Table 5.

Definitions and theoretical underpinnings of MPA interventions with signposting to relevant empirical studies.

Intervention	Overview/Definition/Theoretical underpinnings
Pharmacotherapy	Physiological psychologists conceptualize MPA as a predominantly physiological phenomenon: the perception of threat activates the fight/flight response and the excessive adrenalin released causes physiological changes which can impair performance (Spahn, 2015). Based on this perspective, pharmacotherapy has been proposed as an effective solution to managing MPA (Nagel, 1990). Of the pharmacological treatments available, beta blockers are the most widely used, and widely investigated (Spahn, 2015). Beta blockers (beta-adrenergic blocking agents) are a group of medications designed to treat heart conditions by lowering blood pressure through blocking the impact of adrenalin. They are commonly used as a pharmacological treatment of MPA as they ameliorate some physiological symptoms, including tremor, reduced motor coordination, increased heart rate and palpitations (McGrath, 2012). Although in the early 1980s, several clinicians proposed beta-blockers as an effective solution to MPA (Neftel et al., 1982; James and Savage, 1983; Brandfonbrener, 1990), their use today is controversial, with ongoing debates regarding their efficacy and safety. Large-scale studies investigating the prevalence of beta-blocker use (Fishbein et al., 1988; Lockwood, 1989; Kenny et al., 2014) report 20–30% of professional orchestral musicians take beta-blockers to manage MPA. Anecdotal evidence suggests these figures may actually be significantly higher (Kenny, 2011; Patson and Loughlan, 2014). Concerningly, many of these users are unprescribed, and therefore without medical supervision. The use of beta-blockers remains controversial, with a lack of clarity regarding their efficacy, and more concerningly, their safety. Although they may be effective in reducing the physiological symptoms of MPA, they do not address the psychological components of MPA (Lehrer, 1987) and there are serious concerns associated with their use, especially without medical supervision (Kenny et al., 2014). Given the high levels of usage among professional musicians, and the lack of unanimous opinion regarding their safety (Lederman, 1999), there is an urgent need for approaches which tackle MPA effectively, thus reducing the risk to the health and wellbeing of musicians for whom unprescribed medication seems the only option. Current, methodologically rigorous, studies investigating beta-blockers are not possible due to ethical reasons. Furthermore, their use is associated with risks including psychological dependence, clinical side effects, compromised performance quality and increased anxiety (Brantigan et al., 1979; James and Savage, 1983; Lederman, 1999; McGinnis and Milling, 2005; Burin and Osório, 2017). The continued prevalence of beta blockers (based on both empirical and anecdotal evidence) indicates that there is no viable alternative.
Psychodynamic/psychoanalytic therapies	According to psychoanalytic theory, MPA stems from early life experiences (such as lack of secure attachment with significant caregivers) and expresses unconscious conflicts and defence mechanisms (Spahn, 2015). Based on this theoretical basis, psychoanalytic and psychodynamic therapists seek to enable performers to understand, and thus resolve, the conscious and unconscious conflicts associated with performing (Kenny, 2011). Proponents of this approach further argue that debilitating MPA may offer secondary gains, such as increased attention and care from significant others, or the avoidance of success which may pose greater psychological threat than failure (Sataloff et al., 1999). Only two case reports have investigated the use of psychoanalytic/psychodynamic therapy for MPA (Safirstein, 1962; Kenny et al., 2016). Although both studies reported significantly reduced MPA, they both employed a single-participant design, precluding generalizability. There is currently minimal empirical support for a psychodynamic approach (only two participants, five decades apart). Further research is needed to support the efficacy of this approach.
