1 Cannabidiol, Diaphragmatic Breathing Techniques

Cannabidiol, Diaphragmatic Breathing Techniques, and Mindfulness-Based Intervention as Treatment for Music Performance Anxiety

William John Floss II

B.M., University of Toledo, 2018

A thesis submitted to the

Faculty of the Graduate School of the University of Colorado in partial fulfillment of the requirement for the degree of Master of Music

Department of Music 4/20/21

Committee Members:

Dr. John Seesholtz

Matthew Chellis

Floss, William (M.M.., Vocal Performance and Pedagogy)

Cannabidiol, Diaphragmatic Breathing Techniques, and Mindfulness-Based Intervention as Treatment for Music Performance Anxiety Thesis directed by Associate Professor Dr. John Seesholtz

According to the Anxiety and Depression Association of America anxiety disorders are the most prevalent mental illness in the United States and affect 18.1% of the population. This includes music performance anxiety which often affects music students and can be debilitating for young musicians. Diaphragmatic and controlled breathing exercises, mindfulness-based intervention, and cannabidiol have all been shown to reduce anxiety and stress levels in individuals. This paper compares and analyzes studies that focus on the use of these practices as treatment for diverse types of anxiety disorders. It will then cross analyze those findings with breathing techniques taught from prominent vocal pedagogues. The results will be applicable techniques and exercises music teachers can use to help their students manage performance anxiety. These tactics will equip teachers with further understanding of anxiety symptoms and how to assist students in management.

CONTENTS

CHAPTER

I. Introduction ...... 3

II. Cannabinoids ...... 6

III. Diaphragmatic Breathing Techniques …...... 13

IV. Mindfulness Based Intervention …...... 20

Bibliography ….....…….……………….…………………………………………25

Chapter I: Introduction

Anxiety is the most prevalent mental health disorder experienced in the

United States. 18.1% of Americans suffer from an anxiety disorder.1 Performance anxiety is a medically recognized disorder and is defined as “a physiologic fight or flight reaction that occurs in an anxious person carrying out an activity in the public eye.”2 It is quite common that performing musicians experience this disorder and its unwanted symptoms. A study at Indiana University reported that 97.1% of music students answered “yes” when asked if they have experienced performance anxiety before a performance and 86.5% answered “yes” to experiencing performance anxiety during a performance.3 Performance Anxiety is a crippling disorder that affects many young musicians. Diaphragmatic breathing exercises have been shown to reduce physical and psychological symptoms of anxiety disorders. Voice teachers can and should be equipped to instruct students on breathing techniques to offset symptoms of performance anxiety Because of the nature of breathing for singing. There is also evidence that mindfulness-based intervention practices and use of cannabidiol can also counteract symptoms of anxiety. With the rising epidemic of anxiety in students the modern music teacher

1 "Managing Stress and Anxiety," Anxiety and Depression Association of America, ADAA, Accessed December 04, 2020, https://adaa.org/living-with-anxiety/managing- anxiety. 2 Segen, Joseph. Concise Dictionary of Modern Medicine. 3 Tamborrino, Robert. "An Examination of Performance Anxiety Associated with Solo Performance of College-Level Music Majors.” (Indiana University, 2001).

5 should be equipped with the knowledge and understanding of holistic practices they can incorporate into their classroom and teaching.

Music Performance Anxiety (MPA) is a disorder that effects all types of musicians. The symptoms can include sweaty palms, increased heart rate, a feeling of sickness, tremors, memory lapses, and dry mouth. These are happening because of a human's natural fight or flight reaction to increased stress levels. Sometimes added stress can drive performers to better execute their playing, but often, the stress can lead to a negative sympathetic nervous system response.

The sympathetic nervous system is one of two parts of the automatic nervous system. This system oversees unconscious bodily actions and is associated with the

“flight or fight” reaction. This system does not always know how to discern perceived and actual physical threats. This means that in high stress moments, such as performing, it can cause a sympathetic nervous response that pumps adrenaline through the body. The adrenaline then causes the physical symptoms to appear. If a performer does not know how to negotiate this reaction it can negatively affect their performance.

The other part to the automatic nervous system is the parasympathetic nervous system. This system oversees automatic bodily functions that usually happen post eating. These functions can include sexual arousal, crying, and digestion. This is commonly referred to as the “rest and digest” system.

