On the Neural Mechanisms of Music
Therapy in Mental Health Care: Literature
Review and Clinical Implications
ALEXANDER W.LEGGE, MMT
ABSTRACT: This article reviews literature from various disciplines in
order to provide a conceptual framework for the neural mechanisms
of music therapy in mental health treatment. Literature on the neuro-
biology of music-mediated emotion reveals distinct roles of several
anatomical structures and neurotransmitters, many of which are also
implicated in mental health disorders. Musics impact on these neu-
ral correlates is dependent upon several factors, such as harmonic
structure, autobiographical relevance, the presence of multimodal
stimuli, and level of music training. Music is also capable of activat-
ing specific neural networks through either music listening or active
music-making, with distinct networks involved in different types of
musical experiences. This article explores the neurobiological basis
of music-induced emotion associated with each of the four types of
music therapy experiencesreceptive, re-creative, improvisational,
and compositional. Clinical implications for music therapists in men-
tal health settings are discussed. Music is also a known modulator
of the neurochemistry of trust and social affiliation, highlighting its
ability to help establish therapeutic connections. Relevant literature
is examined regarding the neural mechanisms of effective music ther-
apy and psychotherapy interventions in mental health treatment.
Introduction
How can music therapy contribute to emotional health
from a neurobiological perspective? Musics role in mediating
emotions has been investigated for decades by researchers in
psychology, neuroscience, and music therapy, among other
disciplines. However, many questions remain largely unan-
sweredparticularly those related to the potential of music
to promote healthy emotion regulation. This is especially rel-
evant to music therapists in mental health settings.
Psychology researchers have already provided models to
help understand the connection between music and emotions.
Juslin and Vstfjll (2008) describe seven ways in which musi-
cal stimuli can induce emotions. First, musical elements can
trigger brainstem reflexes related to survival mechanisms. For
instance, a fast tempo or a surprisingly loud sound might cause
arousal. Second, music that is repeatedly paired with positive
or negative stimuli can be classically conditioned to induce
emotions. Third, features of music that mimic other emotional
Alexander Legge recently earned his MMT from Loyola University in New Orleans,
completing his internship at Beth Abraham nursing home and rehabilitation center
in New York City. He is currently coordinating research at Columbia Universitys
Comprehensive Epilepsy Center and will be beginning medical school in the fall.
E-mail: alexlegge@gmail.com
the American Music Therapy Association 2015. All rights reserved.
For permissions, please e-mail: journals.permissions@oup.com
doi:10.1093/mtp/miv025
Advance Access publication June 26, 2015
Music Therapy Perspectives, 33(2), 2015, 128141
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Columbia Comprehensive Epilepsy Center
contexts can lead to a contagious effect; consider the slow,
soft voice of a violin and emotions linked to slow, soft speech.
Fourth, music can lead to new mental imagery. Fifth, music
can also conjure episodic memories, or old mental imagery.
Sixth, features of musical syntax can mediate emotions through
musical expectancy, such as a chord progression without har-
monic resolution. Finally, the presence of music can directly
affect personal/therapeutic goals of any listener, such as the
sound of sedative music helping someone fall asleep.
Juslin and Vstfjlls (2008) model provides a psychological
foundation for music-induced emotions. However, it does not
account for emotional processes that uniquely affect active
music-making or the interpersonal emotional possibilities of
group/dyad music therapy. Nor does it explain (or attempt to
explain) the connections between music-induced emotions
and non-musical components of therapeutic practice, such as
verbal processing and the client-therapist relationship.
Similarly, the neurobiology literature is primarily focused on
emotional mechanisms during music listening, although some
investigators have also explored active music-making. Chanda
and Levitin (2013) summarize evidence that demonstrates
how music can influence neurochemistry in four ways. First,
music listening has been shown to affect neurotransmission
in the brains reward pathways. Second, music can influence
hormonal levels via the hypothalamic-pituitary axis. Listening
to relaxing music, for instance, has been shown to decrease
blood levels of cortisola marker for stress. There is also evi-
dence for decreased cortisol following music therapy inter-
ventions, such as Guided Imagery and Music (Burns, 1999;
McKinney, Antoni, Kumar, Tims, & McCabe, 1997). Third,
Chanda and Levitin cite drum circle studies that have shown
increased immunological measures among participantssuch
as increased natural killer T-cells and 5-DHA-to-cortisol ratio
(Bittman etal., 2001). Fourth and finally, the authors describe
evidence of musics impact on hormones related to social affili-
ation (to be addressed further herein). Although their literature
review does not focus specifically on music-induced emotions
or mental health treatment settings, the biological mechanisms
they discuss have applications in both of these realms.
Within the body of music therapy literature, researchers
have repeatedly demonstrated that music-based interventions
can affect emotional patterns in individuals receiving men-
tal health treatment (Bensimon, Amir, & Wolf, 2008; Bloch,
Reshef, Vadas, Haliba, & Ziv, 2010; Carr etal., 2012; Cevasco,
Kennedy, & Generally, 2005; Hammer, 1996; Kerr, Walsh, &
Marshall, 2001). But what mechanisms of music-induced
emotions are most responsible for the efficacy of music ther-
apy interventions? How do these mechanisms differ between
 On The Neural Mechanisms of Music Therapy in Mental Health Care
different music therapy interventions? And how can the neuro-
biological effects of music influence the client-therapist rela-
tionship? These questions reflect gaps in the scientific litera-
ture, none of which can be answered easily and all of which
demand an interdisciplinary approach.