Cognitive therapies	Cognitive theories emphasize the impact of cognitions on physiological and behavioral symptoms, and argue that as humans have limited attentional resources, how attention is directed will impact task performance (Kenny, 2011; Spahn, 2015). Based on this theoretical premise, cognitive therapies seek to modify irrational or dysfunctional thought patterns through cognitive restructuring, a process of replacing negative, unhelpful, or catastrophic thinking with rational and constructive ways of thinking (Kenny, 2011). Several studies have linked MPA with dysfunctional cognitive processes, including catastrophizing and maladaptive perfectionism (Mor et al., 1995; McGinnis and Milling, 2005; Spahn, 2015), justifying the use of cognitive therapy to manage MPA. Although a number of studies have emphasized the role of negative cognitions in maintaining MPA (Steptoe and Fidler, 1987; Osborne and Franklin, 2002), very few studies have investigated the effects of cognitive therapies alone on MPA. (See Kendrick et al., 1982; Sweeney and Horan, 1982). Evidence to support cognitive therapies is equivocal – there is a lack of consistent evidence to support cognitive therapy as an independent modality (McGrath, 2012). Brugués (2019) posits that no conclusions can currently be drawn regarding the efficacy of cognitive interventions due to insufficient evidence resulting from a dearth of studies. A greater number of studies is needed to build a robust evidence base.
Behavioral therapies	Behavioral interventions encompass those which seek to modify behaviors in order to modify one’s state, including relaxation training and exposure therapies, and to alter dysfunctional behaviors which occur in response to anxiety (Brugués, 2019). Relaxation techniques focus on reducing the physiological symptoms of anxiety from one of two angles: ‘mind to muscle’ or ‘muscle to mind’ (Harris, 1986). ‘Mind’ strategies include visualization, while ‘muscle’ strategies include physical relaxation techniques such as stretching, or Progressive Muscular Relaxation (PMR) (McGrath, 2012). Exposure therapy, whether real or virtual, involves repeated, or graded, exposure to the feared stimulus in the absence of danger, so as to overcome anxiety (Wardle, 1969; Appel, 1976; Kendrick et al., 1982; Sweeney and Horan, 1982; Kim, 2008; McGrath, 2012; Bissonnette et al., 2015; Zyl, 2021; Osborne et al., 2022; Bellinger et al., 2023; Candia et al., 2023) While individually effective, the studies cannot be used in totality to form an evidence base as each study used entirely different treatment approaches: insight-relaxation, systematic desensitization, behavioral rehearsal, cue-controlled relaxation, breathing exercises, free improvisation, and virtual exposure therapy. Although individual studies report positive results, the heterogeneity of intervention modalities, assessment and outcome measures, and sampling strategies (too small/diverse) preclude firm conclusions regarding the efficacy of any one approach within behavioral interventions (Kenny, 2011; McGrath, 2012; Brugués, 2019). Behavioral interventions appear effective, but the heterogeneity of intervention modalities preclude firm conclusions regarding the efficacy of any one approach (Brugués, 2019).
Cognitive-behavioral therapy (CBT)	Emerging from the separate domains of cognitive therapy and behavioral therapy, CBT is based on the premise that emotions and behaviors are largely informed by cognitions – thoughts, ideas or beliefs about oneself and others; as well as impacting emotions and behaviors, cognitive processes which are irrational and self-defeating may cause, or intensify, physiological stress reactions (Kenny, 2011). CBT psychology largely attributes the sources of MPA to performers’ recurrent cognitive patterns and attitudes (McGrath, 2012). CBT interventions are systematic, goal-oriented processes which teach participants to identify, evaluate and challenge (through modifying or replacing) maladaptive cognitive and behavioral patterns (Brugués, 2011a; McGrath, 2012; Spahn, 2015). At first glance, the evidence base for CBT as an effective intervention for MPA appears broad and compelling. Indeed, several studies report significant reductions in MPA following a CBT intervention (Clark and Agras, 1991; Osborne et al., 2007; Braden et al., 2015). However, the