013) as “marked fear or anxiety about one or
more social situations in which the individual is exposed to possible scrutiny by
others” (p. 202). This term replaced social phobia in the fifth edition of the DSM.
Delimitations and Scope
The focus of this study is on nonpharmacologic psychotherapies for music
performance anxiety. It is limited to comparing performance experiences before
and after therapeutic intervention and between treated and untreated groups.
While randomized-controlled trials are commonly considered to be the
gold standard in experimental design (e.g., APA, 1993, 2005), the small number

12
of MPA studies available necessitated inclusion of other study designs. Single-
subject case studies were eliminated.
As there are only two empirical studies of treatments for MPA in children
(Gomes de Sousa, 2011; Su et al., 2010), the present review focused on
experiments involving adult subjects.
The statistical analysis focused on intervention effects on autonomic
measures of MPA, self-reported psychological measures of MPA, and
observational measures of MPA. The analysis did not consider other potentially
relevant factors, such as gender, musical instrument, personality traits, ethnic-
cultural identity, or trait anxiety. Such factors are worthy of study, but exceed the
scope of this study.
All studies represent musicians whose degree of MPA is sufficiently
manageable for them to be associated with performing groups or performance
organizations. No experimental studies have been conducted to date of musicians
who have been so unable or unwilling to manage their anxiety as to have
terminated public performances. Therefore, we do not yet know whether
treatments for manageable levels of MPA would have the same effects on extreme
levels.
The treatments examined in this study are limited to those for which
empirical studies of treatment effects have been conducted. Treatments involving
psychodynamic therapy have not been subject to experimental research, so they
are not represented in the present meta-analysis.

13
CHAPTER 2: LITERATURE REVIEW
The present study focuses on empirical studies of nonpharmacologic
psychotherapeutic treatments for music performance anxiety (MPA). This chapter
reviews the literature on this disorder and the related disorders of anxiety, social
anxiety, and performance anxiety.
Models of Anxiety
State Versus Trait Anxiety
The distinction between state and trait anxiety is important in
understanding MPA. Trait anxiety is the stable tendency to respond to a stimulus
with anxiety. The etiology of trait anxiety can be traced to biological (genetic-
physiological) and psychological factors. State anxiety is a temporary condition
that is influenced by an interaction between trait anxiety and a situational threat
(Eysenck, Derakshan, Santos, & Calvo, 2007). It has also been described as “a
state in which an individual is unable to instigate a clear pattern of behavior to
remove or alter the event/object/interpretation that is threatening an existing goal”
(Power & Dalgleish, 1997, pp. 206-207). This state might be perceived by the
individual as a threat to feeling in control. This perceived threat can give rise to a
fear of fear, which has been identified as a principal component of MPA (Lehrer,
1987; Lehrer, Goldman, & Strommen, 1990).
Yerkes-Dodson Law
Some researchers who study performance anxiety (e.g., Kenny, 2012;
Wilson, 1999) analyze it in terms of the Yerkes-Dodson Law (Yerkes & Dodson,
1908). This law, derived from empirical research, refers to the relationship

14
between arousal and the performance of a difficult task. As a graphical
representation, the two factors appear in an inverted-U relationship; as arousal
increases, performance improves until it reaches an apex (optimal level). Then,
degradation of performance follows levels of arousal beyond the apex. Although
the Yerkes-Dodson Law was derived from studies on mice, it has held up in
research on human subjects (e.g., Lupien, Maheu, Tu, Fiocco, & Schramek,
2007).
The Yerkes-Dodson Law has an important clinical implication: optimal
performance involves an optimal level of arousal. Therefore, the point of a
clinical intervention should not be to extinguish arousal, even if that were
possible, but rather to optimize it.
Catastrophe Theory
To better approximate the human experience, Fazey and Hardy (1988)
presented a theory of the relationship between the two-dimensional Yerkes-
Dodson model and a third dimension of cognitive anxiety. This theory was tested
on athletes in high-stress, competitive situations by Hardy and Parfitt (1991). The
three-dimensional graph of their findings recapitulates the Yerkes-Dodson
inverted-U shape on the side at which there is no cognitive anxiety. At lower
levels of both cognitive anxiety and physiological arousal, performance improves
in a similar fashion. However, beyond a certain level of physiological arousal and
cognitive anxiety, a catastrophe occurs, causing a complete failure in
performance. The graph plummets from the optimal performance level to the
lowest levels of performance and does not recover.

15
Catastrophe theory also specifies an interaction between cognitive anxiety
(e.g., negative cognitions, fear of failure) and physical control in which the
worsening of one can trigger worsening in the other. Hardy and Parfitt studied
athletes, but Kirchner (2003) found a similarly precipitous loss of mental and
physical control in a study of six pianists. Powell (2004) claimed that catastrophe
theory is applicable to all types of social anxiety disorder (SAD) and performance
anxiety.
Music Performance Anxiety in the DSM
Music performance anxiety began to emerge in clinical literature long
before allusions to it were made in the Diagnostic and Statistical Manual of the
American Psychiatric Association (DSM). The related terms stage fright and
performance anxiety first showed up in the fourth edition of the DSM (APA,
1994), under section 300.29, Social Phobia (Social Anxiety Disorder). In the most
current edition, the DSM V (APA, 2013), MPA is more closely associated with
the diagnosis of Social Anxiety Disorder, with the predominantly performance
specifier. As yet, MPA is not specifically represented in the Diagnostic and
Statistical Manual.
In the United States, SAD is the second most common form of mental
disorder (6.8% of adults 18 years of age and older), after Specific Phobia
(Kessler, Chiu, Demler, & Walters, 2005, p. 619). Most people can relate to the
experience of having one’s performance deteriorate in the watchful presence of
one or more others, such as when speaking to an attractive stranger or
demonstrating a dance step to classmates. For individuals with this diagnosis,

16
however, the symptoms are intense and threatening to their ability to work and
socialize. The symptoms can be pervasive and constant. Even mundane activities,
such as endorsing a check or eating, can be painfully awkward.
MPA researchers have investigated the relationship between MPA and
SAD. Steptoe and Fidler (1987) conducted a questionnaire study of the cognitive
processes of student, amateur, and professional orchestral musicians and found a
correlation between MPA and fear of social situations, a defining element of
SAD. They also found a high correlation between neuroticism and MPA. This
personality trait has been shown to correlate with SAD as well (e.g., Stemberger,
Turner, Beidel, & Calhoun, 1995).
These findings raise the question of the breadth and generalizability of the
concept of “feared social situations” in musicians. Cox and Kenardy (1993)
examined the interaction between social anxiety and specific performance
situations. They sorted participants into two groups, socially phobic and not
socially phobic, by their scores on the Social Phobia and Anxiety Inventory
(Turner, Beidel, Dancu, and Stanley,1989) and compared their self-reported
anxiety levels in practice, group performance, and solo performance situations. In
group performance and practice settings, they found no difference in anxiety level
between socially phobic and not socially phobic participants. However, in solo
performance situations, the socially phobic participants reported significantly
higher levels of anxiety than did the not socially phobic participants. The
researchers concluded that “social phobia level is the main determinant of the
level of performance anxiety in solo settings” (p. 56). They suggested that the key