Sena Moore (2013) began tackling several of these ques-
tions in a systematic review of the neuroscience of music-
based emotion regulation, most of which examines studies
of receptive music experiences. Akey finding was that listen-
ing to pleasurable or happy-sounding music activated brain
areas involved in the cognitive control of emotion regulation
(the anterior cingulate cortex, orbitofrontal cortex, and lateral
prefrontal cortex) while deactivating the amygdala. Interested
readers are encouraged to refer to Sena Moores article for
more information and music therapy implications.
The purpose of the present article is to examine literature
from various disciplines in order to provide a conceptual
framework for the neural mechanisms of music therapy in
mental health. To establish such a conceptual framework,
this article will examine neural mechanisms of music-
induced emotion within each of the four major types of
music therapy experiencesreceptive, re-creative, improvi-
sational, and compositional (Bruscia, 1998)in addition to
their clinical implications for different music therapy inter-
ventions. The focus on mental health is especially important
because both music and mental health are closely linked
to emotion. Several mental health disorders are character-
ized by deficits in emotion processing, emotion perception,
and emotion regulation (Atherton, Nevels, & Moore, 2015;
Fulford, Peckham, Johnson, & Johnson, 2014; Maat et al.,
2015). In particular, emotion regulation has been implicated
as a cornerstone of mental health (Berking & Wupperman,
2012; Gross & Muoz, 1995). This article will also exam-
ine neurobiological processes involved during the develop-
ment of the client-therapist relationship and how music can
contribute to these processes. Through a more complete bio-
logical understanding of music-based interventions and the
therapeutic relationship, music therapists working in mental
health settings will be better equipped to plan client-oriented
objectives and interventions, measure the efficacy of music
therapy sessions, and advocate for the importance of music
therapy in an ever-changing system of mental health care.
Table 1 summarizes possible neural mechanisms of music
therapy for a variety of specific mental health goal areas, all
of which will be discussed herein. However, before this can
be accomplished, a brief overview of the neurobiology of
emotion is necessary.
Neurobiology of Emotion
Several neuroanatomical structures and neurotransmitters
have been implicated in specific aspects of emotion. These
neural correlates are closely tied to mental health because
their functions are often most apparent in instances of dys-
function. Consult Figure1 to locate several specific neuroana-
tomical structures. Aglossary of key neurobiological terms is
also available.
Prefrontal cortex. The prefrontal cortex (PFC) plays key
roles in emotional processing and emotion perception. The
PFC is part of the frontal lobe and can be divided into different
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129
substructures. Two subsections of the PFC are especially rel-
evant in emotion: the medial PFC (mPFC) and the dorsolateral
PFC (dlPFC).
The mPFC appears to be particularly active during emo-
tion processing. Activation in the mPFC has been found in a
large variety of emotional contexts, independent of emotional
valence and regardless of whether an emotion is coupled with
cognitive tasks (Phan, Wager, Taylor, & Liberzon, 2002). The
mPFC is also part of a larger default mode network, which
includes parts of the temporal, parietal, and cingulate cortices.
The default mode network is important for introspective emo-
tional processes, as evidenced by its activation during self-
referential tasks and deactivation during externally oriented
tasks (Raichle etal., 2001). Reduced gray matter in the mPFC
has also been linked to mood disorders and disturbances of
the reward system (Soares & Mann, 1997).
The dorsolateral part of the PFC (dlPFC) appears to serve
different functions than the mPFC. In particular, the dlPFC
has been implicated in cognitive tasks related to emo-
tional perception, such as moral decision-making (Greene,
Sommerville, Nystrom, Darley, & Cohen, 2001). Note the
distinction between the dlPFC (more active during cogni-
tive-emotional perception in response to external stimuli)
and the mPFC (more active during internal emotional
processing).
Amygdala. The amygdala, a bilateral structure of the limbic
system located within the temporal lobes, is strongly associ-
ated with fear and processing of unpleasant emotional stimuli
(Phan etal., 2002). This includes aversive, unpleasant, and/or
fearful musical stimuli. The amygdala is activated in response
to unpleasant music listening and deactivated in response to
pleasant music listening (Chanda & Levitin, 2013; Koelsch,
Fritz, von Cramon, Mller, & Friederici, 2006). Damage to
the amygdala can also lead to impaired recognition of fearful
music (Koelsch, 2009). Nearby structures are also related, fur-
ther underlining the central role of the amygdala; in particular,
connections to the subgenual and pregenual anterior cingulate
cortex have been implicated in both regulation and intensifi-
cation of negative emotional responses, although their exact
roles are unclear (Drevets, 2000; Holzschneider & Mulert,
2011; Lanius, Bluhm, Lanius, & Pain, 2006). In mental health
research, hyperactivity of the amygdala has been implicated
in depression, bipolar disorder, and post-traumatic stress dis-
order (PTSD) (Drevets, 2000; Lanius etal., 2006; Zhang etal.,
2011). In depression in particular, increased metabolism and
blood flow in the amygdala are correlated with the severity of
depression (Drevets, 2000).
Sena Moores (2013) systematic literature review revealed
a broader musical theme for the amygdala: it seems to play
a key role in processing musical stimuli containing fea-
tures consistent with a potential threatespecially musical
stimuli that are unpleasant, new, surprising, or complicated.