overall picture is more complex than it initially seems. In their systematic review of MPA interventions, Burin and de Lima Osório (2016) included six CBT studies. While Osborne et al. (2007) and Braden et al. (2015) both report significantly decreased MPA in adolescent music students, the other four studies are not CBT interventions. Bien Aime (2011) explicitly criticizes CBT and uses an approach called Solution-Focused Brief Therapy (SFBT), Errico (2012) uses a ‘researcher-designed intervention’ with no mention of CBT and both Clark and Williamon (2011) and Hoffman and Hanrahan (2012) investigate PST interventions, not CBT. Fernholz et al.’s (2019) systematic review tells a similar story. Of the 10 CBT studies reviewed, all indicated positive impact on MPA. However, six are not CBT interventions. Juncos and Markman (2016), Juncos et al. (2017) investigate Acceptance and Commitment Therapy (ACT), a method which they explicitly differentiate from CBT in terms of its theoretical underpinnings and treatment approach. Similarly, Lazarus and Abramovitz (2004) explicitly differentiate multimodal training (which they investigate in this study) from CBT. Bissonnette et al. (2015) investigate virtual reality exposure training, with no cognitive restructuring component. Nagel et al. (1989) combine cognitive therapy with relaxation and biofeedback training, with no attempt to isolate the specific impact of the CBT components. Rider (1987) describes his intervention as primarily music therapy, incorporating aspects of CBT alongside other treatment modalities. Of the remaining four studies, two use a single subject design (Norton et al., 1978; Salmon, 1992), precluding any generalizability. Sweeney and Horan (1982) (n = 49 undergraduate music students) compared CBT with cognitive and behavioral interventions, with only a fifth of participants in the CBT group, and concluded that it was no more effective than the single modalities. Brodsky and Sloboda (1997) (n = 54 orchestral musicians) assessed three treatment conditions: traditional psychotherapeutic counseling, counseling plus music, or counseling plus music and vibrotactile sensations. While treatment conditions were loosely based on a CBT approach, this study does not strictly adhere to a CBT treatment model. Cognitive-behavioral therapies are surprisingly difficult to evaluate as most of the CBT interventions included in reviews are in fact not CBT. Due to the limited number of studies on CBT as a single intervention and methodological weaknesses across studies, positive results require cautious interpretation, and conclusions cannot be drawn regarding its efficacy (Burin, and de lim A Osóri O, F., 2016). One major obstacle to ascertaining the efficacy of CBT is the lack of clarity between cognitive therapies, behavioral therapies and cognitive behavioral therapies. For example, Kendrick et al. (1982) is regularly cited as a key CBT study, yet the three treatment conditions are cognitive OR behavioral, or control group. Kenny (2011) argues that these distinctions are somewhat arbitrary because in humans, as sentient beings, behavior cannot occur without a cognitive component. Much greater conceptual clarity is needed to delineate clearly between these modalities. While CBT is regularly hailed as the gold standard in anxiety treatment, little evidence suggests it is superior to either cognitive or behavioral techniques in isolation (McGinnis and Milling, 2005). Minimal engagement with the mediators and moderators results in a lack of clarity on how the components of CBT effect change (McGinnis and Milling, 2005). A lack of longitudinal studies preclude conclusion regarding CBT’s long-term benefits (Kenny, 2011) and further investigation is needed, with larger samples and adequate control groups (Nagel, 1990). Due to the limited number of studies on CBT as a single intervention and methodological weaknesses across studies, positive results require cautious interpretation, and conclusions cannot be drawn regarding its efficacy (Burin, and de lim A Osóri O, F., 2016). Conceptually, CBT may be problematic as it may increase performers’ explicit-monitoring of cognitions which could interfere with the automatic processes and motor skills required for performance (Farnsworth-Grodd, 2012). See Faur et al. (2022) for a meta-analysis of CBT interventions for MPA.
