One of the benefits of a career in music is working with inspiring colleagues. These individuals promote artistic growth, offer pedagogical insights, and present different perspectives on professional issues. Thomas A. Brantigan is currently Director of Traditional Music at Central Presbyterian Church in Towson, MD and provides many excellent performances to his community annually. Working with Brantigan for many years in concert settings has been a pleasure. After learning that he in fact published “The effect of beta blockade on stage fright: A controlled study,” the first study in America supporting the effectiveness beta blockers in alleviating symptoms associated with performance anxiety in 1979, I was intrigued to learn his further thoughts on the subject.1 During the past 30 years, the use of beta blockers by musicians has become common. Yet, recently beta blockers have been classified as Performance Enhancers Drugs by the World Anti-Doping Agency and its numerous affiliates including the International Olympic Committee and National Collegiate Athletic Association. Discussing the issue of beta blockers and performing artists reveals many views: some widely accept the use of these drugs as a logical medical solution while others vehemently oppose their use on several ethical grounds. Brantigan provides interesting insights in retrospect after introducing beta blockers to the community of performing artists more than 30 years ago. He opens by placing his career and research in context.
Before I get into this topic, I want to make it very clear that I am not a physician nor am I a psychologist or an ethicist. What I am is a musician who enjoys sharing music with people in an environment that I purposely make less formal and more fun than those who are soloists with a symphony orchestra.
Though I have a doctorate in organ performance, getting that degree was a constant battle with stage fright. I simply found it difficult to communicate the music as well in front of a formal audience as I could when either playing for myself or for friends. When you are more worried about a memory lapse than whether the music makes sense, you are defeated before you start.
My degrees were all prior to the Beta Blocker study, and ultimately, I found ways to get through the process by recasting the performance experience into something less formal and more fun—something that upset my professors who told me that though I was playing better than I ever had, I just wasn’t taking it as seriously as I should and obviously didn’t understand the gravity of what I should be doing. (From that last statement, perhaps one can see how I was being trained to be scared and how absurd formal conservatory training can be!)
Stage fright was particularly an issue when performing from memory, a requirement for all three of my music degrees. After researching and even experimenting with hypnosis and other “solutions,” I found a workable solution by doing the Inderal research but only after I graduated with my doctorate.
Since graduating from Northwestern (University), I spent 13 years as an organist and choral director doing many concerts and yearly solo recitals. I played frequently so performance-anxiety ultimately became a non-issue, as did beta blockers. Then, after the next 30 years as a computer nerd and corporate Chief Technology Officer, I came back to playing the organ and conducting choral and orchestral concerts. Now, I have heard it said that if I were a great musician I would have stuck with it and not left to make a better living, but the decision was more a political and economic one than artistic and had nothing to do with beta blockers or stage-fright.
I don’t consider myself a great performer at the organ though I think I play better than most, and I think that what I play generally has a style that has something to say. Now that I perform less and practice even less, I still find nerves to be an issue but mostly have learned to accept my limitations. On rare occasions, perhaps three or four times over the past ten years, I have taken a Beta Blocker, but I’m not under such pressure that I think it necessary. After all, I don’t depend on note-perfect accuracy to make a living.
Interestingly, I don’t find conducting to have nearly the same performance issues as keyboard playing. Perhaps you can get away with more as a conductor—though our typical performances are stressful in that we are always performing music with too little rehearsal time simply to fit into an available budget. It takes considerable concentration to hold everything together but not the fine motor skill of playing the organ. I do still create performance situations that I think are fun. I talk a lot to the audience and thus do things that reduce the tension that I see in many more formal and stiff performance situations. It is simply my style.
I still get calls about the Beta blocker studies—some from people interested in them and some from people who are writing something to prove how terrible such a thing is. What I have generally found is that prior to those calls, their minds are made up, and they would more likely change their religion than change their opinion about whether or not beta blockers should be considered “mind-altering” or “performance enhancing” drugs and banned from the planet.
Personally, I don’t see one’s monumental effort to get on stage in spite of physical and mental difficulties as being a great badge of courage. I listen to music because I like music and not because I want to wonder if the performer is nervous and will fall apart. I want to be supportive of musicians and not try to throw potential roadblocks in their paths. I think that beta blockers can be to a musician as Beta Enhancers can be to an asthmatic. They are medical means to a specific end that allows the patient the ability to function well in their lives.
More than 30 years have passed since you published the first medical study supporting the effectiveness of beta blockers for alleviating the symptoms of performance anxiety in 1979. Are you surprised that the FDA has still not approved beta blockers for the purpose of anxiolytic treatment? Should they?
Not surprised at all. Use of beta blockers for stage fright is something that internists all know works and freely prescribe. However, this is such a niche market for the drug that the drug companies would never spend the money it would take to make it an “on label” application. I think it is more a matter of economics than ethics or even applicability. There simply isn’t any incentive to do it.