Moreover, she provides an important clinical suggestion
based on her findings: music therapists trying to establish cli-
ent comfort might want to avoid music with these features,
thereby ensuring minimal amygdala-based activity. On the
other hand, some music therapy interventions may be most
effective when client emotions are intensified; these may be
instances when amygdala activity is more desirable (Sena
Moore, 2013).
 130 Music Therapy Perspectives (2015), Vol. 33

Table1
Evidence-Suggested Neural Mechanisms Involved in Music Therapy (MT) and Implications for Mental Health Treatment

Goal Areas and Components of MT Possible Neurobiological

Interventions
Establishing client comfort early in
therapeutic process
Developing trust in client-therapist
relationship
Selecting appropriate instruments/roles
during group music-making activities
Accessing client emotions through
referential MT interventions
Increasing reminiscence through
autobiographically relevant music
Inducing musical pleasure
Processing self-concept through
improvisation
Changing behavioral patterns
Compositional interventions
Improving social functioning
Mechanisms in MT
Emotionally positive music leads to
deactivation of amygdala (Chanda &
Levitin, 2013; Koelsch etal., 2006)
Music and speech mediate oxytocin,
cortisol, and vasopressin (Bittman
etal., 2001; Burns, 1999; Burns
etal., 2001; Nilsson, 2009; Seltzer
etal., 2010)
Musicians and non-musicians invoke
similar neural strategies for simple
musical tasks but different neural
strategies for challenging musical
tasks (Zarate & Zatorre, 2008)
Emotions from multisensory stimuli
mediated by limbic system and
dlPFC (Baumgartner etal., 2006;
Eldar etal., 2007)
Specific harmonic changes in
autobiographically relevant music
activate music memory network
consisting of left mPFC, left
ventrolateral PFC, and left lingual
gyrus (Janata, 2009)
Preferred music activates reward
system: release of dopamine in
ventral striatum leads to release
of endogenous opioids, resulting
in pleasure sensation (Chanda &
Levitin, 2013; Koelsch etal., 2006;
Salimpoor etal., 2011)
Activation in mPFC and deactivation
of dlPFC (Limb & Braun, 2008)
Music-induced dopamine
activity leads to stronger synaptic
connections, reinforcing new
behaviors (Stegemller, 2014)
Widespread neural networks
involved. Several neural strategies
are possible (Shah etal., 2013)
Music and speech mediate increases
in baseline oxytocin levels (Dai
etal., 2012; Nilsson, 2009)
Implications for Mental Health Treatment
Sad and unpleasant music may be
contraindicated during early stages of MT
Negative emotional valence of music is
not solely dependent on dissonance
May be especially important to use
emotionally positive music in populations
with hyperactive amygdala activity: PTSD,
depression, and bipolar disorder
Hormonal changes are most subject to
changes from auditory communication,
underlining crucial roles of music and verbal
processing
Group cohesion may be more easily
accomplished when client roles reflect level
of music training
Pairing music with concrete referents helps
enhance emotion processing
Some harmonic changes may be more
important than others in music-induced
memories
Music memory network may be less
functional in some clients
Music can act as an alternative source
of reward system activation for clients in
substance abuse rehabilitation
Self-reflective improvisation is probably most
effective when clients are familiar with some
structural features of the music
Client-preferred music is effective at inducing
dopamine activity (Salimpoor etal., 2011),
and thus can support neuroplasticity and
learning
Widespread neural activity underlines
high cognitive demand of compositional
interventions
Could be especially valuable for treatment of
social isolation symptoms in schizophrenia
and PTSD

Some literature suggests that the amygdala is a mediator of
positive emotions as well, particularly in the case of a positive
stimulus leading to increased arousal (Davis & Whalen, 2001).
Furthermore, the left and right amygdalae may have different
roles. Direct stimulation of the right amygdala has been shown
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to increase negative-valence emotions, while direct stimula-
tion of the left amygdala has been shown to increase emotions
of both positive and negative valence (Lanteaume etal., 2007).
Frontal alpha asymmetry. Another interesting neuroanatom-
ical feature of emotional perception is an apparent difference
 On The Neural Mechanisms of Music Therapy in Mental Health Care
Figure1. Approximate locations of relevant neuroanatomical areas (side view of right hemisphere). Key: ACC: anterior cingulate cortex; Amy:
amygdala; HC: hippocampus; HT: hypothalamus; NAc: nucleus accumbens; PFC: prefrontal cortex (medial aspect shown in figure); Pit: pituitary
gland; SN: substantia nigra; Figure adapted from clker.com (free public domain clip art)
between right and left frontal lobe activity in response to dif-
ferent types of emotional stimuli. Specifically, electroencepha-
lography (EEG) recordings show more left frontal alpha activ-
ity upon exposure to positive emotional stimuli and more right
frontal alpha activity upon exposure negative emotional stim-
uli (Deldin & Chiu, 2005). This also applies to musical stim-
uli, which lead to such asymmetrical alpha activity accord-
ing to emotional valence of the music (Schmidt & Trainor,
2001). Additionally, individuals with depression often exhibit
a baseline pattern of asymmetrical activity (right > left). In
other words, less left-sided frontal activity compared to right-
sided frontal activity indicates hyper-reactivity in response
to negative emotional stimuli. Such asymmetrical activation
is a marker for depression. Because the asymmetry is mostly
detectable in the alpha frequency band of EEG data, it is
known as frontal alpha asymmetry (FAA) (Deldin & Chiu,
2005). Note that the left/positive and right/negative patterns of
emotional valence in FAA are not necessarily related to similar
valence relationships found in the left and right amygdalae.