“Engagement of the parasympathetic nervous system is desired in performance

6 situations because it slows down your heart rate and relaxes muscles that are key for coordination.”4 This engagement brings down stress levels in the body.

The body will automatically produce some symptoms to alert the person of potential danger because the nervous system cannot distinguish between perceived and actual threat. "Performance can be perceived in two diverse ways: positively, in which the singer copes with the stress and shows little anxiety, or negatively, which leads to symptoms of anxiety in the performer, thus influencing the performance badly.”5 Consequently, it is up to the individual to negotiate these symptoms.

Diaphragmatic breathing, mindfulness-based intervention, and cannabidiol have all been proven to slow, reduce, or stop these symptoms of the sympathetic nervous system response while in highly stressful environments such as performing.

Chapter II: Cannabinoids

Cannabidiol (CBD) is one of hundreds of cannabinoids commonly found in the cannabis sativa plant and the hemp plant. Unlike tetrahydrocannabinol (THC), another cannabinoid found in cannabis sativa, CBD is a non-psychoactive chemical found in these plants that is being used as treatment for several types of illnesses.

It is a completely save and non-addictive substance. With the rising costs and harsh side effects of popular pharmaceutical drugs, CBD is an excellent and natural product to try. The U.S. Government is funding many studies to see the clinical

4 Rosenberger, Amelia. “Take Deep Breaths.” ITA Journal 48, no. 1 (2020),18. 5 Emmons, Shirlee. "Voice Pedagogy: Understanding Performance Anxiety." Journal of Singing - the Official Journal of the National Association of Teachers of Singing 64, no. 4 (2008): 462.

7 positive effects of CDB on chronic pain, anxiety, inflammation, depression, autoimmune diseases, neurological conditions, cancer, and skin diseases.

“For example, when cannabinoids inhibit release from excitatory neurons (indicated by the + sign), the net result is a decreased activity of the target cell and its protection from excitotoxicity: a word that describes the deadly over-excitation of neurons in many pathological conditions such as stroke and epilepsy. This is a key finding, demonstrated by numerous labs looking in many brain areas, and reveals the endocannabinoids as an innate defense mechanism of the brain. It also helps explain how cannabinoids could help lessen the damaging effects of stroke, epilepsy, and perhaps other brain traumas. When endocannabinoids target certain strategically located inhibitory neurons (-), the net result is an increased activity in target cells. This can have complex effects, such as altering synchrony with other neurons in the network. Such a transient regulation of neuronal firing frequency by endocannabinoids is likely to be important for many brain activities, ranging from the regulation of body temperature and stress, to the perception of pain, fear, space, and time. Although CB2 receptors reside mostly on immune cells rather than neurons, activation by cannabinoids leads to related cellular outcomes. Release of inflammatory mediators is decreased and cell migration is inhibited, which can dampen the painful and sometimes destructive symptoms of an immune response. This is a simplified description of what has become a strong scientific rationale to investigate cannabinoids as therapies for autoimmune diseases, stroke, and a number of serious neurodegenerative diseases (which often involve years of chronic brain inflammation)”6

The human body is readily equipped with cannabinoid receptors to process a range of cannabinoids. The brain uses cannabinoids as a defense mechanism to mitigate reactions and responses to certain stress induced events. It has especially been

6 McPartland, M, Guy G. “The evolution of Cannabis and coevolution with the cannabinoid receptor - a hypothesis,” in Guy, et al, eds., The Medicinal Uses of Cannabinoids; and McPartland JM et al. “Evolutionary origins of the endocannabinoid system,” Gene. 2006; 370:64-74.

8 shown to be able to regulate the body’s response to anxiety and help ease symptoms incurred by anxiety disorders.

There has been a recent explosion of studies and research due to cannabis legalization in many states within the United States. The Hemp Farming Act of

2018 is a proposed law to remove hemp (cannabis holding less than 0.3% THC) from being a Schedule I controlled substances federally. This law would make cannabis a common agricultural product. This act was included in the 2018 United States farm bill that became law on December 20, 2018. This caused an immediate increase in the amount and types of CBD products available on the market. In the following years CBD products have become available anywhere you shop making it a readily available and easily accessible medicinal product.