17
factor in the construct of SAD, i.e., the scrutiny that a performer feels from his
audience, might determine his level of music performance anxiety.
Osborne and Franklin (2002) examined MPA for two cognitive processes
that had been identified by Rapee and Heimberg (1997) as essential to SAD—fear
of negative evaluation and fear of social disapproval. Eighty four professional and
advanced student musicians who varied in their musical styles, instruments, and
experience were sorted into three equally-sized groups based on their scores on
the Performance Anxiety Index (Nagel, Himle, & Papsdorf, 1981). The groups,
representing low, medium, and high levels of MPA, were then surveyed. They
found that fears of negative evaluation and of social disapproval were predictive
of MPA. However, only 27% of the musicians diagnosed with high levels of
MPA were also diagnosable with SAD (p. 88). The researchers suggested that this
finding indicates that other factors besides SAD contribute to debilitating MPA.
These findings indicate comorbidity of SAD and MPA and give rise to
questions of etiology. Does SAD give rise to MPA or does MPA give rise to
SAD? Might both syndromes have their source in some other personality factor?
One group of researchers (Bogels et al., 2010) concluded that though the two
syndromes have a high comorbidity rate, they also appear distinct.
Huston (2001) examined the possibility of age and gender differences in
MPA and SAD. In a sample of 163 student and professional orchestral musicians,
Huston found that while SAD did not seem to be affected by age, MPA showed a
negative relationship with age. With regard to gender, this study replicated the
finding of other studies that SAD and MPA are more common in females

18
(Osborne & Kenny, 2008; Rae & McCambridge, 2004; Ryan, 2004; Yondem,
2007).
In their review of research comparing characteristics of SAD and MPA,
McGinnis and Milling (2005) promoted the proposal, first presented by
Heimberg, Hold, Schneier, Spitzer, and Liebowitz (1993), of expanding the SAD
diagnostic construct with a sub-category (specifier), called “circumscribed”, to
capture features specific to MPA. McGinnis and Milling pointed to evidence that
people with MPA are less likely than people with SAD to report that they feel
their anxiety to be excessive or irrational. They suggested that it may be
contextually appropriate for musicians to be concerned about how they are
perceived by particular others (e.g., audience, teachers, jury members, and music
critics). The concept of a new specifier was taken a step further by Bögels et al.
(2010), who recommended a new specification of SAD be adopted to
accommodate performance anxieties. This recommendation is reflected in the
DSM V (APA, 2013) which includes such a new specifier named “performance
only” under the SAD diagnosis (See Table 1). By name, nothing else in the DSM
V appears closer to the description for MPA.

19
Table 1
Social Anxiety Diagnostic Criteria
A. Marked fear or anxiety about one or more social situations in which the
individual is exposed to possible scrutiny by others. Examples include social
interactions (e.g., having a conversation, meeting unfamiliar people), being
observed (e.g., eating or drinking), and performing in front of others (e.g., giving
a speech).
Note: In children, the anxiety must occur in peer settings and not just during
interactions with adults.
B. The individual fears that he or she will act in a way or show anxiety
symptoms that will be negatively evaluated (i.e., will be humiliating or
embarrassing; will lead to rejection or offend others).
C. The social situations almost always provoke fear or anxiety.
Note: In children, the fear or anxiety may be expressed by crying, tantrums,
freezing, clinging, shrinking, or failing to speak in social situations.
D. The social situations are avoided or endured with intense fear or anxiety.
E. The fear or anxiety is out of proportion to the actual threat posed by the social
situation and to the sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or
more.
G. The fear, anxiety; or avoidance causes clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
of a substance (e.g., a drug of abuse, a medication) or another medical condition.
H. The fear, anxiety, or avoidance is not attributable to the physiological effects
I. The fear, anxiety, or avoidance is not better explained by the symptoms of
another mental disorder, such as panic disorder, body dysmorphic disorder, or
autism spectrum disorder.
J. If another medical condition (e.g., Parkinson's disease, obesity, disfigurement
from burns or injury) is present, the fear, anxiety, or avoidance is clearly
unrelated or is excessive.
Specify if:
Performance only: If the fear is restricted to speaking or performing
in public.
Specifiers
Individuals with the performance only type of social anxiety disorder have
performance fears that are typically most impairing in their professional lives
(e.g., musicians, dancers, performers, athletes) or in roles that require regular
public speaking. Performance fears may also manifest in work, school, or
academic settings in which regular public presentations are required.
Individuals with performance only social anxiety disorder do not fear or avoid
nonperformance social situations.
Note. Reprinted with permission from the Diagnostic and Statistical Manual of
Mental Disorders (5th ed.) by the American Psychiatric Association, 2013,
Washington, DC: Author.

20
Performance Anxiety
Performance anxiety (PA) is the prevalent term used to describe a group
of disorders associated with the pursuit of one or more specific endeavors. It
broadly includes anxieties related to live or recorded public performances,
sometimes referred to as audience anxiety or stage fright (e.g., Allen, 2013;
Paivio & Lambert, 1959) and other anxieties related to meeting a standard set by a
teacher, an editor, a coach, a team, a parent, a lover, or self. Empirical studies
have focused on correlates and predictors of performance anxiety and specific
types of performance anxiety, such as those associated with test-taking (Hembree,
1988; Meijer & Oostdam, 2007; Reteguiz, 2006); sport contests (Hanton,
Mellalieu, & Hall, 2004), and music performance (e.g., Fishbein & Middlestadt,
1988; Steptoe & Fidler, 1987). Additionally, specific types of performance
anxiety experienced by writers (Kountz, 1998; Powell, 2004), public speakers
(Blöte, Kint, Miers, & Westenberg, 2009; Powell, 2004), performing artists
(Plaut, 1988), academics (Garcia, Baker, & DeMayo, 1999), and employees and
lovers (Lazarus & Abromowitz, 2004) are described in the psychological
literature.
Debilitating performance anxiety has been diagnosed as a variation of
SAD since the third version of the DSM (APA, 1980). However, some
researchers have questioned this taxonomy. Turner, Beidel, and Townsley (1992)
found significant differences among a sample of subjects with SAD in
symptomatic severity and pervasiveness. Powell’s literature review (2004)
focused on studies of very high levels of performance anxiety in which the

21
performer experiences catastrophic loss of ability to perform competently or at all.
He suggested that anxiety at this high level has qualities that are clearly distinct
from those described as SAD. Specifically, a high level of performance anxiety
involves less pervasive impairment and more specific focus of fears, a higher
expectation of self, less fear of scrutiny by others, and more fear of self-imposed
disapproval or disappointment, greater variability in the experience of anticipatory
anxiety, and less avoidance or ambivalence and more commitment to the feared
task.
Bögels et al. (2010) conducted a systematic review of SAD in advance of
the publication of the DSM-5. With regard to performance anxiety, they declared
that sufferers of both SAD and performance anxiety share the same core cognitive
concern about being scrutinized and judged negatively by others. However, they
concluded that evidence of qualitative differences between SAD and PA drives
the need for a new distinction. Their recommendation that performance anxiety be
written into future diagnostic manuals as a “predominantly performance” specifier
of the diagnosis of SAD has been realized in the recent publication of the DSM
(APA, 2013). However, the construct of music performance anxiety has not yet
been named and included in the DSM.
Music Performance Anxiety
In the same sense that performance anxiety might be considered a subtype
of SAD, music performance anxiety (MPA) might be considered a subtype of
performance anxiety. The two constructs share key elements, such as
symptomatology and the applicability of catastrophe theory. However, the fear

