14 The damage to musicians’ health
Altenmüller and Jasusch (2010) report a shocking finding:
The musical genre of the overwhelming majority of patients suffering from focal dystonia is classical music. [Focal dystonia is a neurological disorder causing muscles to spasm, not uncommon in instrumentalists.] In contrast to pop or jazz music with improvised structures and great freedom of interpretation, … classical music … requires a maximum of temporal accuracy in the range of milliseconds, which is scrutinized by the performing musician as well as by the audience at any moment of the performance. This, as a consequence, combines the situation of public performance in classical music with a high level of social pressure; the gap between success and failure is minimal … (4)
a pattern of anxiety and extreme perfectionism was observed in musicians that had already been present before onset of dystonia… This pattern was not observed in healthy musicians. … [T]he association between highly skilled movement patterns and the development of focal task-specific dystonia is highly suggestive of an environmental contribution from prolonged repetitive use under conditions of high demand on temporal-spatial precision in the context of reward and punishment. (4–5)
[T]he unyielding reward and punishment frame in the classical music performance scene provides a fertile ground for these stresses in musicians. This in turn could explain why, for example, improvisational jazz musicians are much less likely to develop musician’s dystonia. (8)
Altenmüller and Jasusch identify here a toxic combination of factors that harm musicians. To what extent is this due to the stresses and constraints we’ve been looking at? Might a more liberal approach to performance, which allowed more creativity, improve musicians’ health by removing some of the stress caused by the obligation to perform ‘properly’ and by anxiety over the ever-present danger of transgressing narrowly defined (often undefined and thus unpredictable) interpretative norms?
A recent study—tellingly entitled ‘Psychological Strain, Burnout, Perfectionism, Optimism, Pessimism and Recovery Skills in Professional Singers’ (Hodapp, 2018)—sets out some alarming statistics.
The prevalence and self-assessment of mental disorders in professional opera singers (N = 169) was examined in the study by Hannig (2004). Hannig was able to show that in more than a quarter of the singers examined (27%) there was a suspicion of the presence of a mental disorder. Younger singers under the age of 40, and female singers and interviewees with an insecure job situation, seem especially at risk. Nearly 40 percent of opera singers in this investigation reported having mental health problems (39%) and over-exertion (37%). Also nearly 40 percent of the professional singers interviewed have already considered changing their job because of psychological stress.
Instrumentalists are no less affected.
An investigation with 2,536 orchestra musicians from Germany revealed that more than 90 percent of the professional musicians interviewed currently suffer from stage fright in their musical performing (Gembris & Heye, 2012). In an investigation with 2,212 orchestra musicians from the USA, the following picture emerged: 21 percent of professional musicians stated that they were suffering from acute anxiety, 24 percent suffered from depression, 19 percent had sleep problems and 40 percent suffered from performance anxiety (Fishbein et al., 1988).
In this connection Anna Bull reports that
orchestral musicians have recently been exposed as experiencing high levels of drug and alcohol addiction, bullying, boredom and low job satisfaction (Price 2013; Lander 2014).
Hodapp identifies a selection of causes that will be familiar to readers here:
It is clear that the activity of a singer is a profession whose practice is accompanied by a number of potential stressors. Examples include internal and external demands on performance, competitive pressure, job shortage, scope of the repertoire to be learned, rapid workload during rehearsals, artistic constraints imposed by the conductor, expectations of the audience, and stress due to constant practice (for an overview see Hofbauer, 2017). For Hannig (2004), there is hardly any other professional group “exposed to such high on-the-spot stress” (p. 1).
As Chapter 7.6 suggested, these problems begin in childhood. Izabela Wagner (2015, 76) was quoted there reporting an increase in anxiety, among the aspiring soloists she observed, during their teenage years; an increase reported also by Bull in one of her participants:
…internal self-critique had increased exponentially as soon as she started a music performance course at university… Patterns of hard work and repetitive practice could easily turn into obsessive perfectionism, fear, and anxiety (Bull 2019, 141–2)
Young students, Wagner noted, are brought up to feel guilty if they don’t practise enough. The workload ‘helps the teacher maintain the student’s dependence on them’ (Wagner 2015, 121).