In a 2011 study done using CDB to help treat Generalized Social Anxiety

Disorder (SAD), twenty-four subjects with SAD and twelve healthy control subjects were placed into two groups. The treatment group received six-hundred milligrams of CDB that had been dissolved in corn oil and put into capsules. The control group received a placebo capsule that looked identical. This was a completely blind study and neither group knew what capsule they were receiving.7

Physiological baseline measurements were taken that included skin conductivity, arterial blood pressure, and heart rate. Eighty minutes after capsule

7 Bergamaschi MM, Queiroz RH, Chagas MH, et al. “Cannabidiol reduces the anxiety induced by simulated public speaking in treatment-naïve social phobia patients.” Neuropsychopharmacology. 2011 May;36(6):1219–26. doi: 10.1038/npp.2011.6.

9 consumption pretest measures were taken. Immediately following pretest measurements, the subjects were told they had two minutes to prepare a four- minute speech on public transportation in their city. During the speech physiological signs of anxiety were taken using the Visual Analogue Mood Scale.

The findings of this study showed only slightly less physiological symptoms in the treatment group. It also found only slightly less psychological symptoms based off the Visual Analogue Mood Scale analysis that was done. However, there was one significant finding of this study that could apply to the performing arts and

Music Performance Anxiety. “Another important observation of this study was that the increase of negative self-evaluation during public speaking was almost abolished by CBD... In that way, the observed effect of CBD for improving the self- evaluation during public speaking, which is one of the pivotal aspects of SAD, will influence the therapy of SAD patients.”8

This finding is extremely significant to the music world because young musicians are taught to constantly self-evaluate their performances. These self- evaluations can be quite harsh and even crippling, primarily in students who suffer from MPA as that can exacerbate mistakes made in a performance and make them appear or feel more significant than they actually were. These intense and negative self-evaluations can be extremely harmful to the student musician. CBD could be a

8 Bergamaschi MM, Queiroz RH, Chagas MH, et al. “Cannabidiol reduces the anxiety...”

10 way for students dealing with MPA to self-evaluate their performances more fairly and lead to a more positive relationship with performing.

In a more modern study done in 2019, researchers looked at how THC and

CBD could work together to decrease stress, anxiety, and depression. This is a bit more controversial in regard to musicians and MPA since THC can have psychoactive effects, however the findings are significant and important especially since the use of cannabis is rising and more people are looking for alternative ways to mitigate symptoms of stress, anxiety, and depression.

In this study an app was used to track medical cannabis users' symptoms. It analyzed a total of 11, 953 cannabis sessions ((3,151 for depression, 5,085 for anxiety, and 3,717 for stress). It was a solely self-reporting study and asked users to also track the percentages of THC and CBD in the cannabis they were consuming.

“Medical cannabis users perceived a 50% reduction in depression and a 58% reduction in anxiety and stress following cannabis use. Two puffs were sufficient to reduce ratings of depression and anxiety, while 10+ puffs produced the greatest perceived reductions in stress.”9 This is an incredibly immediate reduction. This statistic is important because common anti-anxiety and depression beta blockers can take months to start working and require constant monitoring, check-ups, and dosage changes. They can also come with unwanted adverse side effects that can be debilitating to some users.

9 Carrie Cuttler, Alexander Spradlin, Ryan J. McLaughlin, “A naturalistic examination of the perceived effects of cannabis on negative affect,” Journal of Affective Disorders, Volume 235, 2018, Pages 198-205, ISSN 0165-0327.

Another significant finding of this study relates to THC verses CBD content of the cannabis used. In the modern cannabis industry high THC and low CBD cannabis is sought after by many users. This can actually be more harmful to cannabis users' long term “continued use may exacerbate baseline symptoms of depression over time.”10 This information is commonly looked over and lost since high THC products are pushed at most cannabis dispensaries. Often times a new cannabis user is not aware of this and since THC is still federally illegal not much is being done to educate new users on the different types of cannabinoids and how they work separately and together.

“High CBD (>9.5%)/low THC (<5.5%) cannabis was associated with the largest changes in depression and anxiety ratings, while high CBD (>11%)/high

THC (>26.5%) cannabis produced the largest perceived changes in stress.”11 High

CDB and low THC products should be used to have the highest effectiveness in lowering symptoms of anxiety and depression. There was also no perceived change of the positive effects of cannabis over an extended period of time. Again, high THC products without CDB can exacerbate the baseline effects of depression but had no effect on anxiety or stress. High CBD and low THC content cannabis should be used more commonly to treat anxiety symptoms and this information should be more readily available to students suffering from MPA.