Reward system structures and neurotransmitters. The
reward system represents another well-studied neural circuit
involving specific structures and neurotransmitters. The neu-
rotransmitter dopamine is believed to mediate reward-seeking
behaviors. In the nucleus accumbens, a substructure of the
ventral striatum of the basal ganglia, the neurotransmitter
dopamine leads to the release of endogenous opioids. The
release of these opioids results in the sensation of pleasure.
Dysfunction of this reward circuitry has been repeatedly
implicated in addiction (Sweet, Amlung, & MacKillop, 2013;
Wong, Brasic, Gean, & Nandi, 2013). Low levels of seroto-
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of pleasuremay be a predictor of addiction (Wong et al.,
2013). Low serotonin levels are also a marker for depression
(Zipursky, Meyer, & Verhoeff, 2007).
Oxytocin and vasopressin. Although their roles are less
understood, recent research has implicated two neuroen-
docrine hormonesoxytocin and vasopressinin social
affiliation and trust. Both hormones are synthesized in the
hypothalamus, released into the bloodstream from the pos-
terior pituitary gland, and serve other important roles as well;
vasopressin is an antidiuretic and increases blood pressure,
while oxytocin causes uterine dilation during birth and milk
ejection during nursing. In non-human studies, oxytocin and
vasopressin have been shown to act as neuromodulators that
link social affiliation to reward pathways. In human research,
variations in a vasopressin receptor gene have been associ-
ated with interpersonal skills, pair-bonding, and empathy.
Oxytocin, meanwhile, has been shown to facilitate empathy,
eye contact, generosity, and face memory; it is also associated
with reduced amygdala activation after a threatening stimulus.
Additionally, studies in neuroeconomics have demonstrated
increases in financial trust toward investors and generosity
toward peers following intranasal administration of oxytocin
(Kosfeld, Heinrichs, Zak, Fischbacher, & Fehr, 2005; Zak,
Stanton, & Ahmadi, 2007).
Oxytocin and vasopressin also have important implications
in mental health disorders and treatment. For instance, higher
oxytocin levels are associated with treatment response in
social anxiety disorder (Insel, 2010). Individuals with Williams
syndrome, often characterized by unusually trusting behaviors
toward strangers, have higher levels of both oxytocin and vas-
opressin compared to controls (Dai etal., 2012). And a 2008
 132
study revealed larger variability in oxytocin levels among a
group of depressed women (Cyranowski et al., 2008). Low
oxytocin and/or reduced sensitivity to oxytocin may also be
involved in symptoms of social isolation common in schizo-
phrenia and PTSD (Keri, Kiss, & Kelemen, 2009; Olff et al.,
2014).
Neural Mechanisms Underlying Common
Music Therapy Experiences
Receptive Music Experiences
As mentioned above, most neurobiological investigations
of music-induced emotions have explored music listening
experiences. Their findings are broad and will not be exhaus-
tively discussed here. However, several studies have immedi-
ate implications for music therapists in mental health settings.
Emotion responses to music listening. Many neuroimaging
studies have compared emotional responses to different musi-
cal stimuli. For instance, Koelsch et al. (2006) performed a
functional magnetic resonance imaging (fMRI) study in which
normal adult participants heard pleasant excerpts of classi-
cal music and electronically modified unpleasant versions
of the same excerpts. The unpleasant excerpts led to activation
in the amygdala; this is consistent with the amygdalas role
in processing fear and novel unpleasant stimuli. Similarly, the
pleasant music excerpts resulted in activation of the ventral
striatum (part of the reward system), as would be predicted
in instances of reward-based pleasure. Interestingly, another
brain region was also activated during the pleasant excerpts:
the Rolandic operculum, a part of the motor cortex that nor-
mally controls the larynx. It is possible that this finding rep-
resented participants desire to sing along with the pleasant
excerpts. If so, it could help explain a common occurrence in
music therapy sessionsthe tendency of some clients to sing
or hum during receptive interventions.
In another fMRI study (Green et al., 2008), researchers
compared non-musicians responses to minor and major
piano melodies. Participants reported that the minor melodies
were sadder than the major melodies. Furthermore, the minor
melodies yielded more neural activation in two limbic sys-
tem structures (parahippocampal gyrus and ventral anterior
cingulate cortex), as well as part of the mPFC. Although the
amygdala was not specifically activated, activation in related
limbic structures suggests that emotional processing of minor
modes may be similar to processing of unpleasant and/or fear-
ful stimuli. Interestingly, the same study also included another
condition to determine whether the minor mode activations
were related to dissonance; the researchers examined subject
responses to chromatic melodies, hypothesizing that the same
structures as the minor mode would be activated to a greater
extent. This was the case with the mPFC, indicating high sen-
sitivity to harmonic changes. Chromatic-induced activation in
limbic structures was also expectedly higher than the major
melodies. However, chromatic melodies induced less activity
in limbic structures than the minor melodies. In other words,
brain structures involved in negative emotions were activated
more after minor melodies than chromatic melodies. Despite
being less dissonant than the chromatic melodies, the minor
melodies resulted in a more emotionally negative neural
response. These findings suggest that harmonic dissonance
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Music Therapy Perspectives (2015), Vol. 33
contributes to receptive music-induced emotions, but that
other factors are also involved.