In Chapter 7.5 we saw Juniper Hill quoting a student who after studying for seven years with a teacher was unable to make any decisions of his own. He describes (Hill 2018, 60) how after graduating he went into bible study and then the army. ‘[T]he students from his teacher’s studio often had problems; having had “no space for growing personality, as musicians they were somehow lost”’ (Hill 2018, 95). Looking over her study as a whole, Hill reports that
The most significant psychological inhibitors of creativity reported by musicians in this study are related to self-image, anxiety, self-criticism, and attitude (Hill 2018, 114)… excessively negative feedback and past experiences of negative feedback and anticipation of future negative feedback…(115) … The most restricting attitude reported across all sites was an overemphasis on perfectionism … fear of making mistakes, leading to anxiety. In some cases destructive self-criticism and lowered self-confidence… (116)
Biasutti and Concina (2014) found that advanced performance students suffered more from musical performance anxiety than professionals. In other words, peak anxiety occurs in music students, presumably created by anxiety over being ‘good enough’ (i.e. accurate, reliable, convincing enough) to get work.
Tim Patston (2014) very reasonably considers this as an indictment of music education.
Musicians appear to be significantly more anxious in their ‘workplace’ than the general population. These levels of prevalence are of major concern. There is no other condition in the anxiety disorders where such a high proportion of a population report functional impairment [my emphasis] … Anecdotal evidence suggests that music teachers do little, if anything, to dispel that notion that MPA [Musical Performance Anxiety] is somehow a normal part of being a musician. Qualitative research, based upon formal and informal interviews, indicates that around 30% of musicians who leave the profession because of debilitating MPA become educators rather than continue as performers. It seems logical to assume that MPA may be reinforced in the education sector. … Despite being unable to manage their own MPA, faculty members feel able to manage this condition in their students. It is not surprising that their students do not have effective coping strategies. (Patston 2014, 90)
Recent research (Moretz & McKay, 2009; Patston, 2010) has identified that perfectionism has a key role to play in the development of MPA. If, over time, a musician is convinced that musical perfection is their goal, their search for the unattainable may lead initially to frustration and ultimately to anxiety, as they fail to reach these self-imposed standards (92).
Again, the statistics tell a shocking story. According to Perkins et al. (2017),
Kreutz et al. (2008) reported on musculoskeletal and non-musculoskeletal problems amongst 273 music students drawn from two United Kingdom conservatoires. Their analysis revealed that over 10% of students reported above average or severe sleep disturbance, inappropriate tiredness, weather sensitivity, concentration problems, or headaches requiring medication. Additionally, 48% of the sample reported above average to severe musculoskeletal pain in at least one bodily site. Indeed, that musculoskeletal pain is a frequent experience for conservatoire music students is supported by a number of other studies (Spahn et al., 2002; Hagberg et al., 2005; Ackermann et al., 2011; Steinmetz et al., 2012). … Hildebrandt et al. (2012) … reported that fatigue, depression, and stage fright increased significantly over the 1st year of higher education in three Swiss music hochschule, while Kaspersen and Gotestam (2002) found high levels of music performance anxiety (MPA) among Norwegian conservatoire students, particularly for pianists and string players. Similarly, Papageorgi et al. (2013) found that musical performance anxiety was a concern for the majority of the 244 United Kingdom-based undergraduate student and professional musicians they sampled and that musical genre differentially impacted upon musicians’ experiences of performance anxiety, with those identifying as Western classical musicians reporting the highest levels of performance anxiety. … Demirbatir (2015) argues that the environment of studying music “can be considered as a stressful place because of high competition, isolation, failure to achieve career goals, authoritarian teaching style, and intolerance against errors caused by stress or anxiety and financial uncertainty.” … [O]f almost 200 music students surveyed in Germany, half had actively sought professional help due to playing-related health problems (Spahn et al., 2002)
The most frequently reported challenge was associated with perceived comparison and competition (sub-theme 3.3, n = 15, 75%), which seems to be a feature of the conservatoire environment in a way that the majority of students report to be emotionally challenging … Additionally, the students also described challenges with feelings of pressure and stress (sub-theme 3.4, n = 14, 70%) … Just over half (n = 11, 55%) of the students reported direct or indirect experiences of psychological distress within the conservatoire environment (sub-theme 3.5). Six students (30%) directly described an experience of mental illness.
This is a dreadful situation: it says nothing good about the classical music business that it appears to be considered by many as a necessary price for professional performance. No profession should do this to its workers; no society should be content with it or celebrate hearing its results.