10 Carrie Cuttler, Alexander Spradlin, Ryan J. McLaughlin, ”A naturalistic examination...“ 11 Carrie Cuttler, Alexander Spradlin, Ryan J. McLaughlin, ”A naturalistic examination...”

Safe consumption of cannabis products for musicians should also be discussed. The primary from of consumption of cannabis is through smoking. This can be harmful to singers and instrumentalists and have effects on their performance, lung capacity, and additional damage done to the vocal tract. The safest way for instrumentalists and singers to consume CBD and THC products is through oral consumables. Consumable products are also the best way to control the dosage of THC and CBD since you can track the exact milligram dosage and can be more consistent and accurate in medicating. The downside to consumable products is they can often take longer to start working in the body and the perceived symptom mitigation can take longer.

Dry herb vaporizers are the next safest form of cannabis consumption. There is still not enough research to fully endorse this method of consumption as safe, but the positives are the user will feel the perceived effects at once. This is safer than smoking because vaporizers heat the cannabis to three hundred fifty-six to three hundred seventy-four degrees Fahrenheit as opposed to six hundred degrees

Fahrenheit when you combust cannabis for smoking purposes. The lower temperature is both better for the vocal tract then the higher combustion temperature, but also the lower temperature allows more of the cannabinoids in the cannabis to be activated giving the user a more efficient experience. Smoking cannabis is not recommended for singers and instrumentalists as the smoke can cause significant damage to the vocal tract over extended use. It should also be noted that dry-herb vaporizing comes with risks and is not fully safe but is a better

13 alternative to smoking cannabis which can have negative effects on the ability to breathe and engage in diaphragmatic breathing exercises that can additionally aid with symptoms of anxiety disorders.

Chapter III: Diaphragmatic Breathing Techniques

Controlled breathing is a skill every student of singing must learn and develop. Understanding and knowledge of the respiration system and how singers can use it efficiently is crucial. All teachers of singing should be able to effectively teach these concepts. “Good breathing is the foundation for all other aspects of singing. An adequate, exact map of the structures and movement of breathing will help singers reach their full potential.”12

Active inhalation is the first step of breathing. As the singer inhales, the diaphragm contracts. The diaphragm pulls down on the lungs and out on the ribcage. Back muscles also pull the ribcage back. This causes the thoracic cavity to increase in volume. This also creates negative pressure that causes air to be pulled into the lungs to equalize the pressure. Exhalation can now occur. After we inhale, the stretched back and abdominal muscles experience elastic recoil. This recoil causes the ribs to descend. As they descend, the contraction on the diaphragm is released. This causes the thoracic volume to decrease and pushes the air out of the lungs to support pressure balance. Some continued forced exhalation can happen as

12 Melissa Malde, What Every Singer Needs to Know about the Body. (San Diego, CA: Plural Publishing, 2017), 112.

14 well. This is where the singer contracts their diaphragm, back, and abdominal muscles during exhalation to force any excess air out of the thoracic cavity.

All breathing can be considered diaphragmatic breathing since it is always in use for respiration, but how to control and coordinate this muscle has long been discussed among pedagogues. Perhaps the most prominent vocal pedagogue Manuel

Garcia from the 1800’s included the diaphragm in his early teaching. He believed the breath should be quick with a partially raised chest and lowered diaphragm.

During singing he recommends that the singer have a “continuous and well- mannered pressure of the diaphragm, and he spoke of the necessity for ‘steady,’

‘moderate,’ and ‘prolonged’ pressure.”13

Francesco Lamperti is a vocal pedagogue from the 1900’s that expressed the importance of controlled diaphragmatic breathing as an element in the teaching of singing. “Let him take the deepest inspiration he can, making use of the diaphragm and muscles of the belly. Any effort about the chest-ribs in breathing must be absolutely and entirely avoided. It is here that the evil lies.”14 Lamperti, along with most prominent vocal pedagogues, realized the importance of controlled breathing and the use of the diaphragm and other musculature to effectively and efficiently breathe for singing.

A 2016 study in China sought out the effectiveness of a diaphragmatic breathing training (DBR) program on anxiety symptoms. This study used both a

13 James Stark, Bel Canto (Toronto: University of Toronto Press, 2003), 97. 14 James Stark, Bel Canto (Toronto: University of Toronto Press, 2003), 109.

