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Evaluating the effects of virtual reality and acceptance and commitment therapy on music performance anxiety

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Evaluating the effects of virtual reality and acceptance and commitment therapy on music performance anxiety

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Content

Evaluating the Effects of Virtual Reality and

Acceptance and Commitment Therapy on

Music Performance Anxiety

by

Jasmine C. Lau

A Thesis Presented to the
FACULTY OF THE USC DANA AND DAVID DORNSIFE
COLLEGE OF LETTERS, ARTS, AND SCIENCES
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF SCIENCE
APPLIED BEHAVIOR ANALYSIS

May 2020

Copyright 2020 Jasmine C. Lau

ii
Table of Contents

List of Figures...……………………………………………………………………….….iii

Abstract .....……………………………………………………………………….…….....iv

1.0 Introduction .……...……………………….……………………….…………………...1
1.1 Music Performance .....……………..………….……………….………………….1
1.2 Systematic Desensitization......………….……………….………………………....2
1.3 Virtual Reality …………………...…….…………………………………….……3
1.4 Acceptance and Commitment Therapy...…………………………...………………5
1.5 Acceptance and Commitment Therapy and Music Performance Anxiety. ……….9
1.6 The Current Study.. ……………………………………….……………………….9

2.0 Methods and Materials ...……………………………………….………………...…..11
2.1 Participants and Settings ..………………………………………………………..11
2.2 Measures...……………...…………………………………………………………12
2.3 Performance Schedule …...………………………………………………………...13
2.4 Procedure ...………………………………………….…………………………... 13

3.0 Results.. …………………………………………………………………………….....18
3.1 Heart Rate and Galvanic Skin Response …………………………………….......18
3.2 Kenny Music Performance Inventory .………………………………………… ..20
3.3 Acceptance and Action Questionnaire-2 .………………………………………...21
3.4 Social Validity. …………………………………………...………………………21

4.0 Discussion ..………………………………………………………………………......22
4.1 Limitations ..….…………………………………………………………………...23
4.2 Future Direction and Implications. .……………………………………….……..24

References ...……………………….……………………….……………………….…….27

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List of Figures

Figure 1: Kenny Music Performance Anxiety Inventory.……………………………......30
Figure 2: Heart Rate Measures.…………………………………..………………………31
Figure 3: Pre and Post Heart Rate Measures.…………………………………………….32
Figure 4: Galvanic Skin Response Measures.…………………………..………………..33
Figure 5: Pre and Post Galvanic Skin Response Measures.……………………………...34
Figure 6: Kenny Music Performance Anxiety Inventory Scores…………………….......35
Figure 7: Acceptance and Action Questionnaire II Scores…………………………........36
Figure 8: Social Validity Scores…………………………………………………………36
Figure 9: Social Validity Measures.……………………………………………………...37

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Abstract
Music Performance Anxiety (MPA) can be an extremely debilitating behavior that
inhibits performers, whether amateur or professional, to reach and utilize their maximum
potential. Like other anxiety disorders, MPA manifests in numerous levels, be it
cognitive, physiological, or even physical levels. Various studies on MPA and adult
musicians exist but little to no studies are done on young musicians (children and
adolescents). The purpose of this study is to examine the effects of using alternative
approaches, Virtual Reality and Acceptance and Commitment Therapy, on young
musicians who report performance anxiety.

1
Evaluating the Effects of Virtual Reality and

Acceptance and Commitment Therapy on Music Performance Anxiety

1.1 Music Performance Anxiety
Music performance anxiety (MPA) is type of social anxiety that has been defined
as “the existence of the persistent and distressing apprehension related to performing in
front of an audience (Orejudo Hernández, Zarza-Alzugaray, & Casanova, 2018). MPA is
often suffered prior, during, and post performance, regardless of the instrument played.
Similar to other anxiety disorders, MPA manifests itself on a motor, physiological, and
cognitive level (Herrera & Lorenzo, 2015); the repercussions and effects of MPA can
directly affect the quality of the performance, such as intonation, memory, phrasing, and
rhythm among others. Studies have demonstrated that the cognitive component of
individuals has a direct influence on anxiety itself- in particular, an individual’s self-
evaluation as well as evaluation by others, negative self-statements regarding oneself and
their performance, and the possibility of making mistakes. Aside from certain individual
traits and characteristics that could account for an individual’s MPA, additional factors
such as financial strains, and social and job pressure to maintain one’s professional status
and prestige, worry about job stability, and the desire to meet professional standards and
expectations in the music industry could account for the emergence of MPA (Barlow,
2000).
A previous study by Fehm and Schmidt (2006) has shown that MPA not only
occurs on individuals who embark on a professional career, but also young children who
are just beginning to perform and learn the craft. Thus, one of the biggest obstacles and
challenges that musicians face in their daily lives is performance anxiety. The negative

