Mental Health and Wellbeing Services for Performing Artists: Guidance for the Performing Arts Sector

The prevalence of mental health problems is considerably higher in the performing artist community than in the general population, and suicide rates are well above the national average. As the performing arts industry increasingly recognises the need to support artists with mental health problems, questions about the types of services required are being posed.

One of the most comprehensive pieces of research in this field, undertaken by academics at Victoria University, Melbourne in collaboration with a charity seeking to improve mental health in the Australian entertainment industry, paints a worrying picture. While the authors’ recommendations recognise the passion that performing artists and those who work alongside them, from directors to crew, have for their creative work, the industry emerges as a very unsupportive environment. Survey respondents reported sleep disturbance, lack of services, high levels of drug and alcohol use, anxiety and depression. Suicidal ideation was six times greater, suicide planning four times greater and suicide attempts more than double those of the general population. The Office of National Statistics records for suicide in England, and the recent survey carried out by Help Musicians UK for Music Minds Matter, indicate that the performing arts industry in the UK, too, could be described as a high risk environment.

A survey of over 5000 people working in film and TV, including actors, was conducted by BAPAM and Equity in 2015 on behalf of a wider group including Spotlight and the Stage. The survey found that, for 40% of those who responded, poor mental health had had an impact on their career. Mental health problems were most commonly attributed to financial issues (56%), lack of work in the performing arts (52%), and uncertainty/lack of control over career (52%). 85% of respondents who had reported a mental health problem had worked in the previous six months. There are many people working in the industry who have a mental health problem. These findings resulted in the ArtsMinds web resource.

The British Association for Performing Arts Medicine (BAPAM) offers clinical services and telephone advice to performing artists and has recently reviewed calls to its helpline requesting psychosocial support in 2017 and 2018. Analysis of these calls shows that 35% of patients presented with performance anxiety (“stage fright”) and a further 35% with underlying anxiety and depression. A total of 12% reported a history of psychiatric care. Many of the performing artists who called the helpline revealed that they also needed advice and/or treatment for physical problems, from which it can be inferred that psychosocial and physical difficulties are associated if not mutually causative. It is clear, therefore, that a wide spectrum of support is required to meet performing artists’ needs, which are extensive and can be complex.

It is known that many classical musicians use beta blockers to help with performance anxiety; a recent study in Australia found that they were used by 31% of orchestral musicians. The same study revealed high levels of broader anxiety issues and depression among these musicians. The authors suggest that the link between music performance anxiety and depression needs to be investigated further.

Van den Eynde’s research showed that prevalence of mental ill health is higher for younger people, with the 18-24, and 25-29 age categories significantly higher in anxiety symptoms than the older groups. She highlights the uncertainty and potential vulnerability of the younger adult members of the profession who are trying to establish themselves but do not have the depth of experience to manage this uncertainty. A recent analysis of the Higher Education Statistics Agency student statistics for 2018 showed that there are 55,000 students undertaking some form of performing arts programme of study. Practitioners working in the field commonly report that performing artists often start struggling with their mental health whilst in a performing arts higher education programme

Freelance work in general is associated with poor mental health. Respondents to our consultation on this guidance also cited the external political environment as a cause of stress. Performing artists and professionals have different stresses on them which are linked to their level and the cyclical nature of their careers. Performing artists also face other challenges relating to their profession. Like many athletes who use their bodies intensively, over 70% of performers suffer physical problems that need specialist treatment and which are often not picked up by GPs. Freelance performers of- ten have no choice other than to attempt to maintain their careers, continuing to play or sing while suffering from and managing physical symptoms. These are exacerbated by and contribute to psychosocial issues. There is evidence to suggest that physical and psychological problems are interlinked. GPs also report a rise in medically unexplained physical symptoms that could be triggered by trauma or stress, or have more complex underlying factors. In addition, the environment (e.g. travelling, working late, isolation, experiencing lack of sleep and a poor diet) and the high demands performers make on themselves can all lead, potentially, to deteriorating mental health. Touring schedules often mean that healthcare is not available when most needed, and long waiting times are reported for NHS services. In many of the surveys conducted in this area, and in the accounts of performers, stigma is often mentioned as a reason not to tell colleagues about health problems or to seek help when needed.

Mental health and psychological wellbeing are best represented as a continuum. Poor health and wellbeing include very severe and complex conditions such as psychosis and schizophrenia as well as common albeit no less important mental health problems including depression and performance anxiety. These may result, for performers, from a combination of work-related stressors and psychological vulnerability. It may be sufficient for some performers to learn skills to help them recognise and alleviate work-related stress and foster resilience. For performers with more complex needs, a combination of skills building, psycho-education and therapy will help mitigate both underlying difficulties and current stressors. Medication can also play an important role. Performers have a wide variety of needs. Not everyone needs long term therapy, but an initial clinical assessment is vital to ensure that performers are referred to the appropriate service, and many will benefit from receiving support from a range of clinicians with different kinds of expertise.

Some people will experience just one episode of mental ill-health in their lives. Of those who receive a brief intervention, half will recover and never have another one. Others, however, experience recurrent episodes and will continue to do so through their lives even though they may be well for significant periods of time. It is important that performing artists who experience challenges to their mental health are clinically assessed by an appropriately qualified professional to ensure they access the right care, as soon as possible, without having to be placed on a long waiting list. Where brief interventions are indicated, performers may need access to practitioners who understand the needs of performing artists and have experience of working with them. Practitioners, regardless of their professional discipline, should be able to access support and expert advice from mental health specialists when more complex issues arise, and refer clients on to them if necessary.

Clinical governance protocols should be agreed between providers to ensure quality of services. Commissioners and providers should be looking for feedback from patients and be confident that incidents, when they arise, are handled effectively and learned from; that patients’ complaints are managed; and that patients’ data is protected and transmitted safely when appropriate with the individual patient’s consent. The BAPAM clinic governance toolkit provides more information.

The Guidance

This guidance has been developed by BAPAM’s Psychosocial Working Group, which brings together clinicians, including doctors, psychologists, psychotherapists and counsellors, with charities working with performing artists to support mental health and well-being, and academics undertaking research in this area. Together, these individuals and organisations aim to make a real difference to the quality of services available. The purpose of the group is to provide a forum in which approaches to prevention, care and support can be discussed, and clinical leadership can be provided for developing and maintaining an evidence-based service designed to support performing artists with issues related to performance-related mental health issues. The group has drawn on the clinical evidence base, including National Institute for Clinical Excellence (NICE) guidelines, which contain reviews of published evidence for healthcare interventions from clinical and cost-effectiveness perspectives, to produce this guidance for the performing arts sector.

There are seven recommendations which have been resulted from the work. Some apply to the performance environment, some to performers and performance professionals and some to clinical practice. Combined, they give a picture of what good practice looks like and we hope that this will be helpful to patients and their families and carers looking for support, to those commissioning mental health services for the sector, to those teaching performers and to practitioners providing services.