15 control group and a treatment group. The treatment group were taught a DBR program while the control group was not. They measured anxiety data in two ways; they used the Beck Anxiety Inventory self-reporting test on the patients and four biofeedback tests to measure breathing rate, skin conductivity, heart rate, and peripheral blood flow. Over a series of eight weeks both groups were tested before and after performing a breathing exercise. The control group learned a breathing exercise but not DBR. The experimental group were also instructed to practice their

DBR exercises at home and keep a daily journal.

The study found that after eight weeks there was a significant reduction in anxiety reported on the Beck Anxiety Inventory by patients in the experimental group. However, the control group showed no significant reduction in their BAI scores. Regarding the biofeedback indicators measured there was significant statistical reduction of the experimental group in breathing rate, heart rate, and peripheral temperature. No significant difference in skin conductivity was reported but at the end of week eight the experimental group did have a lower rate of anxiety per skin conductivity measurement than the control group had. “The present study provides preliminary evidence for a positive association between DBR and reduced levels of anxiety. After eight weeks of DBR training, the experimental group made considerable progress in terms of BAI scores. Furthermore, several physiological indicators, including skin conductivity, heart rate, and breathing rate, showed

16 similarly noteworthy progress. These findings suggest that, when used as a relaxation technique, DBR is effective in reducing level of anxiety.”15

In another study in China, forty Information Technology professionals took part to see what the mental and hormonal effects of an eight-week breathing training program would be. The participants were split into an experimental and a control group. The experimental group were taught and coached through a fifteen- minute diaphragmatic breathing exercise. The control group was not taught a diaphragmatic breathing exercise but were instructed to focus on their breathing.

Two types of self-reporting were used. The PANAS to collect participants perceived feelings and the NCT to evaluate attention sustainability. Cortisol levels were also measured in all participants via a saliva cortisol test. Cortisol is a hormone that increases in the body as stress increases.

The results of this study point towards diaphragmatic breathing being a successful treatment for anxiety. The respiration rate of the experimental group was significantly lower than those of the control group. The average respiratory rate to be four times per min in the diaphragmatic breathing condition and seventeen times per min in the resting breathing condition.16 The study also found that the experimental group had an increase in their post diaphragmatic breathing

15 Chen, Yu-Fen, Xuan-Yi Huang, Ching-Hui Chien, and Jui-Fen Cheng. "The Effectiveness of Diaphragmatic Breathing Relaxation Training for Reducing Anxiety." Perspectives in Psychiatric Care 53, no. 4 (2017): 329-336. 16 Ma, Xiao, Zi-Qi Yue, Zhu-Qing Gong, Hong Zhang, Nai-Yue Duan, Yu-Tong Shi, Gao-Xia Wei, and You-Fa Li. “The Effect of Diaphragmatic Breathing on Attention, Negative Affect and Stress in Healthy Adults.” Frontiers in Psychology 8 (June 6, 2017). 6-7.

17 intervention NCT score. This means their sustained attention increased with intervention. Cortisol levels also lowered in the experimental group. Of the four cortisol tests done over the eight weeks (about two months); the second two had much lower levels of cortisol than the first two tests. The control group had no significant variation in cortisol levels in all four tests. This experiment is not fully conclusive but points to the conclusion that there is “potential for diaphragmatic breathing practice to improve cognitive performance and reduce negative subjective and physiological consequences of stress in healthy adults.”17

A study was conducted in 1983 at Ball State University to “address slowed, paced, diaphragmatic breathing as an adaptive technique for persons in stressful life circumstances.” 18 It used ninety-six active-duty Army trainers. There were three groups used in this study: the treatment group, the attention control group, and the no treatment control group. Each group attended four different sessions where they were tested before and after their sessions with a State-Trait Anxiety

Inventory and the Mooney Problem Checklist. The treatment group was taught a ten-minute diaphragmatic breathing exercise cued to a red and green light. The attention control group were told to count the flashing lights. The no treatment control group were given just ten-minute breaks between pre- and post-testing.

1717Ma, “Diaphragmatic Breathing on Attention, Negative Affect and Stress in Healthy Adults,” 4. 18 Mangiardi, Anthony R. "The Effect of Slowed, Paced, Diaphragmatic Breathing on Self-Reported Anxiety and Perception of Life Problems.” (Ball State University, 1983). 2.