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effects of performance anxiety can create performances that do not demonstrate a
performer’s highest ability or potential, thus, possibly ruining promising careers or
opportunities.
Ackermann, Kenny, O’Brien, and Driscoll (2014) examine coping strategies of
adult musicians who struggle with music performance anxiety. Their study documents
adult musicians’ use of specific substances, such as beta-blockers and alcohol, to help
cope with MPA. Medical literature has reported the use of beta-blockers in children for
treating blood pressure and heart arrhythmias. Beta-blockers, which are also muscle
relaxants, may not be the most ideal solution to reducing music performance anxiety so
this study examines the effectiveness of using non-medicated solutions, such as virtual
reality and acceptance and commitment therapy, as alternatives to help young musicians
manage their performance anxiety.
1.2 Systematic Desensitization
Systematic desensitization is a widely used behavior therapy treatment for
anxieties and phobias, which involves substituting an unwanted behavior (e.g., fear,
anxiety) with an alternative behavior (e.g., relaxation). When using systematic
desensitization, the individual develops a hierarchy of situations from least to most
anxiety inducing (Cooper, Heron, & Heward, 2007). For example, a young musician may
identify performing in their living room in front of their parents as least anxiety inducing
and performing at Carnegie Hall to be the most anxiety inducing. By using such method,
the individual is gradually exposed to aspects of the environment or situation that elicits
anxiety or fear.

3
A previous study by Armfield and Heaton (2013) used systematic desensitization
to address fear and anxiety in dental clinics for patients. Using systematic desensitization,
researchers gradually exposed the individuals to feared stimuli, while encouraging the
patient to use relaxation and coping strategies to manage their fear and anxiety. A
program known as the Computer-Assisted Relaxation Learning (CARL) has been
developed to help reduce anxiety and fear while receiving dental injection. Through the
CARL program, individuals viewed a series of videos and were taught to utilize coping
skills, such as muscle relaxation and deep breathing, prior to going through the dental
steps for an injection. Results of the study demonstrated greater fear reduction in those
who participated in the CARL program and patients reported that CARL was an
acceptable program to help address and reduce dental fear.
1.3 Virtual Reality
Virtual Reality (VR) is a computer-generated interactive experience that occurs
within a simulated environment. This computer-based technology allows for the
simulation of a real environment by providing prominently visual and auditory feedback,
as well as other types of feedback. VR provides a computer-mediated environment where
individuals are able to feel the sense of presence and allows for users to engage in their
senses (e.g. the ability to look around 360° or feeling the sensation of falling). Users are
immersed in this virtual environment, allowing them to momentarily ‘escape’ from the
real world, which ultimately helps create certain values for consumers (Van Kerrebroeck,
Brengman, & Willems, 2017).
In previous studies, researchers have examined the effects of utilizing relaxing
VR experiences for consumers in highly populated areas and crowding in stores and

4
shopping malls that lead to consumer dissatisfaction and negative outcomes (Van
Kerrebroeck, Brengman, & Willems, 2017). The findings of this study confirmed that
providing a VR experience for shoppers could be a potential solution for alleviating
negative effects of perceived crowding. The application of VR experience to consumers
in shopping malls can consequently diminish negative experiences and consequences for
consumers. Not only can VR experiences target specifically for consumers who
experience crowding, it can be tailored and adapted based on the shoppers’ state of mind.
Previous research has examined the effects of utilizing VR with school-aged
children (Chen, Cheng, & Lee, 2020). This study has demonstrated the effectiveness of
using Virtual Reality as a distraction for children during intravenous injections in the
emergency department. Intravenous injections are one of the most common types of
medical treatments in events of emergencies; children who experience fear and pain
during medical treatments often exhibit topographies of behaviors ranging from crying,
screaming, and body twisting. Such behaviors can be a barrier to receiving medical
treatment or prolong the amount of time spent receiving treatment. In the study by Chen,
Cheng, and Lee (2020), a group of children underwent the experiment but using age-
appropriate apps for VR. The various environments in the VR were locations such as
wildlife parks, travel destinations, space exploration and rollercoasters. Results of the
study demonstrated that “the use of VR can effectively reduce the degrees of pain and
fear experienced by school-age children receiving intravenous injections” (Chen, Cheng,
& Lee, 2020). The participants, nurses, and caregivers reported that the use of VR
significantly decreased the amount of time required to complete intravenous injections.

5
Moreover, results have shown that immersive VR can help alleviate pain and fear in
children who are receiving invasive medical treatments.
1.4 Acceptance and Commitment Therapy
Acceptance and Commitment Therapy (ACT) is an acceptance and mindfulness-
oriented cognitive and behavioral therapy that focuses on changing the function of
psychological events and an individual’s relationship to them. ACT focuses on six
processes: acceptance, defusion, self as context, present moment, values, and committed
action. As a whole, the ACT literature uses acceptance and mindfulness interventions to
increase psychological flexibility, which ultimately encourages individuals to open up
and accept their unpleasant emotions, learn not to overreact to them, and not avoid
situations where their emotions are invoked. The core of ACT stems from both internal
(private verbal behavior) and external (action) verbal behavior (Feros, Lane, Ciarrochi, &
Blackledge, 2013).
The goal of ACT is “to maximize human potential for a rich and meaningful life,
while effectively handling the pain that inevitably goes with it” (Harris, 2019). ACT is
used to help clarify what is important and meaningful (values) to an individual in life and
how to use those values as a guiding compass to motivate and guide an individual to live
a valued life. Moreover, ACT teaches and trains for psychological flexibility and
mindfulness skills that allow an individual to manage aversive, difficult, and challenging
situations while living a valued life.
Hexaflex. The six points on the ACT Hexaflex represent a behavioral repertoire
that allow individuals to move towards their values, while weakening other repertoires of
behavior that influence an individual to move towards avoidant behaviors. The Hexaflex