Altenmüller & Jasusch (2010), whom I quoted at the beginning of this chapter, conclude with recommendations; essentially, avoiding from the very start teaching perfectionism, avoiding excessive practice (excessive for good health, that is), not seeing recordings as models of perfection to be equalled, focusing instead on ‘the joy of emotional communication shared with the audience and musicians.’ (9)
In the light of these grim data and conclusions it may be slightly less surprising that Allmendinger et al. (1996, 201–2) found that, in terms of job satisfaction and opportunities for growth, orchestral musicians score below US federal prison guards. Orchestras from the UK show overall the lowest general satisfaction, job security satisfaction, pay satisfaction, management satisfaction and growth opportunities satisfaction. For regional orchestras (in UK, USA, ex-W. and ex-E. Germany all together) almost as many leave the profession as leave for another orchestra (table on p. 203).
All this in an art form (if that’s what it is) that purports to touch people in uniquely deep ways.
Katherine Liley, in order to get some perspective on the numerous types of injury suffered by pianists today (documented in her thesis), offers an imaginary Martian’s view of piano playing:
Perhaps his main impression would be that playing the piano is a dangerous activity and that it takes place within an unhappy environment. Human piano players face a high probability of sustaining injury, with 93 possible factors that could plunge them into a nightmare of horrifying symptoms and even more horrifying consequences. All this takes place in a world of demanding and unsympathetic teachers, families, peers, composers, educational institutions, and exam syllabuses… He may ask himself why any human being would play the piano at all, perhaps wondering if some sort of conscription system was in operation…(157).
Her dataset, she says,
conjures up a vista in which physically and emotionally damaged pianists inhabit a morally wanting environment filled with pushy parents, uncaring teachers, reckless composers and irresponsible peers (159).
Much attention has been devoted in recent years to the treatment of musicians’ illnesses through the field of performance arts medicine (PAM).
And yet, so far, treatments often appear to be of limited effectiveness. Partly this must be due to the fact that success in this area consists in being able to send the musician back to resume their duties in the same damaging environment that produced the problem in the first place. When it’s a problem of technique, that can perhaps be worked around if another technical solution can be found. But when it’s also about what the situation does to one’s sense of self then it’s no good just alleviating clients’ symptoms and then sending them back on stage. In that situation PAM is just a proxy or an agent for the system, making musicians (perhaps only temporarily) fit to continue to be harmed.
You don’t have to be a Marxist to see that musicians are disposable, given the ready supply of superlatively able young players eager to take their place. One gets a vivid sense of this in the defence offered in court by the Royal Opera House, sued by Christopher Goldscheider, a member of its orchestra, for hearing damage sustained during a rehearsal of Die Walküre. ‘ …the ROH claimed the artistic value of the music produced by the orchestra meant that some hearing damage to its players was inevitable and justifiable’. So it’s fine, and to be expected, that musicians will suffer hearing loss in the interests of the organisation and its paying audiences. This is entirely in keeping with WCM ideology, where the composer’s wishes are to be realised as vividly as possible, whatever the human cost. ‘The music’ is simply more important than the people making it.
It’s in this kind of context that performers’ ill-health is economically acceptable and need not be effectively treated. So a training that produces it, even in quite high quantities, and a PAM that has so far managed to be of only limited help, isn’t an obstacle to the efficient working of the business. Another question might be whether, if it could be much reduced, that would benefit or challenge the business model. It’s not impossible that performer illness functions partly as a means of maintaining an attractive turnover, with familiar faces being replaced by fresher, younger ones.
At any rate, there is good reason to suspect that much of this illness is caused precisely by the intolerance of individuality that we’ve noted throughout the increasingly distressing Part 2 of this book; so that after many years of apparent success even experienced and well-known musicians find themselves unable to recognise the eager young player who longed for nothing as much as for a lifetime’s professional music-making. After long enough performing the same repertoire in the same way, they come to wonder who they are when they play or sing: themselves or simply a functionary for the system? Some face this earlier: you may recall one of Wagner (2015)’s interviewees who gave up at the last stage of training as a virtuoso to study medicine because ‘When she played, she said, it was only her teacher playing through her.’ Similarly, Hill (2018, 37) quotes one of her participants: ‘I had just so much schooling in all around the violin and everything, and I just couldn’t tap into where my voice was anymore.’