Performance coaching, psychological skills training and multimodal interventions	PST encompasses systematic practice of the psychological skills required for optimal performance, including self-regulation, motivation, imagery, goal setting, confidence, concentration and arousal management (Ford and Arvinen-Barrow, 2019). Based on the conceptualization of MPA as a complex, multi-multidimensional phenomenon, multimodal therapies combine various treatment modalities to target all aspects of MPA from an individualized person- and problem-oriented approach (Spahn, 2015). Modalities include psychodynamic therapy, CBT strategies, autogenic training, body awareness, mental techniques, imaginative techniques, breathing exercises, concentrative exercises, preparation techniques, performance training, cognitive strategies, video-feedback. Psychological/Mental Skills Training (PST/MST) has been used to enhance performance in athletes for over 50 years and has recently been investigated with musicians (see Lazarus and Abramovitz, 2004; Clark and Williamon, 2011; Osborne et al., 2014; Finch and Moscovitch, 2016; Hatfield, 2016; Spahn et al., 2016; Cohen and Bodner, 2019; Pecen, 2019; Finch and Oakman, 2022; Logan, 2022) Interestingly, in their systematic review of PST studies for musicians, Ford and Arvinen-Barrow (2019) include several interventions which are not labeled as PST anywhere else in relevant literature, including meditation, yoga and Alexander Technique. While several studies report a range of benefits, the authors criticized the disparate theoretical and empirical frameworks employed to underpin the interventions, as well as interventions’ inconsistencies across length, frequency and dosage. Aside from the very small sample sizes which preclude generalizability, multimodal interventions are, by definition, highly complex, requiring interrogation into the impact of individual modalities (not included in any cited study). Furthermore, the complexity of a highly individualized (custom-made) approach precludes accessibility. Multimodal interventions and Psychological Skills Training appear highly effective, but their heterogeneity in terms of intervention design (components) preclude firm conclusions being drawn. Overall, PST interventions for musicians appear highly promising, but research is still in the early stages (Matei and Ginsborg, 2017) and there is a need for methodological homogeneity across studies to build a robust evidence base.
Meditation, mindfulness-and-acceptance-based approaches	Meditation can be defined as “a self-regulatory practice designed to “train attention in order to bring mental processes under greater voluntary control” (Walsh, 1995, p. 388) (in Kenny, 2005, p. 195). Mindfulness- and acceptance-based approaches posit that the resistance to challenging emotions creates more problems than the emotions themselves, and therefore promotes awareness and acceptance of difficult experiences (Osborne and Kirsner, 2022) (For studies investigating Acceptance and Commitment Therapy and meditation/mindfulness approaches, please see Chang et al., 2003; Lin et al., 2008; Juncos et al., 2017; Juncos and de Paiva e Pona, 2018, 2022; Stanson, 2019; Clarke et al., 2020; Czajkowski et al., 2020; Shaw et al., 2020; Mahony et al., 2022).
Alexander technique	Alexander Technique is a kinesthetic education method which improves posture and body use through verbal instruction and challenges habitual contraction through intentionally directed inhibition or action. The method emphasizes economy of effort and managing tension to develop optimal physical functioning (Valentine et al., 1995). Only one formal study has investigated the therapeutic impact of Alexander Technique on MPA. In their study with 15 music students, Valentine et al. (1995) reported pre- to post-treatment decrease in MPA and increased positive attitude toward performance, but no changes were statistically significant. In addition to a lack of statistically significant results, Valentine et al. (1995) employed an inadequate sample size and insufficient data to calculate effect sizes for three out of five outcome measures (Kenny, 2005; McGrath, 2012). Furthermore, except HRV, effects were only visible in low stress situations. Overall, more robust research is required to clarify whether weak evidence for beneficial effects can be confirmed (Brugués, 2019; Fernholz et al., 2019).
Yoga	Yoga is a holistic system of practices incorporating cognitive and physical techniques including physical postures (designed to develop strength and flexibility) and breathing exercises (Khalsa et al., 2009). Results (Khalsa et al., 2009; Stern et al., 2012) indicate significantly decreased MPA, and significantly reduced generalized anxiety and depression, with benefits maintained at follow-up. Despite positive findings, all studies reviewed used small sample sizes and problematically, did not acknowledge the complexity of the intervention in terms of its combination of mind and body practices. Burin and de Lima Osório (2016) suggest that anxiety reduction could be attributed to meditation techniques and breathing training, rather than the physical aspect of yoga training. Further research is required to clarify which aspects of yoga training mediate which benefits, and to build a more robust evidence base (Fernholz et al., 2019).