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has six repertoires of behavior: cognitive defusion, acceptance, present moment, self as
context, values, and committed action. A behavioral repertoire is known as the functional
relation between behavior and the individual’s environment and ACT is a procedure used
to strengthen and acquire more flexible ways of responding.
Values. Values are the larger classes of reinforcers to an individual, especially
long term, delayed positive values. In simpler terms, values are what gives individuals
meaning and purpose in life; what individuals care about and what matters. Values must
“be freely chosen” by the individual and “provides a metric for meaning in life” (Lumoa,
Hayes, and Walser, 2017). In other words, values help individuals develop a process of
valuing that can guide them in making choices.
Defusion. As a behavioral repertoire, defusion is a procedure to help individuals
establish more flexible rule following to one’s own rules, especially ones that describe
avoidant behavior. Defusion can be contrasted to “fusion,” the maladaptive behavior or
rigid rule following that defusion aims to weaken. In other words, defusion can be
described as the weakening of rigid rule following.
Harris (2019) discusses the three N’s of defusion: Notice, Name, and Neutralize.
The first step of defusion interventions is to notice the verbal behavior that is present. For
example, “notice what you are thinking,” or “what is your mind doing?” The second step
of defusion involves naming the thought, which can be playful, simple, or self-referential.
For example, a young musician might say, “I am having the thought that I am feeling
anxious before my performance.” Naming the thought disrupts the function of the verbal
behavior and gives it a neutral function. Lastly, most defusion techniques involve
neutralizing the thought. By doing so, this puts thoughts and feelings in a new context,

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hence disarming them. To neutralize the function of the thought, individuals are
encouraged to observe the thought as if it were an object, describe the thought in terms of
size, location, speed, direction, play with the properties of the thought or even give the
thought a character. This helps the individual identify rules that are not helpful and allow
for them to think in a more flexible manner that is not fused to their thoughts.
Acceptance. Acceptance is another behavioral repertoire on the ACT Hexaflex
that helps an individual be present with experience aversive or negative stimuli. As
humans, individuals will always engage in negative thoughts but acceptance is used to
help individuals choose to experience aversive thoughts and feelings in service of their
values, or what they care about.
Acceptance can be contrasted to the maladaptive behavior of negative
reinforcement, which is known as the removal of aversive stimuli that increases the
frequency of future behaviors. Acceptance interventions work to help an individual make
room for negative thoughts and understand the futility of making private events go away.
They are used when experiential avoidance behaviors become a barrier to living by an
individual’s values.
Present Moment. Present Moment is the behavioral repertoire of attending or
paying attention to present moment stimuli in a non-judgemental manner. This repertoire
of behavior aims to strengthen attending to stimuli that are in the current environment
while weakening attending to verbal events or stimuli in the past or future. Present
Moment is often trained through meditation, such as mindfulness training, where an
individual pays attention to their breathing.

8
Present moment can be contrasted to the maladaptive behavior of inflexible
attention. An individual may end up missing out on valuable aspects of current
experiences or performing in a poor manner when they are distracted and unfocused.
Take for example a musician performing on stage. Performances are high stakes
environments and often times, a musician will make a mistake on stage (e.g., memory
slip or missing a shift). When an individual hyper focuses on a mistake during a
performance, the probability of recovering from the mistake is less likely. With present
moment, an individual would be trained to attend to their current posture, their intonation,
or relaxation as opposed to the wrong note they played earlier. In more behavioral terms,
an individual is trained to notice and tact their own attending behavior and by doing so,
an individual builds the repertoire of managing their own attending behavior.
Self as Context. As a repertoire of behavior, the goal of self as context is to
establish more flexible perspective taking or deictic relating in terms of time and place. In
other words, self as context trains an individual to notice their thoughts and feelings as
being an experience, rather than something that they are. Self as context trains an
individual to engage in private verbal behavior about oneself in a flexible way.
Performing on stage can induce high anxiety in young performers and often times,
mistakes are made on stage. A common phrase heard from musicians post performances
can be variations of, “I made a mistake. I am such a terrible performer.” This is an
example of self as content, a maladaptive behavior that self as context aims to weaken.
Self as context utilizes metaphors to help individuals grasp the abstract concept of
viewing themselves as a place or time. Self as context interventions work to help
individuals think of themselves as time or place, meaning that all surrounding stimuli is