22
that characterizes performance anxiety, fear of failure, is only one of the core
fears that have been associated with MPA.
Music performance anxiety is a complex phenomenon in which one or
more core fears may play a role. The most comprehensive definition of the
construct is provided by Kenny (2009):
Music performance anxiety is the experience of marked and persistent
anxious apprehension related to musical performance that has arisen
through underlying biological and/or psychological vulnerabilities and/or
specific anxiety-conditioning experiences. It is manifested through
combinations of affective, cognitive, somatic, and behavioral symptoms. It
may occur in a range of performance settings, but is usually more severe
in settings involving high ego investment, evaluative threat (audience),
and fear of failure. It may be focal (i.e.[sic] focused only on music
performance), or occur comorbidly with other anxiety disorders, in
particular social phobia. It affects musicians across the lifespan and is at
least partially independent of years of training, practice, and level of
musical accomplishment. It may or may not impair the quality of the
musical performance. (p. 433)
One of the features of MPA that distinguishes it from other forms of performance
anxiety is the level of ego-investment involved. Music training often begins at an
early age. Over many years, learning matures from being almost entirely focused
on reading nomenclature, learning to listen, and mastering technique to getting
familiar with music literature and finding a combination of style, genre,
instrument, and ensemble that the musician finds satisfying. Once instrument
orientation and basic concepts are learned, the process involves a great deal of
time in practice and introspection—most of which is accomplished alone
(Gabrielsson, 1999).
For success, a rare combination of personality characteristics, opportunity,
and talent is needed. Also essential is a strong commitment by the student and her

23
support system. The motivation for this commitment may be found in the desire to
express oneself to others and to feel a sense of mastery, fulfillment, or joy in
creativity. These are often stronger motivators than are income and fame. For
some, it is the exhilaration of performance that motivates continued commitment
to being a musician (Williamon, 2004).
The act of performing is extraordinarily demanding. Whether the musician
performs by bowing, blowing, striking, or singing, she is expected to have
mastered several inter-related skills in order for their coordination to be facile in
performance. The musician must simultaneously control tempo and factors
involved in tone production, such as tone quality, articulation, intonation, and
dynamics. Although dazzling technical ability is exhilarating to performer and
audience alike, most musicians aspire to be able to make transparent the technical
aspects of their playing so that the musical and emotional expression can emerge
unhindered. Towards that goal, the performer must set aside the pain and joys of
private life and maintain sustained focus on the music, often for hours at a time
(Williamon, 2004). Unlike the test-taker, for whom the effort is relatively short-
lived, a musician must maintain a constantly high level of concentration,
devotion, and risk.
There often are challenges to the musician’s ability to perform that are not
totally within the control of the musician, including the condition of the musical
instruments or of other performers, the acoustic and environmental qualities of the
performance venue, and the attendance and behavior of the audience. Variations

24
in these factors can throw off the focus of even the most experienced performers
and cause music performance anxiety.
Unfortunately, some musicians believe that if you are talented enough and
practice hard enough, there shouldn’t be any anxiety associated with your
performance. For example, grand master violinist Yehudi Menuhin (as cited in
Havas, 2001) expresses this view with a religious fervor:
Ease and elegance are born of ease and elegance and these graces (for it is
the Christian concept of grace) must be preserved against all odds by
implacable, patient, unremitting persistence and faith. Without moral
courage no amount of brutal self-flagellation will redeem. (p. vi)
Implicit in his heroic language is both the intimidation and the shame inherent in
the complex problem of MPA. In effect, Menuhin declared that the gift of musical
talent must be met with adherence to an unattainable standard of absolute
commitment and control. He conveyed a tacit judgment that a musician’s
difficulty in performing results from his lack of “moral courage” and faith in hard
work. A more sympathetic view was expressed by Ristad (1982) when she wrote
that, “The paradox is that our fingers were trained with the help of the very mind
that now unintentionally cripples them” (p. 203).
Craske and Craig (1984), Fehm and Schmidt (2006), and Kenny (2006)
found that music performers experience the highest level of anxiety in evaluative
situations. In contrast to Powell’s (2004) hypothesis that performance anxiety is
more often triggered by fear of self-judgment than by fear of scrutiny by others,
MPA researchers (Cox & Kenardy, 1993; Osborne & Franklin, 2002; Wilson,
1999) put the fear of negative evaluation by others above other possible causes for
MPA. Discussion of the effects of negative internal dialogues on music

25
performance anxiety is found throughout the literature (e.g., Davis, 1994; Fehm &
Schmidt, 2006; Kenny, 2005; Osborne & Franklin, 2002; Rodebaugh &
Chambles, 2004; Salmon & Meyer, 1992; Schultz et al., 2006). Theorists and
researchers examining the etiology (or etiologies) of MPA differ in their ideas of
what fear is at its core. For example, van Fenema et al. (2013) theorize that fears
of judgment by self and others may be related to narcissistic defense. In any case,
it is broadly acknowledged that the exceptional level of stress of a musician’s
occupation can trigger and exacerbate underlying fears (e.g., Kenny, 2011; van
Fenema et al., 2013).
The more common symptoms of MPA include the physiological distress
of rapid heart beat, difficulty with breath control, and tremor, and the cognitive
distress caused by lapses of memory and distraction (Brandfonbrener, 1990; Lee,
2002; Martin, 1964; Mishra, 2002; Powell, 2004). In addition to the fear of
negative evaluation and catastrophic failure, there is a related fear that
physiological symptoms will impair performance and add to the cognitive
distress. This kind of compound anxiety (fear of fear) creates a disastrous positive
feedback loop that is a common MPA experience. Brandfonbrener (1990) states
that, “the anxiety generated by the symptoms of anxiety is frequently perceived as
being more threatening than is the stress of the performance” (p. 23). Additional
emotional problems, such as guilt and shame, can arise from a lack of satisfaction
with performance (Lee, 2002) and can even arise from a successful performance
(Nagel, 1990).

26
With the cognitive, physical, and emotional challenges of MPA added to
the high level of skill and focus needed to perform, one might say that the worst
time to perform is at a performance! With the disabling effects of acute MPA,
musical passages that were challenging in practice may be felt as impossible in
performance. These cognitive, behavioral, and physiological symptoms can set up
a catastrophic feedback mechanism within the performance and generalize to
other performances. The musician may become unable to face the anxiety that
performing causes him and give it up all together.
In surveys of professionals, more female musicians than male report
suffering with MPA (Abel & Larkin, 1990; Craske & Craig, 1984; Fishbein &
Middlestadt, 1988). Abel and Larkin (1990) speculated that this discrepancy
might be explained, at least in part, by a difference in willingness to openly admit
to feelings of anxiety. This research finding raises questions about whether MPA
is related to other factors such as socio-economic background, personality,
ethnicity and personal development.
In the author’s clinical experience, male and female music conservatory
students attending a focus group on music performance anxiety were timid with
their disclosure of symptoms and insistent that their participation in the group be
kept confidential from other conservatory students, administrators, and faculty. In
spite of conservatory administrators’ open efforts to address their students’
anxiety, the students in the support group reported feeling that the administrators
were naïve about the level of competition and culture of perfectionism. They
reported fearing their teachers and other students finding out about their anxiety

27
and judging them as weak, defective, or inferior. They also spoke about the self-
doubt generated by the tremendous demands on their concentration and agility
and their ability to communicate character and emotion in the symbolic language
of music.
In a qualitative study, Kirchner (2003) reported finding similar fears
among six professional musicians. In addition, Kirchner presented a model of
MPA that speculates that it arises from the perception of a threat to one’s identity.
This model may offer a psychological foundation underlying both the fear of
scrutiny by others and the fear of self-doubt mentioned by other researchers.
Kirchner’s model gains validation in more recent research by van Fenema et al.
(2013). As part of a broad study of psychiatric characteristics of musicians, these
researchers reported significantly higher mean scores on a measure of narcissistic
personality traits among musicians presenting themselves for outpatient treatment
than in general outpatients and non-patient controls.
In summary, several models have been developed to describe MPA, but
none has emerged as being comprehensive. The Yerkes-Dodson model of the
relationship between arousal and performance provided a good starting point and
researchers still refer to it (e.g., Spahn, Echternach, Zander, Voltmer, & Richter,
2010). Three-dimensional catastrophe theory (Fazey & Hardy, 1988; Hardy &
Parfitt, 1991) gets closer to addressing the complexity of dynamics seen in MPA.
Psychotherapeutic Treatment
There are two primary approaches to the treatment of MPA; the
management of physical tension and the management of maladaptive thoughts.