Results from Green et al. (2008) raise the possibility of
non-harmonic factors affecting neurobiological responses to
receptive music. But what are these factors? And how can they
impact music therapy? James, Britz, Vuilleumier, Hauert, and
Michel (2008) investigated the effects of musical training on
processing perceived harmonic incongruities. Specifically,
they compared EEG responses of trained pianists versus non-
musicians upon hearing deceptive cadences. Their results
revealed a characteristic response in right-sided limbic regions
that was evident only in the trained musicians. This implies
that trained musicians respond differently to musical grammar.
In music therapy, this may mean that clients and therapists
have different emotional responses to music because of differ-
ences in training. This is particularly relevant when consider-
ing irregular limbic system responses in mental health disor-
ders such as depression, bipolar disorder, and PTSD (Drevets,
2000; Lanius et al., 2006; Zhang et al., 2011). One might
suspect even more drastic differences between therapists and
clients with these disorders who lack musical training. This
underlines the importance of meeting clients at their unique
emotional and musical levels.
Emotion responses to multimodal stimuli. Another non-
music factor influencing music-induced emotions is the pres-
ence of additional stimuli. For instance, Eldar, Ganor, Admon,
Bleich, and Hendler (2007) conducted an MRI study in which
participants without music training were exposed to combina-
tions of emotionally neutral film clips and/or three different
kinds of simultaneous musical clips: positive commercial
pop music, negative music from horror soundtracks, and
monotonic neutral music. Behavioral tests indicated that
the music (and not the film clips) established the participants
emotional responses. But amygdala activation in the com-
bined music-film condition was significantly greater than in
film-only or music-only conditions.
In a similar investigation, Baumgartner, Esslen, and Jncke
(2006) examined the capacity of music to enhance responses
to emotional images. Participants viewed pictures of differ-
ent faceswith or without simultaneous music stimulus
and were asked to identify the facial emotions. An fMRI
contrast of the two conditions revealed more limbic system
activation with music present. Furthermore, the picture-only
condition yielded more activation in the dlPFC; recall that
the dlPFC is typically involved in more externally driven
cognitive-emotionaltasks.
Considered together, the results of Baumgartner et al.
(2006) and Eldar etal. (2007) demonstrate two closely related
qualities of music-induced emotion. First, music can enhance
emotional responses related to other types of cognitive stim-
uli. Second, it appears that music alone does not stimulate
emotional processing centers as much as a combination of
music and concrete cognitive stimuli. Although the studies
mentioned here apply largely to visual stimuli, one might
expect other types of concrete cognitive stimuli to elicit simi-
lar responses when coupled with music. This would suggest
that music therapy interventions with concrete non-musical
referents can activate limbic structures (leading to stronger
emotional responses) more than non-referential music
experiences.
 On The Neural Mechanisms of Music Therapy in Mental Health Care
The benefits of referential music therapy interventions
could be especially important in mental health treatment. For
instance, music therapists could use concrete referents and
music to help access positive emotions in clients suffering
from a depressive episode after losing a loved one. Similarly,
referential music therapy interventions may be helpful in
accessing emotions during PTSD treatment or assisting in
cognitive restructuring. Pairing concrete referents with music
might also help eliminate phobias or promote rehabilitation of
sensory integration pathways in clients with dissociative PTSD
subtypes.
Music listening, emotion, and memory. Music listening can
also induce emotions via elicitation of autobiographical mem-
ories. Janata (2009) examined the neural mechanisms behind
this in a population of undergraduate students. Inside an fMRI
scanner, students heard Billboard Top 100 clips from their ado-
lescence (when they were 719years old) and then rated each
clip according to arousal, familiarity, and autobiographical
associations. For clips with strong self-reported autobiographi-
cal associations, participants completed a series of follow-up
questions regarding the vividness of music-induced memories.
Several neuroanatomical areas were associated with reported
positive affect, particularly in the left hemisphere. The intensity
of autobiographical associations was also related to activity
in the left mPFC and left ventrolateral PFC. Taking the results
one step further, Janata analyzed neural activity via tonality
tracking, a method to detect neuroanatomical regions whose
activity corresponds temporally to changes in the harmonic
structure of music. Both autobiographically associated PFC
sites exhibited tonality tracking, in addition to the left lingual
gyrus. These results suggest that listening to autobiographi-
cally relevant music activates a memory network consisting of
three left-hemispheric sites: the left mPFC (linked to self-ref-
erential cognition), the ventrolateral PFC (linked to cognitive
control of semantic memories such as facts), and the lingual
gyrus (linked to visual memories). Furthermore, activation of
this memory network mirrors tonal changes in the music. This
explains musics ability to induce emotions via autobiographi-
cal memories. Janatas findings also imply that specific har-
monic changes in autobiographically relevant music might be
uniquely linked to memory formation.
It is possible that the memory network is less functional in
populations with hypoactive prefrontal areas. Participants with
schizophrenia exhibit reduced PFC activation during working
memory tasks (Weinberger etal., 1996). And several reports
have demonstrated differences in PFC activation between
PTSD patients and healthy controls (Lanius etal., 2006). This
poses an interesting question for future research in PTSD and
schizophrenia treatment: can autobiographical music promote
formation of new neural connections in damaged brain areas?
Either way, music therapists using autobiographical music to
facilitate reminiscence in these populations should be aware
that the memory network might be compromised.