9
constantly changing with the exception of the “you” that is experiencing it. This
repertoire of behavior aims to help individuals build a strong sense of self and take their
beliefs less seriously. By doing so, it enables individuals to access a more stable sense of
self.
Committed Action. In behavioral terms, committed action is described as an
individual taking effective action or stating that they are going to engage in a behavior
that accesses their long-term, delayed positive reinforcers. Committed action includes
both overt (action) and covert (private) verbal behavior. Harris (2019) refers to
committed action as “doing what it takes to effectively live by your values.”
1.5 Acceptance and Commitment Therapy and Music Performance Anxiety
Previous research (Juncos & Markman, 2015; Juncos et al., 2017) has examined
the effects of ACT on adult musicians (e.g, vocalists and violinists) in university settings.
Results of the Juncos and Markman (2015) study demonstrated improvement on various
self-report measures at post treatment and were maintained during follow up, along with
improvements on symptom-based measures at post treatment and maintenance.
Moreover, Juncos et al.’s (2017) participants showed improvements in at least two ACT
measures and the Believability in Anxious Feelings and Thoughts (BAFT) assessment
used to measure cognitive defusion. Juncos et al. (2017) state that the students reported
increased confidence levels in performance, which they correlated with less time spent on
controlling MPA symptoms and focusing more energy on values and committed actions.
1.6 The Current Study
Although previous research (Juncos et al., 2017) has examined the effect of ACT
on adult musicians, little to no research has evaluated the effects of ACT on young

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musicians. Given the results of previous research on ACT and MPA in adult musicians,
the purpose of this study is to examine the effectiveness of VR and ACT on music
performance anxiety for young musicians. This study aims to address the research
question: can using Virtual Reality and Acceptance and Commitment Therapy be an
effective desensitization intervention for performance anxiety? The following hypotheses
for the study were made: First, there would be improved scores in the Kenny Music
Performance Inventory and Acceptance and Action Questionnaire 2. Second, it predicts
that post intervention video recordings would show improved performance practices and
skills in comparison to pre-intervention. This research will include dependent variables
such as improvement in galvanic skin response (GSR), heart rate (HR), and anxiety
inventory measures (Kenny Music Performance Inventory and Acceptance and Action
Questionnaire 2) within the current text of varying degrees of stress exposure. By
measuring heart rate and galvanic skin response, the goal is not to decrease or increase
the physiological readings but rather, keeping them comparable to baseline measures
through Virtual Reality and Acceptance and Commitment Therapy intervention.

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2.0 Methods and Materials
2.1 Participants and Settings
Two participants of the ages ten and fifteen participated in this study. Both
students are typically developing children and adolescents who have respectively played
their instruments for 15 to 36 months. Participant A is 15 years old and has been playing
cello for 18 months with some prior history of music (e.g., other instruments, theory,
group classes, etc.). Participant B is a 10 year-old cellist who has been enrolled in private
instruction for 3 years with 2 years of prior piano background. During the two years of
individual piano instruction, neither participant had any performance experience or
exposure. Both musicians’ private instructor is the primary investigator for this study.
The study was conducted in a music institution where the participants received
individual or group instruction. Students at this institution are expected to perform every
semester at the culmination recital and have numerous opportunities to perform in
monthly “upbeats,” which are “practice” performances for musicians to perform a work
in an informal setting and receive constructive feedback.
All string musicians between the ages of 6 and 16 were eligible to participate
from their self-reported music performance anxiety (MPA). Examples of self-reported
MPA symptoms included worrying about memory slips and mistakes during a
performance, receiving negative reactions from audience members, feeling out of control
during a performance, and concerns about negative self-evaluation. Musicians reported
physiological changes such as increased heart rate, shallow breathing, and sweaty hands
as well as changes in covert behaviors, which include utilizing sheet music for mastered

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works and avoiding challenging repertoires of works. No behavioral avoidance behaviors,
such as avoiding performance opportunities were reported.
2.2 Measures
Acceptance and Action Questionnaire-2 (AAQ- II). The Acceptance and Action
Questionnaire-II is used by researchers to measure experiential avoidance and
psychological inflexibility. Developed by ACT researchers and therapists, the AAQ-I,
depending on the version, uses a Likert-style scale to rate items such as negative
thoughts, or avoidance of thoughts (Bond, Hayes, and Baer, 2011). The AAQ-II asks
participants to rate their level of agreement on 7 items using a 7-point Likert scale where
7 equals always true and 1 is never true. Higher scores on the AAQ-II indicate higher
levels of psychological inflexibility.
Kenny Music Performance Anxiety Inventory (K-MPAI). The K-MPAI is a 40-
item scale that is designed to measure performance anxiety in musicians. This tool, based
on Barlow’s (2000), utilizes a 7-point Likert scale, where depending on the statement, 0
equals strongly disagree and 6 equals strongly agree or vice versa. According to
Ackermann, Kenny, and O’Brien (2014), higher total scores indicate higher levels of
performance related stress and anxiety. In addition, the authors suggest that scores higher
than 105 may indicate higher levels of MPA.
Heart rate (HR). Commercially available heart rate monitors, such as Fitbits and
Mi Bands, were utilized throughout this study to collect the heart rates of participants
throughout the study. During the intervention phase, the participants measured their heart
rates at the beginning of the session, prior to the use of VR, during the VR intervention,
and post VR intervention in the same session.