Music therapy	Music Therapy is the clinical, evidence-based use of music-based interventions to achieve individualized outcomes within a therapeutic relationship by a qualified and accredited professional (https://www.musictherapy.org/) [See Cheng (2020), Montello (1989) and Montello et al. (1990) for studies investigating music therapy and MPA]. While results appear promising, more studies are needed with larger sample sizes (Brugués, 2019).
Biofeedback	Developed in the 1960s by experimental psychologist Neal Miller, biofeedback training is based on the theoretical premise that awareness is a necessary first step to changing one’s physiological state, and this awareness can enable new habits to be formed (Deen, 1999). Biofeedback training encompasses a range of techniques including heart rate variability (HRV) biofeedback, which involves slowing one’s breathing rate to regulate autonomic activity, and electromyographic (EMG) biofeedback, which measures a range of bodily functions including blood pressure, heart rate, muscular tension and skin temperature. In either type, participants’ physiological processes are fed back to them through sensors and real time on-screen monitoring, allowing them to gain control over these processes and thus alter their state. Additionally, biofeedback enables participants to identify the thoughts or emotions which trigger particular physiological responses (Niemann et al., 1993). In their study of 21 music students with severe MPA, Niemann et al. (1993) reported that biofeedback was effective in reducing MPA. However, the intervention’s complexity (combined biofeedback with CB strategies, e.g., coping, muscle relaxation, breathing awareness & imagery) precludes drawing any firm conclusions regarding biofeedback as a single treatment modality. Van McKinney (1984) (n = 32 wind players) found no effect on anxiety levels but reported improved performance quality (effect size = 0.83). However, Kenny (2005) attributes this improvement to increased familiarity with the performance situation during the study, questioning the validity of the claim. Thurber et al. (2010) investigated the impact of HRV biofeedback training and emotional self-regulation techniques on MPA in 14 university music students. Results indicated significant reductions in MPA and heart rate variability as well as improved performance quality. However, as the intervention combined HRV with mental and emotional refocusing strategies, it is unclear which component mediated the improvements. In their study of 46 musicians, Wells et al. (2012) found that HRV biofeedback training produced no differential results but breathing regulation significantly increased HRV and reduced self-reported anxiety. Overall, studies investigating biofeedback report mixed results. While a few studies report positive results (Niemann et al., 1993; Thurber et al., 2010), Van McKinney (1984) and Wells et al. (2012) found no reduction in MPA. Unfortunately, the studies all combine biofeedback with other treatment modalities, precluding any conclusions being drawn regarding its efficacy. McGinnis and Milling (2005) argue that although some biofeedback studies report positive change (Nagel et al., 1989; Niemann et al., 1993), it is impossible to differentiate the effects of biofeedback training from other components of the interventions. It may offer a beneficial option in conjunction with other modalities, but further research is required. Regarding biofeedback training alone, there is no good evidence to suggest it reduces MPA (Brugués, 2019). Studies investigating biofeedback training in isolation are needed to support its efficacy.
Hypnotherapy	The term ‘hypnosis’ refers to “a state of physical relaxation accompanied and induced by mental concentration”; in the context of interventions, the American Psychological Association defines hypnotherapy as a procedure used to “encourage and evaluate responses to suggestions for changes in subjective experience, alterations in perception, sensation, emotion, thought, or behaviour” (McGrath, 2012, p. 11). According to large-scale cross-sectional studies, hypnosis was rated as beneficial in managing MPA by 60–76% of musicians (Fishbein et al., 1988; D. Kenny et al., 2014; Middlestadt, 1990). However, very few studies have investigated empirically the impact of hypnosis on MPA (see Plott, 1986; Stanton, 1993). More recently, cognitive hypnotherapy has been combined with EMDR by Brooker (2018), showing promising results. Overall, there are insufficient data available to draw any conclusions regarding the efficacy of hypnosis for MPA (Brugués, 2019).
Other modalities	Oxytocin (Sabino et al., 2020) Expressive writing (Tang and Ryan, 2020) Depth relaxation music therapy and silence (Pfeifer et al., 2020)