28
The body of MPA literature in the fields of music education, psychology, and
psychiatry describes a wide variety of interventions within these two approaches.
However, only a relatively small number of empirical studies of their
effectiveness have been published to date. Particularly notable is the absence of
empirical studies on the effectiveness of psychodynamic treatments. This absence
may be explained by the fact that this approach does not lend itself easily to
scientific measures needed for efficacy studies.
Efficacy Studies
The first efficacy study of a nonpharmacologic treatment for MPA was
published in the Journal of Music Therapy (Appel, 1976). The study was a
randomized controlled trial (RCT) that compared the effects of systematic
desensitization (a psychological method for the control of the physiological
anxiety response) with the effects of music analysis training with performance
rehearsal (an educational method for enhancing intellectual mastery of the
performance material). Following that study, empirical studies of MPA treatments
appeared in journals at the rate of about one a year until recently, when the rate
appears to have increased dramatically. This increase is likely the result of (1) the
movement toward evidence-based practice, (2) greater consensus on the construct
of MPA, and/or (3) an increasing acceptance of the use of pharmacotherapies for
MPA.
Reviews of Efficacy Studies
To date, three narrative systematic reviews of treatments for MPA have
been published. These three—McGinnis and Milling (2005), Kenny (2005), and

29
Brugués (2011)—characterized the status of research on treatments for music
performance anxiety at the time of their writing. McGinnis and Milling (2005)
reviewed nine studies. They found the most promising treatments to involve
cognitive restructuring (Appel, 1976; Kendrick, Craig, Lawson, & Davidson,
1982; Sweeney & Horan, 1982) and exposure therapy (Sweeney & Horan, 1982).
However, the review pointed to limitations in the research methodology that
confounded efforts to compare the findings of different studies. In particular, they
cited "overreliance on self-report outcome measures and a lack of long-term
follow-up data, as well as the use of a single therapist to provide treatment along
with the absence of a treatment manual" (McGinnis & Milling, 2005, p. 371).
They characterized the field’s evaluation of psychological treatments for MPA as
being in a "nascent stage of development” (p. 371).
Kenny (2005) performed a more extensive review of the literature with a
comparison of the findings of 21 studies, including 12 studies reported in journals
and nine dissertations/theses. Kenny did not consider it feasible to conduct a
meta-analysis at that time because only a few studies provided sufficient
statistical information. In her opinion, the diversity of subject groups, treatments,
duration, and intensity of treatment, and use of disparate outcome measures ruled
out the use of meta-analysis.
Brugués (2011) reviewed the same studies as Kenny and added another
five studies on MPA treatments and studies on pharmacotherapies. Brugués’
focus was on analyzing the studies in terms of evidence-based medicine (EBM)
criteria and presenting them in terms of their relative compliance. Brugués

30
determined that, of the nonpharmacologic experimental studies of treatments of
MPA, twenty-four out of twenty six studies included in her review could be
characterized as having "evidence obtained from at least one properly designed
randomized controlled trial" (p. 164).
The present review takes a statistical approach to comparing
psychotherapies. It was inspired in part by the work of the Cochrane
Collaboration, an international effort to promote best evidence practices for
healthcare utilizing standardized reviews. Its guide, The Cochrane Handbook for
Systematic Reviews of Interventions (Higgins & Green, 2011) is an invaluable
reference. However, weaknesses in experimental design cited by previous
reviewers combined with varying experimental designs and data formats present
exceptional challenges to a meta-analysis. Operationalization of MPA varies from
study to study, so careful selection of studies and measures was essential in
compiling the outcomes for comparison. Variation across studies (heterogeneity)
was addressed in the choice of the more conservative random-effects model of
meta-analysis.
Conclusion
Previous systematic reviews provided a set of findings about the
effectiveness of psychotherapies for MPA that had been studied empirically. In
addition, they provided commentary on the state of the art of construct definition,
symptom measurement, and experimental design. Authors of these reviews noted
problems with consistency in all these areas and underscored the difficulty in
comparing outcomes.

31
The next step towards determining best clinical practices is to employ
state-of-the-art research synthesis methods to collect, catalog and combine
primary research as well as is possible and to better determine where the field
stands. The present study is the first to use the method of meta-analysis to
compare outcomes in treatment trials for MPA.

32
CHAPTER 3: METHODS
Search Strategy
The purpose of the present study was to review the research literature on
nonpharmacologic interventions for music performance anxiety (MPA) on skilled
adult musicians (college-level music students and professional musicians) and
compare the relative effectiveness of these interventions. An exhaustive search
was conducted to find all studies published in English-language journals and
dissertations, including all those reviewed by Brugués (2011), Kenny (2005 and
2011), and McGinnis and Milling (2005). A total of 46 empirical studies were
obtained for the present review, including 13 studies not previously reviewed.
The search for relevant studies involved the use of these databases: (1) the
internet databases ProQuest, MEDLINE, PubMed, Worldcat, ERIC, PLOS ONE,
JSTOR, EBSCO, ILLIAD (inter-library loan service), UMI Dissertation Express,
Trove, PsycInfo, and Google Scholar; (2) the online library catalogs of the San
Francisco Public Library, the Cochrane Library, and the Laurance S. Rockefeller
Library of the California Institute of Integral Studies Library; (3) the archives of
the journals Medical Problems of Performing Artists, Psychology of Music,
Visions of Research in Music Education, and Journal of Research Studies in
Music Education; (4) the reference sections in relevant articles, books, and
internet websites; and (5) the Google search engine.
The following search terms were used: [(music* + perform* + anxiety)
OR (stage fright + music*)] in the title AND [(therap*) OR (treat*)] in the text.
For many search engines, the asterisk on a word stem represents all words

33
beginning with those letters; e.g., music* searches for music, musician, musicians,
musician’s, musical, musicality, and others. All searches were unbounded by start
date, and the last search was conducted in August 2013. Besides quantitative
studies for the meta-analysis, this search protocol identified systematic reviews of
MPA and publications on the theory and history of MPA as a construct.
About half of the relevant publications were found in one or more of the
following online databases: ProQuest, MEDLINE, PubMed, and ERIC. Many of
those publications were directly downloadable. Eight of the studies were
downloaded from the online archive of the journal Medical Problems of
Performing Artists. The Harris (1987) study was available by mail order from the
publisher. Most of the dissertation studies were obtained digitally through
ILLIAD or UMI Dissertation Express. The dissertation by McKinney (1984) was
not available digitally, so it was obtained in hardcover form through ILLIAD. The
Patston (1996) thesis, which had been cited in previous reviews, was deemed
unavailable after several failed attempts to obtain it.
Selection Criteria
The initial criteria for selection of experimental studies for this meta-
analysis were the following:
• Experimental
Design:
Randomized, controlled trials (RCTs) with N≥10
• Subjects: Adults (≥18 years) with advanced musical skill
• Measures: Pre- and post-treatment observational measures
(e.g., quality of musical performance and

34
evidence of nervousness), present-state anxiety
questionnaires, and measures of autonomic
responses to stress (e.g., heart rate)
• Quantitative Data: Sample sizes and means and standard deviations
of pre- and post-treatment data
As the studies were collected and assessed for these criteria, it became evident
that the meta-analysis could not be conducted unless the criteria were relaxed
sufficiently to ensure representation from each of the classes of psychotherapy
that were studied: behavioral, cognitive, combined, and complementary and
alternative (C & A).
Twenty nine of the initial set of 46 studies were included in the analysis.
They include 22 studies that had appeared in systematic reviews by McGinnis and
Milling (2005), Kenny (2005, 2011) and Brugués (2011), and an additional seven
studies (see Table 2). Ten of the studies are academic theses, and the others were
published in journals of psychology or performance science. Most are RCT in
design; seven are neither randomized nor controlled. Two studies had fewer than
ten subjects (Kim, 2005; Stern, 2012) and one involved a wide range of ages and
musical experience, including subjects as young as 12 years old (Kendrick et al.,
1982). None of the included studies separated outcomes in terms of MPA
symptom intensity. See Appendix A for full citations of the included studies.