The left-sided nature of the music-induced memory network
may also be important. Perhaps this is related to left frontal
activation in response to emotionally positive stimuli. If so,
it would be consistent with both FAA and the asymmetrical
functional features of the amygdala. Although highly specu-
lative, this could mean that music-induced autobiographical
memories have a greater tendency to be emotionally positive.
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Neurotransmission in music-induced pleasure. In addi-
tion to limbic structures and the mPFC, neurotransmission in
the reward system plays a key role in emotional responses to
music listening. Salimpoor, Benovoy, Larcher, Dagher, and
Zatorre (2011), in an investigation of normal participants
listening to self-chosen music, found that music-induced
chills corresponded to release of dopamine in the ventral
striatum. Listening to preferred music has also been shown
to increase blood serotonin levels (Evers & Suhr, 2000). In
other words, music-induced pleasure appears to utilize iden-
tical mechanisms as other types of pleasure. These mecha-
nisms are especially relevant for clinical work in addiction
and depression, disorders that are respectively characterized
by abnormal dopamine and serotonin neurotransmission. It
is possible that music-based changes in neurotransmission
particularly those resulting from music-induced pleasureare
the primary vehicle for successful music therapy treatment in
these populations. This would support Baker, Gleadhill, and
Dingles (2007) study of group music therapy for patients in a
substance abuse rehabilitation treatment program. Their music
therapy sessions featured a cognitive behavioral approach to
therapy and included lyric analysis, song parody, instrumen-
tal improvisation, and song listening/singing interventions.
Patient questionnaires indicated moderate to high levels of
emotion during sessions, especially pleasure-related emo-
tions. Further analyses also revealed an association between
patients who reported using music to regulate their moods and
patients who indicated that more music therapy would help
them do something enjoyable without the use of substances
(Baker etal., 2007). Future music therapy research might con-
sider replicating this study along with collection of serum
neurotransmitter levels. In particular, dopamine is associated
with pleasurable chills during music listening (Salimpoor
etal., 2011) and has also been established as a critical neu-
rotransmitter for learning and neuroplasticity. Stegemller
(2014) suggests that music-induced changes in dopamine
activity may help strengthen synaptic connections related
to newly learned behaviors that are paired with the music.
Dopaminergic responses to preferred music may therefore be
able to enhance the neural processes involved in establishing
new behavioral patterns, such as abstaining from drugs and
alcohol.
Re-Creative Music Experiences
Little research to date has looked at real-time neural pro-
cesses involved in active music-makingparticularly in
instances of playing or singing precomposed music. One
possible reason for this is that active music-making requires
motor movement that could compromise neuroimaging data.
Furthermore, active music-making inside a scanner is often
unfeasible.
Singing represents a logical starting point for research
because it is universal and requires less limb movement.
Jeffries, Fritz, and Braun (2003) conducted a PET study compar-
ing non-musicians neural activity during speech versus sing-
ing. The participants sang well-known songs such as Happy
Birthday. Additionally, participants spoke these same songs
in a naturalistic speaking manner. Consistent with left-hemi-
spheric localization of speech and language, results showed
that left-sided structures were activated more in the speaking
 134
condition and right-sided structures were activated more in the
singing condition. In particular, their results revealed a cluster
of activity in the right mPFC and dlPFC following the singing
condition. These results could be interpreted as a tendency
of singing to employ emotional cognition and self-referential
processes. Therefore, singing could be particularly helpful if a
client is cognizant of something during verbal processing but
wants to internalize it on a deeper emotionallevel.
In another singing investigation (Zarate & Zatorre, 2008),
musicians and non-musicians participated in two singing tasks
in an fMRI scanner. In one task, participants simply reproduced
single tones (simple task); however, in another task, they
were asked to match tones and maintain the same pitch while
ignoring another auditory stimulus one whole note above the
target pitch (ignore task). Comparison of neural activations
between the musicians and non-musicians revealed an intrigu-
ing pattern: for the simple pitch-matching task, both groups
exhibited activity in the same areas. However, in the ignore
pitch-matching tasks, the two groups exhibited activations in
different sites. Non-musicians exhibited more activity in the
primary motor cortex, while musicians exhibited more activ-
ity in temporal lobe auditory processing centers. The authors
suggest a difference in neural strategy when faced with a more
challenging singing task: non-musicians appeared to adopt a
motor-control strategy, while musicians appeared to utilize an
auditory feedback strategy. This implies that neural process-
ing differences between musicians and non-musicians are
most pronounced during complex musical tasks. This find-
ing would be valuable to a therapist trying to find appropriate
instrumentation for a group of clients with varying musical
backgrounds or facilitate similar neural activity between client
and therapist.
Improvisational Music Experiences
Investigations into the neural architecture of instrumental
improvisation have proved challenging for the same reason
cited above: such research is often unfeasible in a scanner. The
spatial constraints of a scanner pose problems, and metallic
objects cannot be used near an fMRI scanner, limiting pos-
sibilities for instrumental play. However, some studies have
used alternative experimental methods to examine musical
improvisation with fMRI technology.