Do you believe that all university professors/instructors should make students aware that beta blockers are a viable way of treating performance anxiety?
I think it can be dangerous for a professor to suggest it. People have been fired over this. When professors see a real issue with performance anxiety and have actively tried to work a student through the problem, then I personally think it should be something they are allowed to do but should only do so with sufficient knowledge of the potential dangers and even then to insist that the student do this through a personal physician who can screen for individuals for which problems are likely to occur.
I don’t think beta blockers should be prescribed lightly and even when prescribed should be accompanied by well thought out performance training. When I was a student, there was no discussion of the performance process and no concept that anyone could be trained to do it. It was just one more requirement to get a degree along with other requirements that may or may not have anything to do with how good a musician someone might be—memorization, for instance.
Yes, we had “solo classes” where students would perform for each other but we, or at least I, looked at these as hatchet crews where there was little support for each other and lots of criticism particularly when we were pushed into memorized performance long before we were comfortable with the piece. We all just waited for things to fall apart. Supporting each other was the last thing anyone really thought about.
What students need is the opportunity to perform for their peers often and in supportive environments to help them get through the nerves and fear of criticism. Performance should be fun. Performance shouldn’t be so special. It should not be a proof of ability but rather a sharing of something personal in a non-threatening environment. You can also read into this my solution to make it less formal and more fun though I understand that orchestral musicians don’t have any control of this.
I “beat the rap,” as it were, by informally talking with my audiences, first one-on-one and later collectively prior to and during the recital. I made it fun for them and fun for me. I programmed things that were unusual in addition to the standard repertoire. Contrast this to the approved approach where we were told to sit alone in the Green Room and contemplate the seriousness of what we were about to do. If you came out of that room with any sanity left, you were lucky!
I think you will still find people who have real problems with stage fright, and these people could benefit from beta blockers as a way to get past the nerves and retrain themselves to know they can play without them. I have seen, over the years, some players who started to take beta blockers who then felt that the medication really didn’t do anything anymore and subsequently quit taking them once they had sufficient successful experiences otherwise. I was one of those.
Are you surprised that in recent years beta blockers have been banned as a performance enhancer by organizations such as the PGA, NASCAR, Olympics, World Anti-Doping Agency, certain NCAA sports, and even the World Bridge Federation? Do believe the banning of these substances has any considerations on the ethical use of these drugs by performing artists?
No, it doesn’t surprise me though I haven’t followed any of these decisions. The word “drug” carries such extreme baggage and the concept of drugs in “performance” bring on images of bulked up athletes on steroids who are perfectly willing to destroy their bodies for their moment of fame and big dollars.
Do I equate ten million dollar steroid filled athletes with performing artists? Sorry, but no. Beta blockers, when used correctly, aren’t going to kill anyone or destroy their bodies like steroids do to athletes. The economics of the situation are vastly different too. Though we may be competing for a job, we certainly aren’t competing for millions—but I don’t discount the importance of the job.
I think an ethics case can be mounted about all of this, but it is a very difficult set of questions, circumstances, and issues. For instance:
- People may have high blood pressure for various reasons and can be given Beta Blockers to control this. Does this mean that those with high blood pressure cannot be professional musicians?
- If an athlete has asthma, should they be prevented from taking a Beta Enhancer so they can breathe outside during a sports event? (Actually, I don’t know whether that is considered legal or not anyway!)
- If someone suffers from epilepsy, should they be allowed to take a medication to prevent this from happening during a performance? After all, doesn’t that give an advantage to them since others without epilepsy don’t take them?
- If someone can’t metabolize calcium and needs to supplement this, should they be prevented from some activity because without it they would have brittle bones?
- The list can go on . . .
There have been many publications supporting the use of beta blockers after your original study. However, there have been other publications that cited some concerns, such the excerpt below in a 1985 ICSOM article:
The June 22, 1984 issue of the Medical Letter on Drugs and Therapeutics notes that propanolol “is usually well tolerated but is potentially dangerous in patients with heart disease or asthma, since even low doses can cause bradycardia, congestive failure, or life threatening bronchospasm. Fatigue, depression, nightmares, and impaired sexual function are fairly common adverse effects of continued use.”
Dr. Frank Wilson, in a paper entitled “Inderal for Stage Fright?, further notes that Inderal can lower blood pressure to levels that cause fainting, can complicate the management of diabetes, can alter the body’s reaction to agents used for general anesthesia, and has caused fatalities in individuals who have suddenly discontinued its use.2
Do you have any concerns that the use of beta blockers could be too prevalent? Are musicians taking the easy way out and not utilizing other methods of coping with performance anxiety and as a result being exposed to side effects and other possible medical consequences? Is it possible that musicians who do not take beta blockers are at a disadvantage in an increasingly competitive job market?