35
Table 2
Studies Selected for Meta-Analysis
Systematic Reviews of
Treatments for MPA
McGinnis &
Milling (2005)
Kenny
(2005, 2011)
Brugués
(2011)
Study
Design
Behavioral Therapies
Appel (1976) X X X RC
Conklin (2011)* N
Deen (1999) X X RC
Grishman (1989) X X RC
Kendrick et al. (1982) X X X RC
Lund (1972)* RC
Mansberger (1988) X X RC
Reitman (2001) X RC
Richard (1992) X X RC
Sweeney & Horan
(1982)* X X RC
Cognitive Therapies
Esplen & Hodnett (1999) X N
Hofmann & Hanrahan
(2012)* RC
Kendrick et al. (1982) X X X RC
Sweeney & Horan (1982) X X RC
Treatments for MPA
McGinnis &
Milling (2005)
Kenny
(2005, 2011)
Brugués
(2011)
Study
Design
Combined Therapies
(including CBT)
Bissonnette, et al. (2011)* RC
Craske & Rachman
(1987)*
N
Harris (1987) X X RC
Kim (2008) X N
Nagel et al. (1989) X X X RC
Reitman (2001) X RC
Roland (1993) X X RC
Sweeney & Horan (1982) X X RC
Sweeney-Burton (1997) X X RC
Tarrant & Leathem
(2007)*
N

36
Treatments for MPA
McGinnis &
Milling (2005)
Kenny
(2005, 2011)
Brugués
(2011)
Study
Design
Complementary and
Alternative Therapies
Chang et al. (2003) X X RC
Khalsa et al. (2009) X RC
Kim (2005) X N
Lin et al. (2008) X RC
McKinney (1984) X X RC
Montello et al. (1990) X X X RC
Richard (1992) X X RC
Stanton (1994) X X X RC
Stern (2012)* N
Thurber et al. (2010) X RC
* Newly-identified studies
RC = randomized and controlled; N = not randomized or controlled.
Note: Some of these studies involve more than one class of intervention and are
therefore listed more than once in this table.
The ten studies listed in Table 3 were included in previous reviews but
were excluded from the present meta-analysis because they reported insufficient
descriptive statistics or were only peripherally related to the research question
One study that had been cited in two earlier reviews (Patston, 1996) was not
available.

37
Table 3
Previously Reviewed Studies Excluded From Meta-Analysis
McGinnis &
Milling (2005)
Kenny
(2005,
2011)
Brugués
(2011) Reason
Brodsky,
Sloboda
(1997)
X X X insufficient data to determine
effect size
Clark, Agras
(1991)
X X X drug or placebo conditions
only
Gratto (1998) X insufficient data to determine
effect size
Lazarus
(2004)
X insufficient data to determine
effect size
Merritt et al.
(2001)
X not MPA
Niemann et al.
(1993)
X X X insufficient data to determine
effect size
Patston (1996) X X study not available
Saunders et al.
(1996)
X meta-analysis of general
performance anxieties/not
primary study
Su et al.
(2010)
X subjects are children
Valentine et
al. (2006)
X not MPA
Valentine et
al. (1995)
X X non-comparable test
situations
Wardle (1969,
1975)
X X insufficient data to determine
effect size
Five additional MPA experiments were not included for varying reasons. They are
listed in Table 4.

38
Table 4
Additional Studies Determined to Be Ineligible for Meta-Analysis
Study Reason for Exclusion
BienAime, J. K. (2011) Insufficient data to determine effect size
Gomes de Sousa, C. M. (2011) Subjects are children
Huang, M. S. (2011) Trait data only
Su et al. (2010) Subjects are children
Wells et al. (2012) Insufficient data to determine effect size
Data Analysis
Researchers have used various instruments to measure MPA. For example,
the experiment by Kendrick et al. (1982) involved the administration of eight
different measures, and the experiment by Kim (2008) involved seven. Although
both studies used the state-related portion of the State Trait Anxiety Inventory,
each used a different version (Spielberger, Gorsuch, & Lushene, 1970;
Speilberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983). None of their other
assessment tools were the same. Between these two studies, a total of 15 different
assessment measures were administered.
In sum, the experiments synthesized in the present study involved the
administration of more than 50 different measures, including more than 40 self-
report measures, two observational scales (visible nervousness and performance
quality), and eight autonomic measures.
The present review addressed the otherwise unwieldy variety of measures
by excluding those that were not directly named in the operational definition of

39
MPA (i.e., levels of anxiety and performance quality). The excluded measures
were primarily self-report instruments that were designed to measure assumed
correlates of MPA, such as rational behavior, achievement anxiety, cognitive
interference, cognitive strategies, expectations of efficacy, flow state,
performance-related musculoskeletal disorders, and sleep quality.
It should be noted that self-report measures of perception of performance
anxiety are commonly worded in terms of usual or trait experience rather than
present-state experience, for example: Kenny Music Performance Anxiety
Inventory (Kenny, Davis, & Oates, 2004) and the Performance Anxiety Inventory
(Nagel, Himle, & Papsdorf, 1981) and its variations by Deen (1999), Conklin
(2011), and Osborne & Franklin (2002). Although this focus on usual experience
may equate state and trait anxiety, analysis of the effect of including such
measures resulted in no significant change to the findings of the meta-analysis.
Also excluded in the meta-analysis were redundant self-report measures of
lesser relevance. For example, the Performance Anxiety Inventory was selected
over the Test Anxiety Inventory to represent self-report measures for two studies:
Nagel, Himle, and Papsdorf (1989, and Harris (1987). A list of self-report
measures used in the meta-analysis is presented in Appendix B.
Data Extraction
The meta-analysis required the development of categories to
characterize key features and data points of the experiments that were
reviewed. A spreadsheet was created to keep track of the categories and
data points while the statistical program was being set up.

40
The assessment time points included in the present meta-analysis are
(1) pre-treatment at or near the time of a performance and (2) post-
treatment at or near the time of another performance. Ten of the studies
included follow-up assessments subsequent to the post-treatment
assessments, but these follow-up assessments were problematic. Most
relied on reflective self-report. Subject attrition and large methodological
differences, including different time intervals following administration of
the post-treatment measure, confounded attempts to incorporate them
meaningfully into the database for the meta-analysis. Therefore, the
decision was made to not include follow-up data in the meta-analysis.
The determination of control groups in studies of treatments for
MPA has been problematic. Some studies put control subjects on a waiting
list for the experimental intervention and require them to take the same
measures at the same time points as the experimental group (e.g.,
Grishman, 1989; Reitman, 2001). Others provide didactic conditions (e.g.,
musical training, Appel, 1976) or “standard” therapies (e.g., Kendrick et al.,
1982). Sweeney and Horan (1982) created two control groups—one in
which the subjects took the measures while on a waiting list and another in
which the subjects were measured before and after being trained in music
analysis. In the present study, all groups receiving an intervention designed
to alleviate MPA are considered experimental groups. All other groups
(wait-listed, no-contact, or no treatment) are considered control groups. The