13
Galvanic Skin Response (GSR). A commercially available device such as the
Fabrication GSR Galvanic Skin Responses biofeedback unit was used to measure GSR in
the participants. The device is a small, hand-held device used to monitor stress levels via
the translation of small tension-related changes in the skin in to rising or falling tones.
The biofeedback unit provides tonal feedback as the participants rest their index and
middle fingers on the sensing plates. The GSR emits higher tones as the individual is in
higher states of emotional arousal and emits lowers tones with relaxation. Participants
measured their GSR at the beginning of the session prior to the use of VR, during the VR
interval of the session, and post VR of the same session.
2.3 Performance Schedule
Participants performed a work in maintenance and one novel work of their choice
of similar difficulty once in the baseline condition. The principal investigator video
recorded the live performances and served as the accompanist to both participants. Both
participants provided consent to be video taped for research purposes. During the
intervention phase, the students performed regularly as opportunities were available.
Students had opportunities to perform formal and informal recitals, known as “upbeats,”
which were practice performances in front of a live audience.
2.4 Procedure
Informed Consent. This study was explained to potential participants by the
primary investigator. Participants had the opportunity to ask questions and once the
primary investigator ensured that the participants understood the study, the participants
discussed the study further with their parents and/or caregivers, as participants in this
study are under the age of 18. Once participants and parents discussed and reviewed the

14
consent form and were willing to participate, both participants and parents signed the
consent form.
Assessments and Interview. Prior to taking baseline data, the participants were
asked to fill out a Kenny Music Performance Anxiety Inventory and Acceptance and
Action Questionnaire-2 (see Figure 1) to assess anxiety rates. As each individual exhibits
symptoms of anxiety differently, a preference assessment was conducted during this time
to assess what various symptoms to measure: examples consist of heart rate and galvanic
skin response. Throughout the study, 3 pieces that were already mastered and in
participants’ repertoire were rotated randomly using a number generator and were used in
the sessions to be filmed for scoring.
Baseline. The baseline phase was conducted in two phases: resting baseline and
baseline in the participant’s natural environment. During the resting baseline phase, the
participants measured resting heart rate (HR) and galvanic skin response (GSR)
immediately after waking up in the morning. In the next baseline phase, the primary
investigator measured HR and GSR after the participants arrived at their instructional
setting – prior to the onset of any warming up, playing, or instruction.
Virtual Reality. In this phase, the primary investigator explained the concept of
Virtual Reality to the participants and they were asked to deconstruct their steps to the
eventual goal of performance from least to most anxiety inducing environments. After
deconstructing, the primary investigator and the participants found the appropriate live
audience videos to be synced into the Virtual Reality technology. For example, a
participant could deconstruct their performance environment into 9 steps from least to
most anxiety inducing: 1) home practice room with just parents watching, 2) home living

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room with parents and additional 5 family members or friends watching, 3) lesson setting
with just teacher observing, 4) lesson setting with teacher and musical peers watching, 5)
ensemble classroom (larger sized classroom) with parents, teacher, and peers watching,
6) small concert room with no stage, 7) small concert hall with a small stage and slightly
dimmed lights, 8) stage with bright lights with all known individuals in the audience, and
9) stage with darkened audience and known and unknown individuals. Each stage of the
desensitization only proceeded to the next step when the participant felt comfortable
enough to move on. With the desensitization process, each participant was taught to
utilize coping strategies through a preference assessment. The primary investigator asked
each participant what their preferred choice of calming mechanisms were and utilized
them during each session.
Acceptance and Commitment Therapy (ACT). Acceptance and Commitment
Therapy (ACT) was used throughout this study. The principle investigator used the six
points on the ACT Hexaflex, Cognitive Defusion, Present Moment, Acceptance, Self as
Context, Values, and Committed Action. Each of these points are repertoires of behavior
that help individuals respond in more flexible manner. With both participants, the
primary investigator explained the rationale and reasoning behind using ACT. As there
was already rapport between the investigator and participants, the participants chose or
created their ACT exercises through a preference assessment.
Acceptance. Participants were led through Noticing and the Pushing Away Paper
exercise (Harris, 2019). The primary investigator and participant sat on chairs against the
wall and wrote feelings, emotions, thoughts, and sensations that the participant was trying
to escape. After writing the thoughts, the investigator and participant threw the paper

16
with full force, trying to remove those thoughts as far away as possible, while noticing
how much energy was used in trying to remove the thoughts. Following this, the
participant was encouraged to drop the paper in order to see what is in front of them in
that moment. With the Noticing exercise, the participant was encouraged to close their
eyes and notice where in their body they felt the feeling, where the feeling was most
intense, and the different sensations within the body.
Present Moment. As described in Harris (2007), participants were led through the
Drop the Anchor and Notice Five Things exercises. In the Notice Five Things exercise,
participants were encouraged tact or name five things in their environment using their
five senses. Using the Drop the Anchor exercise, participants were asked to notice their
thoughts and feelings and to take a moment to acknowledge the pain or difficult private
events. These exercises were used to train participants to pay attention to their own
behavior of paying attention; in other words, paying attention to what is around them
non-judgmentally.
Defusion. Participants were led through the Silly Song or Voice and variations of
Leaves on a Stream exercises. The participants are active swimmers and tennis players so
they imagined their thoughts being written on tennis balls and waves of water.
Participants then imagined themselves hitting those tennis balls or pushing away pools of
water as they were swimming. In the Silly Song or Voice exercise, the participants were
told to put their thoughts of negative self-judgment into a short sentence and to sing it in
a silly tune. Participants were trained in defusion strategies to help disrupt and distance
themselves from their negative thoughts.