First, let me point out that in every article we published about beta blockers and stage fright we pointed out that anyone with asthma could very well die if they took them and that no one should take them without consulting their own physician. Passing around a prescription drug willy-nilly is both foolish and dangerous. I don’t know Dr. Wilson’s article but he reinforces my point that physicians should control who can and can’t take the drug and even then should do so only with sufficient knowledge of both the benefits and risks involved.
Secondly, if I remember correctly, the long term issues with beta blockers are from groups that are taking them for other reasons where the normal dosage is ten or twenty times what is effective for performance anxiety and where they are taking large doses over long periods of time.
Beta blockers for stage fright are small doses on only an occasional basis. If someone is taking them constantly then I would question their use of them. Any drug can be abused. Too much Tylenol can kill you.
Are musicians that don’t take the drug at a disadvantage? You can look at this in several ways. Perhaps, those who don’t take it are at an advantage in that they find it possible to perform well without it so can perform more consistently and with greater confidence. There are people who perform flawlessly without them.
I have never met anyone taking them that does so “just in case”. If there weren’t a problem, they wouldn’t be taking them. I have also never met anyone who was a better musician because of beta blockers. Beta blockers simply tone down the nerves on a situational basis and don’t provide anyone with a better sense of phrase or rhythm or knowledge of the composer’s style or message.
When looking at the differences between almost any attribute of one individual versus another, it seems that the differences are not binary. One is not simply nervous or rock solid, smart or dumb. I don’t believe people are totally male or totally female either though there is certainly a lot of religious and political baggage wrapped around that. All of these things are spectrums and continuums between potential extremes. Beta blockers, when used correctly, can simply alleviate some of those extremes for people where they pose a real problem.
Are you surprised to learn that there was a university professor (Ruth Ann McClain who taught flute at Rhodes College in Memphis) who was terminated for recommending beta blockers to her students?
I was disappointed to learn this. I originally learned of this from someone who was writing an article saying that the only way to solve performance anxiety was Freudian psychoanalysis. Then again, that same person couldn’t provide any statistics to prove that even after lengthy and expensive treatments, psychoanalysis would have any beneficial result in “curing” the problem.
I’m not convinced that performance anxiety is a “curable” disease. People are just different. Some people are born with a musical sense while others are tone deaf. Some people are born athletes while others are anything from couch potato to being an invalid. Some people seem to be born with inferiority complexes while others are so sure of themselves that even when dead wrong they will fight you to the death to get you to accept their opinion.
A lot of performance-anxiety may come from conditioning and should thus be able to be reversed through conditioning. Others may simply have physical disposition to shaking and nerves. People are different.
Given that there is a growing presence of drug use in America, concerns exist that many drugs are being overused including beta blockers. For example, a recent study showed that 34% of students at a large state institution used Ritalin without a doctor’s prescription to improve test performance. A 1987 study by ICSOM revealed that 70% of orchestral musicians using Beta Blocker were doing so without a prescription. If professionals openly use beta blockers, how will this use not expand to university students and possibly high school students as they face increasing challenges through a competitive environment? Should there be a line drawn somewhere? Do you have any advice for educators coping with this dilemma?
Any and every drug can and will be abused particularly in a society where drug use seems to be recreational as much as anything. But do you then say to a Glen Gould that he should not be a musician because he suffers from stage-fright. The world may lose great talent that it could otherwise benefit from. People may not reach a potential that they could otherwise achieve.
No, people should not use beta blockers without a prescription and personal consultation with a physician. Do I personally think that a musician should take beta blockers every day to perform? No. Do I have a real reason for that opinion? Well, no; I’m biased against the use of drugs, too. It may not matter but even I don’t think one should be that dependent on something—but that’s not fair either since I don’t depend on performance to feed my family.
Perhaps, that’s the real issue. Those who don’t suffer from stage fright want to hold on to that advantage by preventing competitors from more easily overcoming theirs. Life is like that. We all want to win. If I have to accuse you of bad ethics to give me an edge, then so be it. If the issue is feeding my family versus your feeding yours, I want to feed mine.
Where should the line be drawn? I’m not the one who can answer that. Without adequate research on low dosages of beta blockers, something that economically will never happen, there can be no definitive statements made medically, but the argument isn’t generally medical.
The prescribed use of beta blockers for heart conditions usually requires patients to be on a steady dose of medication. There have been some studies indicating long-term side effects or even a rebound effect of hypertension when individuals ceased use of the beta blockers. Musicians use the drug when necessary for performance anxiety and hence go on and off the drug (possibly over and over again for years). Are you aware of any medical studies where the effects of frequently going on and off the medication were measured? Do you have any concerns about musicians continually going on and off the medication?