41
Sweeney and Horan study included two no-treatment controls. Only the
waiting list group was included in the data analysis.
These decisions resulted in a database of 29 experiments with 124
intervention effect sizes.
Categorization of Data
The data for each experiment were assigned to one of four categories of
intervention: cognitive (classic mental skills training), behavioral (classic
relaxation training), combined (combination of two or more types of intervention,
including cognitive-behavioral therapy), and complementary and alternative
(yoga, hypnosis, meditation, Ericksonian Resource Retrieval, biofeedback, and
music therapy). Two other categories, didactic and psychodynamic, were dropped
from the meta-analysis due to low representation (k ≤ 2) in the studies selected for
the meta-analysis. The assignment of studies to each of these categories is shown
in Table 2. Duplications of study authors in the table indicate studies that tested
more than one category of intervention (i.e., Kendrick et al., 1982; Reitman, 2001;
Sweeney & Horan, 1982).
The measures were classified into three categories: autonomic
(physiological measures), observational (observers’ assessments of performance
quality and/or nervous behaviors), and self-reported (questionnaires about the
perceived experience of MPA). Most studies included multiple assessments of
each participant (i.e., repeated measurements and measurements of different
aspects of MPA). The descriptive statistics for each outcome measure in the meta-
analysis are presented in Appendix C.

42
Data Entry
The meta-analysis was performed with the computer software program
Comprehensive Meta-Analysis, Version 2.2.050. Descriptive data elements are
detailed in Table 5. Outcomes for each study were entered into the database
according to experimental design and manner in which each data point was
reported. Four formats were utilized, as follows: (1) mean pre- and post-treatment
measures for both the treatment and control groups (k = 18); (2) mean pre- and
post-treatment measures of one group (k = 7); (3) mean post-treatment measure
for the experimental group and the control group (k = 4); and (4) raw mean
differences between pre-and post-treatment measures for the experimental group
and the control group (k = 2).
In experiments with pre-and post-treatment measures, within-group
standardization is calculated on the standard deviation of the change score and
with an estimation of the correlation between pre- and post-treatment outcomes.
Pre-post correlations are not generally reported in the studies reviewed, so a
conservative correlation r = 0.70 was used for all measures. This decision was
based on a similar consideration by Hoffmann, Sawyer, Witt, and Oh (2010) in
their meta-analysis on treatment effects on anxiety symptoms.
To enable the compilation of change data from different types of
measures, attention had to be given to the direction of the treatment effect
(relative to the control group) and the different meaning of valences in measures.
For example, in a self-report measure of anxiety, improvement is indicated by a
reduction of scores. In an assessment of performance quality, however,

43
improvement is indicated by an increase in the score. The present study adopted
the convention of coding effect sizes that indicate improvement of MPA as
positive and those that indicate worsening of MPA are coded as negative.
Table 5
Meta-Analysis Data Elements
• Experiment ID
• Subgroup
o type of intervention
behavioral
cognitive
C&A
combined
• Quantitative Data
o experimental group
sample size
pre- and post-trial means and standard deviations or
post-trial mean and standard deviation or
mean difference and standard deviation
o control group (where applicable)
sample size
pre- and post-trial means and standard deviations
• Moderators
o randomized-controlled trial indicator (y/n)
o data source
self-report
autonomic
observational
o description of therapy
o independency code (randomly assigned code for grouping
independent outcomes)
For studies with more than one outcome in the meta-analysis,
independency was achieved by coding each outcome within a study with a unique
number from 1 to 10 generated by randomnumbergenerator.com, an online
random number generator. The range of code numbers was determined by the

44
maximum number of outcomes administered among the experimental groups.
Grouping by dependency code ensured independence among treatment effects.
Meta-Analysis
Step 1: Effect calculation. Each treatment effect was standardized to
indicate its estimated standard deviation from the midpoint of a normal
distribution. The effect size (ES) was calculated using Hedges’ g formula, which
addresses the bias that occurs in analyses of small samples (n ≤ 25). It is
calculated by dividing the difference in mean outcome score between groups by
the standard deviation of the outcome scores for both groups, and then
multiplying by a correction factor (J) (Borenstein, Hedges, Higgins, & Rothstein,
2009; Cooper & Hedges, 1994; Deeks, Higgins, & Altman, 2008; ).
Different designs require different calculations. For one-group pre-post
designs, the difference between pre and post means is divided by the standard
deviation of the pre-intervention scores. For controlled groups, an adjusted ES can
be calculated that corrects for sampling biases. It is, therefore, assumed that
controlled group ESs are more precise and that is reflected in the weight they are
given in the next step.
Step 2: Combination of effects. A mean of the intervention effects was
calculated. The software program automatically assesses relative weights based
on sample size. Larger experiments contribute more to the weighted average.
The random-effects model of meta-analysis was chosen as the statistical
method of combining effect sizes. It incorporates both within-study sampling
error and between-studies variation in the assessment of uncertainty of the results

45
in the meta-analysis. It is based on the assumption that the studies are not all
estimating the same intervention effect, thereby addressing the heterogeneity of
the samples. This decision was based on the argument that this model is more
“real world” than its alternative, the fixed-effects model (Cooper & Hedges,
1994) by addressing variation across studies (heterogeneity) with a more
conservative estimate of effects.

46
CHAPTER 4: RESULTS
The meta-analysis was guided by two research questions: (1) Are
nonpharmacologic psychotherapies for MPA effective? and (2) Which of four
classes of empirically-studied nonpharmacologic psychotherapies is most
effective in reducing MPA?
Review of Effect Sizes
The following review of individual study effect sizes was done with
consideration for the fact that they are from small samples and therefore may not
be an accurate representation of effect sizes for the populations from which they
were drawn. Also, the analysis of effect sizes was done with respect to
benchmarks recommended by Cohen (1988). He considered an effect size as
“small” at 0.20, “medium” at around 0.50, and “large” at 0.80 or greater.
The meta-analysis resulted in a single mean effect size against which
individual study effects were compared. Each of ten groupings of independent
outcomes was subjected to a random-effects analysis (Appendix D). Combined
effects sizes are reported in Table 6, along with the number of measures
represented (k). This approach results in an estimated mean effect size for the
whole study as well as estimated mean effect sizes for each class of intervention.

47
Table 6
Analysis of Random Groupings of Independent Outcomes
Behavioral C & A Cognitive Combined ALL TYPES
Group-
ing
# ES k
Std
Err ES k
Std
Err ES k
Std
Err ES k
Std
Err ES K
Std
Err
1 .82 3 .30 .60 3 .16 .88 2 .31 .31 4 .10 .58 12 .16
2 .46 3 .24 .38 2 .32 .40 2 .24 1.20 5 .16 .64 12 .26
3 .78 4 .18 1.07 2 .39 .83 2 .25 .62 5 .13 .73 13 .11
4 .86 3 .43 .31 2 .46 .49 2 .48 .95 5 .28 .72 12 .22
5 .65 4 .25 .73 3 .23 .46 2 .36 .63 4 .20 .64 13 .12
6 .40 5 .17 .78 3 .25 .73 1 .35 .54 5 .13 .56 14 .11
7 .28 5 .23 .51 2 .37 .68 1 .49 .55 4 .23 .45 12 .14
8 .49 5 .19 .30 2 .27 1.12 1 .65 .84 4 .17 .61 12 .18
9 .52 4 .35 1.09 3 .37 .98 1 .57 1.12 4 .32 .92 12 .22
10 .77 3 .38 .63 3 .42 .14 1 .78 .49 5 .29 .57 12 .20
TOT 39 25 15 45 124
M .57 .26 .67 .32 .65 .41 .73 .20 .64 .17
Range .28 - .86 .30 - 1.09 .14 - 1.12 .31 - 1.20 .45 - .92
The estimated mean effect size for all outcomes in the study is .64. With
regard to the relative efficacy of the classes of intervention, the average treatment
effects are close in size, ranging from a low of .57 (behavioral interventions) to a
high of .73 (combined interventions).
The size of the standardized errors are evidence of the random-effects
model’s conservative approach. The smaller number of outcomes, the larger the
standardized error. Thus, there is need for caution in interpreting individual
treatment effects (e.g., Montello, 1990).