17
Value. Participants engaged in the Quick Look at Your Values (Harris, 2007)
checklist. This exercise involved the participants coding a 60-item list of common values,
with V is very important, Q is quite important, and N is not important. Once this list was
coded, the participants were asked to take note of their importance and to write down
their top 3 values that were most important to them as a musician or performer.
Committed Action. At the end of each session, the participants revisited their
values and were encouraged to write down a goal to achieve that would move them
towards their values. Participants wrote down a goal they could achieve in 24 hours, 1-
day, and one week (by their next session).
Novel and Performance Target Probes. Participants were asked to “perform”
novel targets, which included brand new pieces of literature of similar difficulty that the
participants have never encountered in their sessions. For performance targets,
participants were asked to perform a piece in their repertoire outside of their original
repertoire of 3 works used in this study. The participants used a number generator to see
which sessions would include a target probe.

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3.0 Results

3.1 Heart Rate and Galvanic Skin response
The data from Figures 2 to Figure 5 represent a non-concurrent multiple baseline
across two participants, measuring heart hate (HR) and galvanic skin response (GSR) in
resting baseline (right after the participant wakes up in the morning), baseline (upon
arrival to session with investigator), and intervention: pre-intervention, during VR and
ACT, and post intervention, all in the same session. In addition, HR and GSR were
measured in performance probes with novel and maintenance performance targets. For
GSR, higher numbers indicate higher levels of emotional arousal.
Participant A went through 4 phases of intervention using Virtual Reality and
ACT. The number of sessions per phase varied from 2, 4, 5, and 3 sessions. The criterion
to move into the next phase of the desensitization process was based on the participant’s
consent and data. When the participant felt comfortable performing for the live audience
in the Virtual Reality headset and when heart rate and GSR stabilized, the participant and
investigator decided on the next phase using a preference assessment. For Participant A,
the phases were as follows: 1. Classroom setting, 2. Informal performance setting at
music institution for about 50 audience members, 3. Formal performance setting at music
institution (stage) for an estimate of 100 audience members, and 4. Small recital hall
seating 300 audience members,
In the resting HR and GSR condition, Participant A’s heart rate averaged at 78
beats per minute in the first three sessions but averaged at 103 beats per minute in
sessions 4 and 5 of this phase (overall average of 88 beats per minute in resting HR). The
participant reported that they had an exam on those two days, which maybe have

19
influenced the results of the HR and GSR reading. For GSR, the average reading was
calculated around 2 but like the HR, session 4 and 5 readings were higher in comparison
to sessions 1, 2, and 3. In the baseline phase, the investigator took the HR and GSR
reading at the beginning of the session, prior to any instruction or playing. Results were
averaged around 104 beats per minute and 3 for GSR. The participant had an opportunity
to perform in the baseline phase so HR and GSR were measured for both maintenance
and novel works. HR was significantly higher (122 for maintenance and 132 for novel) in
comparison to baseline and GSR readings read at 3.75 for novel performance probe and
3.25 for a maintenance probe.
In the first two phases of intervention for Participant A, ACT was used in sessions
9 and 13 and starting phase 3, ACT exercises were used at every session. Consequently,
the two sessions with ACT (sessions 9 and 13) had the lowest HR and GSR readings in
the two phases. Throughout the intervention phases, the participant’s HR were the highest
at the beginning of the phase and decreased or stabilized as the participant used VR and
ACT. For both novel and maintenance performance probes, there is a decreasing trend in
HR and GSR for participant A. (See Figure 2)
Like Participant A, Participant B’s sessions also varied throughout the three
phases of intervention, ranging from 4, 3 and 6 sessions per phase. In the resting phase,
session 3 had a higher HR compared to the other 4 sessions as Participant B reported that
they had a sports tournament. The overall average of resting HR for this participant
measured to be 68 beats per minute with GSR of 2.2. In comparison, the average HR in
baseline was 92 beats per minute with a GSR of 3. Unlike Participant A, Participant B
started intervention with both VR and ACT in every session. Participant B went through