Again, the results showed that diaphragmatic breathing reduced anxiety in individuals. The experimental group had a significant difference in their pre- and post-test A-State Anxiety test. The difference showed a decrease in anxiety for the experimental group. No significant difference was found between the pre- and post-

A-State Anxiety testing for the focus control group and the no treatment control group. However, it should be noted that both control groups had a slight upward trend in reported anxiety. No significant difference was found in any of the groups when it came to their Moony Total scores. This means there was no real perception changes on their life problems, which is what that test measures. “The results indicated that training and practice in slowed, paced diaphragmatic breathing can have significantly beneficial effects under some conditions.”19

This final study examines the effects that relaxation breathing training can have on music performance anxiety in young musicians.20 The study included fifty- nine musicians ranging, in age, from third to sixth grade. The entire group was taught relaxation breathing training. This training incorporated ideas of slowed diaphragmatic breathing. A Music Performance Anxiety Inventory for Adolescents

(MPAI-A) test was given four times throughout the study; two months, one month, thirty minutes, and five minutes prior to the student's jury time. The MPAI-A has fifteen questions that asks students to name any physical symptoms of music

19 Mangiardi.” The Effect of Slowed, Paced, Diaphragmatic Breathing...”. 52. 20 Su, Ye-Huei, Jer-Junn Luh, Hsin-I Chen, Chao-Chen Lin, Miin-Jiun Liao, and Heng-Shuen Chen. 2010. "Effects of using Relaxation Breathing Training to Reduce Music Performance Anxiety in 3rd to 6th Graders." Medical Problems of Performing Artists. 82.

19 performance anxiety that they may be experiencing. However, there was no control group for this experiment.

The results show that there is an increase in music performance anxiety as the jury or performance increases up to thirty minutes before. The results of relaxation breathing training seemed to not affect anxiety rates two months, one month, and thirty minutes before the jury. The peak anxieties documented were at thirty minutes before the jury. Interestingly, the music performance anxiety significantly decreased when the relation breathing was done 5 minutes before the student’s jury.21 The anxiety levels reported after treatment at two months away from the jury and after treatment with five minutes until the jury are almost equal with a sharp increase at thirty minutes until the jury. This points to the conclusion that diaphragmatic breathing exercises can reduce music performance anxiety prior to performance. An added comment from this study is that the breathing treatment seemed to work marginally better on female students than on male students.22

As previously stated, music performance anxiety can manifest itself in both physical and mental symptoms. There are multiple approaches teachers should take to help their students to negotiate these different symptoms. The first technique is known as the four-seven-eight Breath and was developed by Dr. Andrew Weil. This breath exercise is great because it activates the parasympathetic nervous system by using slowed diaphragmatic breathing to help with physical symptoms and involves

21 Su. "Effects of using Relaxation Breathing Training...“. pg. 84 22 Su. "Effects of using Relaxation Breathing Training... “. 85.

20 counting to help focus the mind away from physiological symptoms as well. The following are instructions to perform the four-seven-eight breath.

“Find a place to stand, sit, or lie down comfortably with a tall posture in your spine. Prepare for the practice by taking a few deep breaths in through your nose and out through your mouth. The following steps should be carried out within one breath cycle. Count at a comfortable pace and do not force anything. 1. Begin by exhaling completely through your mouth. 2. Close your mouth and inhale for 4 counts through your nose. 3. Pause for 7 counts. Hold your breath with ease. Avoid collapsing your chest and closing your throat. 4. Open your mouth and exhale evenly for 8 counts. You may find that pursing your lips will help you control the flow of your exhalation. 5. Pause for a moment at the end of your exhale. This is not metered.”6. Repeat at least 4 times.”23

Chapter IV: Mindfulness Based Intervention

Cultivating a sense of mindfulness is also a particularly important concept when trying to combat symptoms of music performance anxiety.24

Helping lead students in a mindfulness activity can also refocus the brain on the performance at hand and level out some of the negative thoughts that arise because of MPA. Have the student's name their negative thoughts about their upcoming performance and then replace those statements with positive ones or revised versions of those thoughts/statements. For example, a student may say “I’m feeling really anxious about bombing this performance,

I don’t think I practiced enough.” Now, frame that into a positive statement such as “I have prepared for this performance and my audience wants to hear

23 Rosenburg. “Take Deep Breaths.” 20. 24 Nixon, Wendy. “Helping Singers Manage Music Performance Anxiety.” Choral Director. March 2013, Vol. 10 Issue 2. 11.

21 me succeed.” Altering the state of mindfulness can help combat negative physiological symptoms of MPA that can appear.