Villarreal etal. (2013) studied neural correlates of musical
creativity in college music therapy students. In an fMRI scan-
ner, each subject heard a series of brief rhythms and used a
response box to tap a new, improvised rhythm or repeat the
rhythm they had just heard. The researchers then divided the
students into a high creativity group (HCG) and low crea-
tivity group (LCG) based on rhythmic originality compared
to the stimulus. Interestingly, the researchers found that the
two groups exhibited neural differences during the impro-
vised rhythm task. The HCG exhibited more activity in left
dlPFC and right insular cortex, another limbic-related struc-
ture implicated in pleasurable music listening. The LCG, in
contrast, exhibited more activity in their supplementary and
primary motor areas (Villarreal et al., 2013). Although all
these music therapy students came from the same degree pro-
gram, the researchers did not control any further for level of
music training. It is therefore difficult to gauge what the dif-
ference between HCG and LCG means. Perhaps these results
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Music Therapy Perspectives (2015), Vol. 33
implicate training-related differences in neural strategies dur-
ing a complex music task, similar to the auditory-feedback
singing experiment by Zarate and Zatorre (2008). Regardless
of the cause of difference between groups, these results cer-
tainly suggest that different people use different neural strate-
gies during musical improvisation. Additionally, only one of
these strategies (in the HCG) involved activity in neural cent-
ers linked to emotions. Perhaps some individuals simply have
more connectivity between emotional circuitry and struc-
tures needed for musical improvisation. If so, this would have
significant implications for music therapists hoping to use
improvisation as a medium for emotional processing.
Several neuroscience researchers have recently investi-
gated instrumental improvisation using keyboards specifically
designed for use in fMRI scanners. For example, de Manzano
and Ulln (2012) compared neural responses of professional
pianists during three different performance tasks: sight-read-
ing, improvising a melody, and random note generation. The
results revealed activity in the left inferior frontal gyrus (also
home to Brocas area for expressive speech) during both the
improvisation and random note generation, but not during the
sight-reading. Also, somewhat surprisingly, there were many
more areas activated during the random note generation than
the melody improvisationsand no structure was uniquely
active during the improvisation. Although this may seem to
suggest that random note generation is simply more stimulat-
ing, the authors are careful to point out that the subject sample
may be related. In other words, improvisation in professional
pianists might be automatic and strictly based on motor
memory, whereas random note generation involves a neuro-
logically foreign process. This might suggest more stimulation
for anyone introduced to an instrument for the first time, as is
so often the case during music therapy sessions.
Two other fMRI studies of keyboard improvisation yielded
seemingly contradictory results. Bengtsson, Cskszentmihlyi,
and Ulln (2007) examined concert pianists improvising
modifications of written melodies. Their brains showed activ-
ity in the dlPFC and premotor area, among other sites. On the
other hand, Limb and Braun (2008) investigated jazz pianists
improvising over chords of a known song. They found deac-
tivation in the dlPFC in addition to activation in the mPFC.
Assuming that the results are not simply related to sample size,
how does one make sense of the inconsistency? One inter-
pretation might be the differences in experimental protocol.
As mentioned above, the dlPFC is known to be involved in
cognitive-emotional tasks related to perception of external
stimuli, whereas the mPFC is involved in more self-referential
and introspective emotional processes. Perhaps the written
notation used during the Bengtsson etal. (2007) experiment
demanded a different neural strategyone that was more
externally oriented. In contrast, the jazz pianists in the Limb
and Braun (2008) study might have been familiar enough with
the chord progressions that their brains adopted a more self-
reflective improvisational strategy. This, if accurate, would be
highly relevant to music therapists, suggesting that familiar-
ity and external stimuli during improvisation can impact how
much self-concept processing is possible. The premotor activ-
ity evident in results of Bengtsson et al. (2007) could also
be consistent with the motor-based strategy more prominent
during novel tasks (similar to previously mentioned studies).
 On The Neural Mechanisms of Music Therapy in Mental Health Care
Alternatively, the contradictory results between these improvi-
sation studies might simply be explained by other slight dif-
ferences in research method (e.g., control conditions, jazz
pianists vs. concert pianists, etc.) or even just sampling error.
Either way, further research is necessary.
The neural correlates of vocal improvisation are largely
un-researched. However, a 2012 publication by Liu et al. is
an exception. The aim of their experiment was to examine
neural structures involved in freestyle rapping. Participants
were experienced freestyle rappers, and each performed two
raps in the fMRI scanner: a freestyle rap and a preplanned/
rehearsed rap. Researchers subtracted the rehearsed rap data
from the freestyle rap data to (presumably) reveal neural struc-
tures of the spontaneous creative process. Similar to results
of Limb and Braun (2008), freestyling uniquely activated the
left mPFC and deactivated the right dlPFC. This is consistent
with the idea of musical improvisation as a reflective, self-
referential behavior. Furthermore, there was actually more
activity in left hemispheric language centers during freestyl-
ing, despite language use in both conditions. This might rep-
resent a heightened degree of linguistic cognition necessary
for freestylingand perhaps any lyrical improvisationwhich
could support the use of improvisational singing interventions
for clients having trouble verbalizing their feelings during ver-
bal processing. Future investigations are necessary to establish
population-specific benefits of lyrical improvisation.