20
the intervention phase in three phases: 1. Formal performance hall (for about 80 audience
members), 2. Formal concert hall (for 150 audience members) and 3. University concert
hall that seats 1,200 audience members.
The horizontal dotted lines on Figures 2 – 5 represent the average heart rate or
galvanic skin response per phase. For Participant A, the average resting heart rate and
baseline heart rate measured to be at 88 and 104 beats per minute. In the following four
phases of intervention, heart rate measures averaged at 91, 104, 98, and 94 beats per
minute respectively. For galvanic skin response, resting GSR and baseline GSR read at 2
and 3, while the four intervention phases averaged to be at 2.4, 2.6, 2.6, and 3.4
respectively. With the exception of the last phase of intervention, the remaining phases
averaged to be comparable to baseline readings.
For Participant B, resting heart rate and baseline heart rate averaged to 68 and 92
beats per minute. In the following 3 phases of intervention, heart rate averaged to be 90,
92, and 89 beats per minute, which similar or below baseline readings. In terms of
galvanic skin response, resting GSR and baseline GSR read at 2.2 and 3, where as
intervention measures averaged at 2.5, 2.4, and 3. These readings were also comparable
to baseline measures.
3.2 Kenny Music Performance Inventory
The Kenny Music Performance Inventory (K-MPAI) is a 40-item tool used to
measure music performance anxiety in musicians. Ackermann, Kenny, and O’Brien
(2014) suggest that scores higher than 105 may indicate higher levels of MPA.
Participant A had a total score of 129 in pre-intervention but there was a significant
decrease in scores to 94 in post-intervention. Overall, there was a significant decrease in

21
scores across all sub-categories of the K-MPAI scores for Participant A (see Figure 6).
The overall total score for Participant A went from 56% in pre-intervention to 39% in
post intervention. On the contrary, Participant B’s total score diminished from 40% to
31%.
3.3 Acceptance and Action Questionnaire-2 (AAQ-II)
AAQ-II is a seven-item assessment tool that assesses the psychological
inflexibility of an individual. Higher scores indicate higher levels of psychological
inflexibility. In baseline, Participant A had obtained scores of 23 (out of 49) and
Participant B had scores of 14. Post-intervention scores for Participant A decreased to a
score of 20 while Participant B’s scores dropped to 12 (See Figure 7).
3.4 Social Validity
Both participants rated the intervention and expressed satisfactions with goals,
procedures, and outcomes at scores of 5 (Figure 8: 1 is least satisfied and 5 is most
satisfied).

22
4.0 Discussion

MPA constitutes a risk factor for young musicians to develop high rates of
anxiety, which could ultimately impact their attitude towards music. Although anxiety
symptom reduction was not the main purpose of this study, K-MPAI scores diminished
across both participants. These results demonstrated that using Virtual Reality and
Acceptance and Commitment Therapy was an effective way to help young musicians
desensitize and reduce music performance anxiety when performing. Each session
represented a run through of a work of literature less than 5 minutes in duration. The
private instructors and principle investigator worked together to pick 3 works of similar
difficulty that the participants’ had already previously mastered. Mastered works of
repertoire were chosen to eliminate possibilities of skill acquisition. With passage of time
and with practice, musicians naturally should be improving their performance as their
skills should improve as they become more familiar with musical works.
Participants reported that they had used ACT skills independently outside of this
study in the presence of aversive or negative private events. Participants found
themselves using Noticing Five Things and Silly Songs or Voices exercises when they
were experience negative thoughts and feelings. The primary investigator and
participants checked in each session regarding their committed actions. An individual
performs in committed action by engaging in a behavior that accesses long-term
reinforcers; in simpler terms, an individual states that they are going to take the steps
needed to reach their goals. In committed action, the goal should small and achievable in
service of their values. For Participant A, the committed action was to walk on stage
without engaging in avoidant behaviors (i.e., calling in sick) while for Participant B’s

23
committed action was to perform an entire work without stopping mid-way due to errors
or mistakes.
4.1 Limitations
One potential limitation of the study could be the student-teacher relationship
between the participants and the principle investigator, which may have influenced the
results. The primary investigator has been has been working with the participants for up
to 18 months prior to this study and may have tight stimulus control over the participants
behavior. It is possible that the presence of the primary investigator may have served as a
prompt to engage in relaxation or coping strategies throughout the intervention.
A second possible imitation maybe the external environmental factors, such as the
temperature of the room, or the lights, which may have impacted results. Thus, heart rate
and galvanic response readings need to be interpreted with caution. The study tried to
control for as many external variables as possible but it is nearly impossible to control for
all. For example, an individual’s heart rate may increase due to the lighting or
temperature of the room. On stage, there are more lights that focus on the performer as
opposed to the room where the research was conducted; having the additional focused
light can increase the temperature on stage, which could have possibly influenced the
participants’ HR and GSR readings.
A final limitation could skill acquisition. In principle, an individual’s skill should
improve over time with practice. The study aimed to control for this variable by choosing
works in maintenance, that the participants already “mastered” but it could be possible
that even practicing a work in maintenance could improve a performer’s skill set. In

24
addition, the number of times “practiced performing” may have allowed for the
performer to feel less anxious each time they performed.
4.2 Future Direction and Implications
Future studies should include maintenance and generalization probes across
environments for these young performers. Using VR and ACT as a combined
intervention allowed the performers to experience performing in front of a live audience.
Although the study tested for maintenance and generalization probes in the participants’
familiar environments, future studies should test for generalization in novel
environments, as well as novel works.
In the life of a musician, there are crucial milestones for the development of
MPA. The first is a musician’s first performance, where the expectations are often
unclear. The first performance often imprints the musician’s memory with the
experience, whether it is positive or negative and those memories are often stored in great
detail (Osbourne and Kenny, 2008). Another sensitive period is during the adolescence
phase, where musicians have heightened psychological vulnerability. Additional
milestones include exams or auditions, which are crucial points for musicians who want
to embark on a professional career. Prevention to avoid manifestations of MPA begins
during early musical training for young musicians. Music teachers and instructors have
an obligation and responsibility to provide their students with various performance
conditions and experiences that help foster healthy, positive performance practice and
stage etiquette. These experiences are crucial to young musicians as musicians develop
their identity and confidence on stage.