With all this very much in mind, in 2018 I wrote to a psychoanalyst, Monia Brizzi, who works partly under the aegis of BAPAM, the British Association for Performing Arts Medicine, treating performance artists for performance-related conditions. I was interested to learn whether she encountered in her work musicians with physical or psychological problems related to a lack of agency or opportunity to bring individuality or creativity to their performing. It seemed possible, in theory, that the constraints forced on creativity by the profession might cause some of the problems that PAM was reporting. Here is part of her reply.
I am so pleased you decided to get in touch – the issues that you have identified are of great interest to me and do directly resonate with the predicament of past and current clients I’ve been working with. … Performance requires an active attitude of participation and existential commitment involving the whole being, not just some form of half-hearted cognitive adherence to external standards. When the alignment of performer and human being is missing, art loses vividness, fulness and integrity – and so does individuality.
I see performers that have left themselves behind in this way, so when they engage with people, who can these people see? There is nobody there to see. They need to find a way to reach out to the person they left behind and bring it to the art and on stage with them. But the consequences of doing this are uncertain… When performers have emptied themselves, their art and other people in their world respond to them as these empty beings – they respond to this emptiness in empty ways and they respond to themselves as these empty beings. To feel that they are someone again they need to bring that someone that they left behind. Yet as you say they get censored and penalised for doing so. If they can’t be themselves, who are they now? They might like the story that they have ‘changed’ but this doesn’t often ring true or fit their experience. Blanking out one aspect of their life so often results in blanking everything out and so they become like machines but without a heart. Unfortunately all their achievements seldom give them what they want, and they are still empty, dissatisfied and miserable. They, and the world, respond only to what they do rather than to them…. It is sad that many performers can regain a sense of freedom only when they choose to leave the profession, or, when they develop disabling physical and psychological symptoms, and being unable to play an instrument or losing their voice is often the way they have found to evade these conflicts. Breakdowns and illness are ways of “discovering the self to whom one can be true”, as you eloquently say, and escaping their trapping. This needs to be recognised and worked with avoiding to pre-empt things prematurely by indoctrinating them with yet another system/trap to reproduce or hide behind, rather than allow an opportunity for true becoming, creativity and artistry.
Violin teacher John Crawford makes a similar case in an article in The Strad (9 Sept 2020):
There will always be the very gifted whose natural flow can survive almost anything, but many find themselves gradually losing their love and enjoyment of playing because, often without their realising it, they are being asked to do something which doesn’t come from their own voice or conception, so they end up viewing performance as a kind of obstacle course. In such a situation energy cannot flow ‘from the inside out’, and this is undoubtedly one of the main factors in the increasing number of our students needing physiotherapy and suffering from blockages of various kinds. Often the poor student is then given the impression that there is something wrong with their ‘body’, apparently a thing separate from them, which needs to be ‘fixed’ through exercises. If I have nothing genuine to say, to express, my energy doesn’t flow: in fact it may well move in the wrong direction – inwards, the opposite of expression, which by definition is a sending out. We call this wrong direction ‘tension’ – a player pulling in on themselves in a desperate attempt to follow someone else’s idea and try to ‘get it right’.
Given, then, that the very low level of agency and creativity permitted to classical musicians does seem to be a notable factor in the extraordinarily high levels of illness among performers, it seems only reasonable to hypothesise that the changes to musical practice justified by and modelled in this book would reduce the extent of the problem in worthwhile ways. There’s a clear ethical case based in performers’ physical health and psychological well-being for the changes I’m proposing.
A remarkably original and interesting case has been made by horn player Martin Lawrence for using musicians’ performance anxiety to generate more creative readings of scores. Martin has written about this, with examples, as Chapter 23.4 of this book, within Part 3 which is where we look at musical solutions to many of these problems.
 Altenmüller, Eckart, and Hans-Christian Jasusch. 2010. Focal dystonia in musicians: phenomenology, pathophysiology, triggering factors, and treatment. Medical Problems of Performing Artists 25/1, 3–9. My thanks to Lukas Fierz for drawing my attention to this study.
 Hodapp, Bastian. 2018. Psychische Belastung, Burnout, Perfektionismus, Optimismus, Pessimismus und Erholungskompetenz bei professionellen Sängerinnen und Sängern, Jahrbuch Musikpsychologie 28.