Mindfulness Based Intervention (MBI) is another method to help treat symptoms of anxiety disorders. “Mindfulness refers to a process that leads to a mental state characterized by nonjudgmental awareness of the present moment experience, including one’s sensations, thoughts, bodily states, consciousness, and the environment, while encouraging openness, curiosity, and acceptance.”25 There are two main MBI schools of thought. The first involving the self-regulation of one’s attention. The second involves the grounding or centering and acceptance of the current moment one is in.

Mindfulness is not the default setting especially in our rapidly changing society that is constantly demanding of attention and quickly changing where one’s attention is focused.

A 2015 MBI study sought to see how internet MBI could positively impact those with anxiety disorders. Ninety-one participants diagnosed with anxiety disorders were split into two groups. The first group received access to an internet based MBI program. The second group was a control group and had access to an internet-based discussion forum. Both groups were told to engage with their programs six days a week for eight weeks. Participants filled out a pre- and post- Beck Anxiety Inventory questionnaire. The

25 Bishop SR. Mindfulness: A Proposed Operational Definition. Clinical Psychology: Science and Practice. 2004;11(3):230–241. doi: 10.1093/clipsy/bph077.

22 participants in the MBI group showed a large degrease in symptoms of depression, anxiety, and even insomnia. There was little to moderate change in the control group.26

There is an ever-growing amount of MBI programs available on the internet and on phone and computer applications. This study points out that internet based MBI can be just as effective as face-to-face MBI programs.

Access to MBI is at an all-time high and teachers should be recommending these programs to students with MPA. The practice of mindfulness has consistently and clinically been proven to mitigate symptoms of anxiety. In another study individuals in the MBI group demonstrated significantly more reduction in anxiety symptom severity than the control group that was measured by self-report measures of anxiety.27

The use of CBD products and other cannabis products with high THC and CBD have both been shown to reduce perceived symptoms of anxiety disorders. Consumed safely, these products are readily available to help aid students dealing with MPA. These products can and should be encouraged as a frontline assistance to help those students. Knowledge of how the

26 Johanna Boettcher, Viktor Åström, Daniel Påhlsson, Ola Schenström, Gerhard Andersson, Per Carlbring, Internet-Based Mindfulness Treatment for Anxiety Disorders: A Randomized Controlled Trial, Behavior Therapy, Volume 45, Issue 2, 2014, Pages 241-253 27 Hoge EA, Bui E, Marques L, Metcalf CA, Morris LK, Robinaugh DJ, Worthington JJ, Pollack MH, Simon NM. Randomized controlled trial of mindfulness meditation for generalized anxiety disorder: effects on anxiety and stress reactivity. J Clin Psychiatry. 2013 Aug;74(8):786-92. doi: 10.4088/JCP.12m08083.

23 cannabinoids THC and CBD react in the body together and separately is also crucial for correct usage. Also, the use of CBD has been proven to reduce or eliminate overly negative self-evaluation which is crucial to creating more accurate self-evaluation as a musician and creating a more positive performing experience for students dealing with MPA. This knowledge needs to be more readily available.

Controlled DBT has also been proven to help reduce and mitigate the symptoms of anxiety disorders. Teachers of singing and instrumentalists should both be equipped with this knowledge since controlled breathing is such a big skill in both mediums. These exercises can easily be taught and incorporated into the classroom. Which can relate directly into incorporating

MBI into the classroom as well.

Lastly, MBI has again been shown to decrease levels of stress and symptoms of anxiety and depression. It is crucial that MBI starts to make its way into the modern classroom. The rise in technology is intensely affecting attention spans and non-mindful auto-pilot living. Students should be encouraged to engage in MBI in all aspects of learning, but this practice is especially crucial in performance-based practice of music as performing demands our attention to fully be in the experience of performing music.

Anxiety disorders are the most prevalent mental health issue humans face today. Recent studies confirm that controlled diaphragmatic breathing, cannabinoid use, and mindfulness-based intervention can reduce or eliminate

24 symptoms of anxiety. These products are readily available to teachers and students. There is no reason that the use of these practices should not be standardized as we face startling high numbers of people being diagnosed with anxiety disorders. It is even more crucial that music pedagogues equip their students with knowledge of controlled breathing in the context of both performing and as an aid to deal with performance anxiety. This research and practice should extend into any discipline where anxiety symptoms occur.

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