48
Because not all studies incorporated all three types of measures
(observational, self-report, and physiological), it is not possible to profile
individual treatment approaches in terms of relative effectiveness for a particular
type of outcome. That is, one cannot say that any one particular treatment
approach is best for addressing autonomic, observational or self-perceived (self-
report) symptoms.
Behavioral Therapies
Table 7 shows treatment effects on each type of outcome for experiments
on behavioral interventions. The table also indicates whether each effect size
exceeds the meta-analysis mean effect size (.64). The two largest effect sizes are
for Sweeney and Horan’s cued relaxation therapy (self-report). Over half the
observational and self-report measures show treatment effects that are higher than
the study mean effect size.

49
Table 7
Behavioral Therapies Treatment Effects
Study Intervention Measure ES
Compared
to Study
Mean ES
Autonomic Measures
Grishman (1989) relaxn EMG .34 -
Reitman (2001) sys desens EMG -.40 -
Reitman (2001) sys desens HR .35 -
Kendrick et al. (1982) behav rehears HR .08 -
Grishman (1989) relaxn HR .08 -
Appel (1976) piano sys desens Pulse 1.11** +
Sweeney Horan (1982) cued relaxn Pulse 1.08** +
Appel (1976) sys desens Pulse .37 -
Observational Measures
Appel (1976) piano sys desens Errors 1.02** +
Sweeney Horan (1982) cued relaxn Errors .94 +
Appel (1976) sys desens Errors .92 +
Lund (1972) #1 sys desens Errors .80** +
Lund (1972) #2 relaxn w/ appl Errors .47 -
Kendrick et al. (1982) behav rehears Errors -.03 -
Sweeney Horan (1982) cued relaxn Nervous .07 -
Lund (1972) #1 sys desens PQ .90* +
Lund (1972) #2 relaxn w/ appl PQ .79** +
Deen (1999) awareness PQ .75* +
Mansberger (1988) sys desens PQ .22 -
Richard (1992) cued relaxn PQ .16 -

50
Compared
to Study
Mean ES
Self-Report Measures
Conklin (2011) sys desens CPAI .83* +
Grishman (1989) relaxn MPAQ .71* +
Reitman (2001) sys desens MPAQ .44 -
Deen (1999) awareness PAI .52 -
Reitman (2001) sys desens PARQ- .96** +
Lund (1972) sys desens PARQ+ 1.11* +
Lund (1972) #2 relaxn w appl PARQ+ .51 -
Kendrick et al. (1982) behav rehears PASSS .08 -
Sweeney Horan (1982) cued relaxn PPAS ca 1.29* +
Sweeney Horan (1982) cued relaxn PPAS ea 1.39* +
Appel (1976) sys desens PRCP 1.22** +
Appel (1976) piano sys desens PRCP .86 +
Richard (1992) cued relaxn PRCP .29 -
Mansberger (1988) sys desens w relaxn SASAS .99* +
Kendrick et al. (1982) behav rehears SSS 1.03* +
Reitman (2001) sys desens STAI-S .69 +
Grishman (1989) relaxn STAI-S .63* -
Kendrick et al. (1982) behav rehears STAI-S .14 -
Richard (1992) cued relaxn STAI-S .10 -
* = p ≤ 0.05, ** = p ≤ 0.1
EMG = electromyography; HR = heart rate; PQ = performance quality
Note: Acronyms for self-report measures are in Appendix B.
Complementary and Alternative Therapies
Experiments on complementary and alternative interventions have relied
heavily on self-report measures of outcomes, so it is not possible to determine
whether complementary and alternative interventions are differentially effective
across the three types of outcomes. The effect sizes are shown in Table 8. The
two largest effect sizes are in both of Montello’s group music therapy studies
followed by Richard’s Ericksonian resource retrieval and Stanton’s hypnotherapy.

51
Table 8
Complementary and Alternative Interventions Treatment Effects
Compared
to Study
Mean ES
Autonomic Measures
Thurber et al. 2010 biofeedback HR .25 -
McKinney 1984 biofeedback Temp .53 -
Richard 1992 erick res retriev PQ .00 -
Thurber et al. (2010) biofeedback PAI .23 -
Thurber et al. (2010) biofeedback STAI-S .61 -
McKinney (1984) biofeedback STAI-S .77* +
Richard (1992) erick res retriev PRCP -1.01** +
Richard (1992) erick res retriev STAI-S .78 +
Montello et al. (1990) #2 group mus tx PRCP -2.67* +
Montello et al. (1990) #1 group mus tx PRCP -2.28* +
Montello et al. (1990) #2 group mus tx STAI-S .10 -
Montello et al. (1990) #1 group mus tx STAI-S .80 +
Stanton (1993) hypnotherapy PAI 1.15* +
Lin et al. (2008) meditation MPQ .45 -
Lin et al. (2008) meditation PAI .67 +
Chang et al. (2003) meditation PAI .67 +
Lin et al. (2008) meditation STAI-S .47 -
Chang et al. (2003) meditation STAI-S .47 -
Kim (2005) mus tx LAS .80* +
Kim (2005) mus tx PARQ .23 -
Kim (2005) mus tx STAI-S .60* -
Stern (2012) yoga K-MPAI .59* -
Stern (2012) yoga PAQ .59* -
Khalsa et al. (2009) yoga PAQ .55 -
Stern (2012) yoga POMS .59* -
* = p ≤ 0.05, ** = p ≤ 0.10
HR = heart rate; PQ = performance quality; Acronyms for self-report
measures are in Appendix B

52
Cognitive Therapies
Relatively few experiments involved cognitive interventions, but Table 9
shows treatment effects that exceed the study ES for all three types of outcomes.
Of the top five effect sizes, four come from Sweeney and Horan’s (1982)
experiment on cognitive restructuring. It produced superior effects for all three
treatment outcomes. Although the effect sizes were smaller in Hoffman and
Hanrahan’s (2012) experiment on mental skills training, they exceeded the overall
effect size mean (.64) across all three types of treatment outcomes.
Table 9
Cognitive Therapies Treatment Effects
Compared
to Study
Mean ES
Autonomic Measures
Hoffman Hanrahan 2012 mental skills training HR .73* +
Kendrick et al. 1982 attentional training HR .17 -
Sweeney Horan 1982 cog restructuring Pulse 1.02** +
Kendrick, et al. 1982 attentional training Errors .44 -
Sweeney Horan 1982 cog restructuring Errors .14 -
Sweeney Horan 1982 cog restructuring Nervous 1.57* +
Hoffman Hanrahan 2012 mental skills training PQ 1.00* +
Hoffman Hanrahan 2012 mental skills training PAI .68** +
Kendrick, et al. 1982 attentional training PASSS .69** +
Sweeney Horan 1982 cog restructuring PPAS ca 1.12** +
Sweeney Horan 1982 cog restructuring PPAS ea 1.07** +
Kendrick et al. 1982 attentional training SSS .66** +
Esplen Hodnett 1999 guided imagery STAI-S .98* +
Hoffman Hanrahan 2012 mental skills training STAI-S .35 -
Kendrick, et al. 1982 attentional training STAI-S .20 -
* = p ≤ 0.05, ** = p ≤ 0.10

53
Combined Therapies
This class of interventions involves the use of two or more therapies with
each client. It is reasonable to expect that their efficacy would be at least as good
as its best single component. In fact, the meta-analysis estimates the overall
effect of this approach to be strongest of the four. This is apparent in Table 10,
which shows superior effect sizes for all three types of outcome measures. More
than half of the self-report measures are larger than the study ES. The largest
treatment effect in this class of interventions is the self-report measure of Nagel et
al.’s (1989) muscle relaxation/cognitive therapy/ biofeedback therapy.