25
Of course, there are performance constraints that are unable to be controlled for in
live performances, which can enhance MPA. This occurs with musicians in training and
also musicians who have had a long history of performing. Young musicians with MPA
may choose to forgo the art and choose another field to study because performance
anxiety is so debilitating and prevents musicians from performing their best, thus creating
negative self-perceptions about themselves as artists. Addressing music performance
anxiety in musicians has major implications because this could prevent burnout in in the
field or help alleviate some avoidant behaviors in regards to performance. There are so
many possibilities that come with being a musician, whether it is to be a soloist, chamber
musician, orchestral player, teacher, composer, studio musician, band member,
accompanist..etc. but all come with the element of performance regardless of the art.
The primary investigator observed one participant talking to other musician peers
about values and utilizing defusion strategies while waiting to perform. In one incident,
the young musicians were waiting in the green room to perform and a peer had
mentioned that they were “so scared they were going to die” and “feels like everyone is
judging me.” The student participant asked the peer, “Well, why are you performing
today? Do you like it?” and stated that, “We are human. We all feel nervous. I sing ‘I’m
so scared, I’m so scared’ in a squeaky voice because it makes me laugh a little and
reminds me why I do this…..because I love it.” In another live performance, the
participant was observed to be to be using present moment skills (i.e., soles of the feet
and 5 senses) independently prior to walking on stage. Post performance, the participant
let the investigator know that they had imagined the audience to be “naked bobble head
dolls.” No attempt was made to examine the generalization of ACT strategies from the

26
participants to peers outside of the study; even so, it seems unlikely that the musician
would have been able to use ACT strategies from the short ACT trainings throughout
sessions with the primary investigator. Although, future research could examine the
generalization effects of young musicians or children who receive ACT training.
Future research should evaluate the effects of addressing MPA in musicians prior
to their first performance. In addition, research moving forward could look into other
areas of performance including theater, dance, and even public speaking to help
individuals address their anxiety-inducing behaviors and feel more comfortable with
“performing.” This study provides initial evidence that using Virtual Reality and
Acceptance and Commitment Therapy were effective in addressing music performance
anxiety. This study represents a small step in addressing MPA in young children within
the field of Applied Behavior Analysis.

27
References

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30
List of Figures

Figure 1: Figure 1 is a small sample size of the Kenny Music Performance Anxiety
Inventory

31

Figure 2: Heart Rate measures for Participant A and B (Participant A: arrows in sessions
9 and 13: ACT sessions– starting phase 3, ACT was run every session)

32

Figure 3: Pre and Post Heart rates in intervention (Participant A: arrows in sessions 9 and
13: ACT – starting session 13, ACT was run every session)

33

Figure 4: GSR rates for Participant A and B in intervention (Participant A: arrows in
sessions 9 and 13: ACT sessions – starting session 13, ACT was run every session)

34

Figure 5: GSR rates in pre and post intervention (Participant A: arrows in sessions 9 and
13: ACT sessions – starting session 13, ACT was run every session)

35

Figure 6: K-MPAI scores in pre and post intervention - Ackermann, Kenny, and O’Brien
(2014) suggest that total scores higher than 105 may indicate higher levels of MPA

36

Figure 7: AAQ-II scores in pre and post intervention (higher scores indicate greater levels
of psychological inflexibility)

Figure 8: Social Validity measures pre and post intervention
(0 = disagree; 5 = agree)

37
Social Validity Measure for Participants
1 : least satisfied; 5 : most satisfied
I approve of the goal of addressing
performance anxiety.
1 2 3 4 5
I approve of the procedures used in this
study.
1 2 3 4 5
I believe that I am better able to manage my
performance anxiety because of
participating in this study.
1 2 3 4 5
Comments:

Figure 9: Social Validity measure – Participants

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Asset Metadata

Creator Lau, Jasmine C. (author)

Core Title Evaluating the effects of virtual reality and acceptance and commitment therapy on music performance anxiety

School College of Letters, Arts and Sciences

Degree Master of Science

Degree Program Applied Behavior Analysis

Publication Date 04/27/2020

Defense Date 03/20/2020

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag acceptance and commitment therapy,desensitization,Music Performance,OAI-PMH Harvest,virtual reality

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Cameron, Michael (committee chair), Manis, Frank (committee member), Tarbox, Jonathan (committee member)

Creator Email jasmine.c.lau@usc.edu,laujasmi@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-291237

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