 ‘In der Studie von Hannig (2004) wurde die Prävalenz und Selbsteinschätzung psychischer Störungen bei professionellen Opernsänger/innen (N = 169) untersucht. Hannig (2004) konnte zeigen, dass sich bei mehr als einem Viertel der untersuchten Sänger/innen (27%) ein Verdacht auf das Vorliegen einer psychischen Störung ergab. Besonders gefährdet scheinen jüngere Sänger/innen unter 40 Jahren, Sängerinnen sowie Befragte mit unsicherer Arbeitsplatzsituation zu sein. Fast 40 Prozent der Opernsänger/innen gaben in dieser Untersuchung an, unter psychischen Problemen (39%) und Überanstrengung (37%) zu leiden. Ebenfalls fast 40 Prozent der befragten Profisänger/innen haben schon einmal darüber nachgedacht, den Beruf aufgrund psychischer Belastungen zu wechseln.’ For a wider recent review of musicians’ health see Matei, Raluca, Stephen Broad, Juliet Goldbart, and Jane Ginsborg. 2018. Health Education for Musicians. Frontiers in Psychology 9, 1137. https://www.frontiersin.org/article/10.3389/fpsyg.2018.01137
 ‘Eine Untersuchung mit 2 536 Orchestermusiker/innen aus Deutschland ergab, dass über 90 Prozent der befragten Berufsmusiker/innen angaben, aktuell bei ihrer Musikausübung unter Lampenfieber zu leiden (Gembris & Heye, 2012). Bei einer Untersuchung mit 2 212 Orchestermusiker/ innen aus den USA zeigte sich folgendes Bild: 21 Prozent der Profimusiker/innen gaben an, unter akuter Angst zu leiden, 24 Prozent unter Depressivität, 19 Prozent hatten Schlafstörungen und 40 Prozent litten unter Auftrittsangst (Fishbein et al., 1988).’
 ‘Fest steht, dass es sich bei der Tätigkeit einer Sängerin/eines Sängers um einen Beruf handelt, dessen Ausübung von einer Reihe möglicher Stressoren begleitet wird. Als Beispiele können innerer und äußerer Leistungsanspruch, Konkurrenzdruck, Stellenknappheit, Umfang des zu erlernenden Repertoires, rasantes Arbeitstempo während der Proben, künstlerische Einschränkung durch die Dirigentin/den Dirigenten, die Erwartungshaltung des Publikums und Belastungen durch ständiges Üben genannt werden (für eine Übersicht vgl. Hofbauer, 2017). Für Hannig (2004) gibt es kaum eine andere Berufsgruppe, „die solch hohen punktuellen Stressbelastung[en]” (S. 1) ausgesetzt ist.’
 Biasutti, Michele and Concina, Eleonora. 2014. The Role of Coping Strategy and Experience in Predicting Music Performance Anxiety. Musicae Scientiae 18/2, 189–202.
 Patston, Tim. (2014). Teaching stage fright?: Implications for music educators. British Journal of Music Education, 31(1), 85-98.
 Perkins Rosie, Reid Helen, Araújo Liliana S., Clark Terry, Williamon Aaron. 2017. Perceived Enablers and Barriers to Optimal Health among Music Students: A Qualitative Study in the Music Conservatoire Setting. Frontiers in Psychology 8, 968. https://www.frontiersin.org/article/10.3389/fpsyg.2017.00968
 A good starting-point for further study is MacDonald, Raymond A.R., Kreutz, Gunter, and Mitchell, Laura (eds). 2012. Music, Health and Wellbeing. Oxford: Oxford University Press.
 William Cheng finds the same in his important book Loving Music Till It Hurts (New York: Oxford University Press, 2020), esp. pp. 4 & 6: ‘Plenty of internal and external forces—stubborn personal habits and loyalties, or powerful institutions and creeds—can seemingly present us with a choice between loving music and loving people.’
 Liley independently makes a similar point about performer injury as transformative in forcing confrontation (Liley 2018, 267).
 Extracts of emails to Daniel Leech-Wilkinson from Monia Brizzi, 23 & 27/08/2018. My sincere thanks to Dr Brizzi for her cooperation and collegiality in many subsequent discussions, and for allowing me to quote her here.
 Warm thanks to Mai Kawabata for this reference.
 Lawrence, Martin. (2020). Music Performance Anxiety as Hidden Desire and Emerging Self: the Development and Exploration of a Conceptual Lens for Performers and Practitioners. PhD thesis, City, University of London.