54
Table 10
Combined Therapies Treatment Effects
Compared
to Study
Mean ES
Autonomic Measures
Reitman (2001) w mus sys desens +
music
EMG -.48 -
Roland (1993) #1 cognitive +
behavioral
HR -.70 ** +
Reitman (2001)w mus sys desens +
music
HR .56 -
Roland (1993) #2 cognitive +
behavioral
HR .50 -
Craske Rachman (1987a) relaxn +
attentional focus
HR .49 * -
Craske Rachman (1987b) relaxn +
attentional focus
HR .31 * -
Sweeney Horan (1982) cued relaxn +
cog restrict
Pulse .43 -
Bissonnette (2011) sys desensization +
virtual psychoed
Pulse .13 -
Kim (2008) #1 mus tx +
relaxn + imagery
Temp 1.68 * +
Kim (2008) #2 mus tx +
sys desens
Temp .77 * +
cog restruct
Errors .56 -
cog restruct
Nervous 1.41 * +
Sweeney-Burton (1997) relaxn +
biofeedback
PQ .65 **
Roland (1993) mod cognitive +
behavioral
PQ .24 -
Roland (1993) cognitive +
behavioral
PQ .12 -
Nagel et al. (1989) muscle relaxn +
cog tx + biofeedback
APQ .03 -
Reitman (2001) w music sys desens +
music
MPAQ 1.30 * +

55
Compared
to Study
Mean ES
Kim (2008) #2 mus tx +
relaxn + imagery
MPAQ 1.12 *
+
Kim (2008) #1 mus tx +
sys desens
MPAQ .22 -
Tarrant & Leathem (2007) cognitive +
behavioral prog
MPAS .43 * -
Nagel et al. (1989) muscle relaxn +
cog tx +
biofeedback
PAI 2.25 * +
Harris (1987) cognitive +
behavioral group
PAI 1.65 * +
music
PARQ- .71 +
Sweeney & Horan (1982) cued relaxn +
cog restruct
PPAS ca 1.32 * +
Sweeney & Horan (1982) cued relaxn +
cog restruct
PPAS ea 1.38 * +
Bissonnette (2011) sys desens +
virtual psychoed
PRCP .53 -
Roland (1993) mod cognitive +
behavioral
STAI-S 1.52 * +
Kim (2008) #2 mus tx +
relaxn + imagery
STAI-S 1.09 * +
Roland (1993) cognitive +
behavioral
STAI-S 1.06 * +
Sweeney-Burton (1997) relaxn +
biofeedback
STAI-S 1.00 * +
Nagel et al. (1989) relaxn +
cog tx +
biofeedback
STAI-S .74 +
virtual psychoed
STAI-S .52 -
Kim (2008) #1 mus tx +
sys desens
STAI-S .51 * -
music
STAI-S .50 -
Harris (1987) cognitive +
behavioral group
STAI-S .48 -
Craske Rachman (1987)
#1
relaxn +
attentional focus
SUDS 1.53 * +
Craske Rachman (1987)
#2
relaxn +
attentional focus
SUDS 1.51 * +

56
Compared
to Study
Mean ES
virtual psychoed
SUDS 1.
02
* +
Kim (2008) #2 mus tx +
relaxn + imagery
VAS
Comfort
.5
6
* -
Kim (2008) #1 mus tx +
sys desens
VAS
Comfort
.0
1
-
Kim (2008) #2 mus tx +
relaxn + imagery
VAS
MPA
.8
2
* +
Kim (2008) #1 mus tx +
sys desens
VAS
MPA
.3
5
** -
Kim (2008) #1 mus tx +
sys desens
VAS
Stress
.6
2
* -
Kim (2008) #2 mus tx +
relaxn + imagery
VAS
Stress
.2
2
-
Kim (2008) #2 mus tx +
relaxn + imagery
VAS
Tension
1.
08
* +
Kim (2008) #1 mus tx +
sys desens
VAS
Tension
.6
7
* +
* = p ≤ 0.05, ** = p ≤ 0.10
Conclusion
The research questions (1) Are nonpharmacologic psychotherapies for MPA
effective? and (2) Which of four classes of empirically-studied nonpharmacologic
psychotherapies is most effective in reducing MPA? were answered by combining
outcomes in a random-effects meta-analysis. The overall effect size of .64 is
interpreted as being of medium to large magnitude, according to Cohen’s metric
(1988). This interpretation is consistent with that of the meta-analysis by
Hofmann, Sawyer, Witt, and Oh (2010) on the efficacy of mindfulness-based
therapy in reducing anxiety. In that study, the researchers interpreted the Hedges’
g effect size of 0.63 as indicating that the therapy is “moderately effective”. Of

57
the four intervention classes, the combined psychotherapies have produced the
highest mean therapeutic effects.

58
CHAPTER 5: DISCUSSION
There is a growing body of research experiments testing the efficacy of
nonpharmacologic treatments for music performance anxiety (MPA). Previously
published reviews of this body of research have used a narrative approach to
describe and compare treatments. The present review of 29 studies breaks new
ground with the application of the statistical methods of meta-analysis to combine
and compare treatment effects observed in this body of research.
The meta-analysis yielded two key findings: (1) all four types of therapies
that were tested are moderately effective and (2) the most effective type of
psychotherapy is combined therapy involving two or more types of interventions,
although the superiority of its effectiveness is not of sufficient magnitude to have
practical significance.
The meta-analysis yielded a mean effect size of .64 across all 29 studies
and all outcomes measured in them. Previous meta-analyses, most notably the
study by Lipsey and Wilson (1993), found a mean effect size of .50 for 302
studies of psychological, educational, and behavioral treatments. Smith and Glass
(1977) found an effect size of .68 in their meta-analysis of 375 studies of
psychotherapy. More recently, Hofmann et al. (2010) analyzed 39 studies of
mindfulness-based therapy for anxiety reduction. They found an estimated mean
effect size of .63. The similarity in mean effect size across these meta-analyses
suggests that the interventions for MPA in the present meta-analysis, on the
whole, are as effective as those for other psychological disorders.

A META-ANALYSIS OF NONPHARMACOLOGIC PSYCHOTHERAPIES FOR MUSIC PERFORMANCE ANXIETY.pdf

A META-ANALYSIS OF NONPHARMACOLOGIC PSYCHOTHERAPIES FOR MUSIC PERFORMANCE ANXIETY.pdf

Recommended

Recommended

More Related Content

Similar to A META-ANALYSIS OF NONPHARMACOLOGIC PSYCHOTHERAPIES FOR MUSIC PERFORMANCE ANXIETY.pdf

Similar to A META-ANALYSIS OF NONPHARMACOLOGIC PSYCHOTHERAPIES FOR MUSIC PERFORMANCE ANXIETY.pdf (16)

More from Michelle Shaw

More from Michelle Shaw (20)

Recently uploaded

Recently uploaded (20)

A META-ANALYSIS OF NONPHARMACOLOGIC PSYCHOTHERAPIES FOR MUSIC PERFORMANCE ANXIETY.pdf