The issue here is dosage. Those taking beta blockers for heart conditions take substantially larger dosages than the 10mg typically needed for the performance effect and even then these small doses are not constant. No, I don’t know of medical studies tracking musicians who use beta blockers though it would be interesting to see such results. Again, I don’t see it as economically feasible for this to ever be done.
In conclusion, I was once interviewed on the Canadian version of “All Things Considered” and the topic was beta blockers since someone found that they were being used by one of the professional Canadian orchestras. They essentially told me I was a drug pusher and should never have done the research because now that people know it works, they will use it. Shouldn’t I be ashamed?
I did some early research on beta blockers because I personally needed for a way for me, a professional musician, to perform better and to enjoy my life as a musician. I put the pieces together that led me to beta blockers as a potential solution, enlisted the help of my older brother, a physician with great credentials in cardiac medicine, and set up formal double blind studies to determine whether I was or was not correct. Obviously, I was correct in what it could do. We were not trying to create a drug sub-culture among professional musicians. Had we not done it, someone else would have. In fact, the same research was conducted in Great Britain.
Knowledge is a good thing but it doesn’t eliminate the need for responsibility in the use of that knowledge. No, I don’t think that beta blockers should be banned but no, I also don’t think they should be passed around as candy. It is just too dangerous to do so.
Particularly in a university setting, I don’t believe that professors should be fired for sharing their knowledge and caring about their students. In a symphony orchestra or any other employment situation, I guess the owners should be able to declare themselves a Beta Blocker free zone if they think this will make them a better orchestra though I suspect that wouldn’t be the basis for the policy.
I am fortunate that I am not in a position where my job depends on it. I am also pleased to see that you are actively discussing and researching the issue. Only with the full light of day will truth be found.
Do you have any further thoughts or insights you would like to share?
There is so much wrapped around it that it is difficult to get a handle on what the actual issue is—medical, ethical, religious, competitiveness. Just as with religion and politics, the issue is burdened by anything anyone can think of whether it is pertinent or not.
In the race issue, the US is finally working itself through the issue making it illegal if not unethical to discriminate on race—though it is still done and there are still white supremacists who would argue this even on a religious basis. The gender issue is also fairly resolved though still prevalent. It is illegal to discriminate based on gender but females are still paid less than males. On the issue of sexual preference we are much earlier in the process where legal issues are half resolved and half being debated, religion has chimed in as it always does (if you aren’t like me you are a sinner), and ethics debates have hardly even started. Athletes and drugs have pushed on the medical and ethical arguments and passed localized rules to combat the issues while drugs in general are controlled by federal and state laws. All of these have competitive components—we don’t want someone else to have an advantage that we don’t already have.
Specific organizations can determine for themselves what they want to do but only in certain cases. You can’t officially base hiring decisions on gender or race but it is sketchy in terms of sexual preference. Organizations can ban performance-altering drugs and do so legally. I suppose they can also ban beta blockers if they so choose but I would hope they would be out front about it. I disagree wholeheartedly with universities banning the discussion of beta blockers and especially firing someone for suggesting that they may help someone. Banning the open dissemination of knowledge just leads to uninformed abuse of something like this.
“Beta blockers and musicians” is too small a topic to ever be resolved through medical research. I suspect organizations will probably more and more ban them just as a knee-jerk reaction to athletes and steroids but I think that would be a shame. I firmly believe this is a medical issue and should remain so and not get tied up in legal, ethical, or religious baggage. My original research was not to start a drug culture but just to advance medical knowledge of an issue I was personally involved in.
Another interesting anecdote that came to mind was a communication we got 30 years ago from an Air Force jet pilot who wrote to thank us for the research. He was very nervous about his check-flights and was taking Valium before these tests. He claimed that his check-flights were all about criticism while his normal flights were all about his concentration on the job at hand. He found that 10mg of a beta blocker solved his problem. At least, that is one less pilot flying around in a fighter plane while taking Valium!
Notes
1Brantigan, Joseph, and Brantigan, “The effect of beta blockade on stage fright: A controlled study,” 227.
2Senza Sordino. “Concern Over Widespread Use of Beta-Blockers,” 2.
Bibliography
Brantigan, Thomas A., Neil Joseph, Charles O. Brantigan. “The effect of beta blockade on stage fright: A controlled study.” Rocky Mountain Medical Journal 76, no. 5 (September-October 1979): 227-233.
Senza Sordino. “Concern Over Widespread Use of Beta-Blockers.” 23, no. 3 (February 1985): 2.
Wilson, Frank R. “Music and medicine: Inderal for stage fright?” The Piano Quarterly, 134 (1986): 30-35. Quoted in Senza Sordino. “Concern Over Widespread Use of Beta-Blockers.” 23, no. 3 (February 1985): 2.