Compositional Music Experiences
Neural mechanisms involved during musical composition
have not been researched. Arecent study by Shah etal. (2013),
however, provides some interesting insight into the neural cor-
relates of creative writing. In this study, participants with crea-
tive writing experience took part in four tasks inside an fMRI
scanner. First, they read a creative writing passage. Then, they
copied the passage. Third, they were instructed to brainstorm
a new creative writing passage. And finally, they wrote a pas-
sage using pen and paper (they were able to angle their arms
outside the scanner and write on a notepad). Unsurprisingly,
the reading and copying tasks, respectively, activated language
and motor brain structures. The other two tasks, however,
yielded more intriguing data. Several sites exhibited activity
during brainstorming, including the left dlPFC (cognitive-emo-
tional perception), the right anterior insular cortex (implicated
in physiological self-awareness [Critchley, Wiens, Rotshtein,
Ohman, & Dolan, 2004]), and bilateral portions of the visual
cortex. Clearly, the thought process involved in composition
involves a complex integration of multisensory cognition and
introspection. To analyze the writing tasks, researchers sub-
tracted neural activations that were also involved in the copy-
ing tasks to detect circuits unique to the creative process. Their
analysis revealed activations in bilateral temporal lobe struc-
tures associated with episodic memory and memory retrieval.
Taken as a whole, these results suggest a wide-ranging array of
cognitive, emotional, and sensory processes that contribute to
composition. Although additional literature regarding the neu-
robiology of composition is sparse, one might imaginegiven
Shah etal.s (2013) resultsthat several neural strategies are
possible throughout the process. The results also demonstrate
how complicated the creative process can be, highlighting the
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135
cognitive demand of any compositional intervention in music
therapy.
Summary
Investigations of music listening have revealed several neu-
ral mechanisms of music-mediated emotion. The limbic sys-
tem (especially the amygdala) plays a key role in determin-
ing emotional salience of music (Koelsch et al., 2006). This
process is sensitive to harmonic dissonance, although other
factors also contribute, such as the listeners musical back-
ground and the presence of multimodal stimuli (Baumgartner
etal., 2006; Eldar etal., 2007; Green etal., 2008). The neuro-
transmitter dopamine is involved in music-mediated pleasure
(Salimpooor etal., 2011) and is also critical for neuroplastic
changes during behavioral learning, suggesting that it may be
crucial for music therapists helping their clients establish new
behavioral patterns (Stegemller, 2014). Listening to autobio-
graphically important music activates a left hemisphere music
memory network, which includes the PFC and is responsive to
specific harmonic changes (Janata, 2009).
Although neurobiological mechanisms during active musi-
cal experiences have not been studied in depth until recently,
some trends are beginning to emerge. Singing is capable of
activating portions of the PFC associated with self-referential
processing and emotional cognition (Jeffries et al., 2003).
Similarly, musical improvisation can activate PFC areas
involved in self-reflection, particularly when the improvisa-
tion occurs within a familiar musical structure (Limb & Braun,
2008; Liu etal., 2012). Neural responses during active music-
making may also depend on musical complexity, level of
music training, and creativity of the music-maker (Villarreal
etal., 2013; Zarate & Zatorre, 2008). The neural correlates of
music composition have not been investigated but are likely to
include a wide range of neural networks involved in emotion
and cognition.
The above sections have provided a conceptual framework
for neural mechanisms involved during distinct types of music
therapy interventions. Other features of the therapeutic rela-
tionship will be discussed below. Specifically, the neurochem-
istry of trust and social affiliation will be explored, as well as
musics influence on this neurochemistry. Finally, this article
will review neuroimaging research of psychotherapeutic tech-
niques in mental health treatment.
Music, Neuroendocrinology, Social Functioning, and the
Client-Therapist Relationship
Neuroendocrinology research has demonstrated the impor-
tance of two peptide hormonesoxytocin and vasopressin
in social affiliation and trust (both hormones also serve other
functions). Although their social functions are still largely
unknown, preliminary findings have suggested that music can
influence both hormones. If so, this may be a key to under-
standing musics biological role in the clinical relationship
between client and music therapist. It could also demon-
strate a unique ability of music to promote healthy develop-
ment of the client-therapist relationship. Furthermore, pro-
motion of positive relationships and trust is often crucial in
mental health treatment. Social isolation is a common symp-
tom of schizophrenia, and improved social functioning is a
 136
common predictor of remission (Schennach et al., 2012). In
clients with PTSD, connecting with others is often a primary
treatmentfocus.
Several animal studies suggest that vocalizations are a key
component of neuroendocrine-mediated social behaviors.
For instance, female hamsters have demonstrated increased
vocalizations following administration of oxytocin. Unusually
abundant oxytocin receptors have been found in two spe-
cies of singing mice known for their complex vocalizations
(Chanda & Levitin, 2013). In prairie voles, whose oxytocin and
vasopressin receptors are concentrated in reward pathways,
social isolation triggers ultrasonic calls. By contrast, meadow
voles, whose oxytocin and vasopressin receptors predominate
elsewhere, show no response to social isolation (Insel, 2010).
This indicates that oxytocin and vasopressin are capable of
modulating reward-seeking emotional communicationspe-
cifically, auditory emotional communication.
In human research, a study by Seltzer, Ziegler, and Pollak
(2010) examined the effect of vocalization on oxytocin using
a mother-daughter dyad paradigm. First, elementary-age girls
completed a stressor task (public speaking and math perfor-
mance in front of an audience). Depending on group allo-
cation, they were then consoled by their mothers in person,
over the phone, or not at all. Researchers measured levels of
oxytocin and cortisol, a hormone released during stress. The
girls cortisol and oxytocin levels were measured before the
stressor, immediately after the stressor, and at 15-minute post-
stressor intervals up to one hour. Results showed distinct post-
stressor differences in cortisol levels between all three groups,
with the highest levels in the control group and the lowest
for girls who had in-person consolation. This makes intui-
tive sense, suggesting that in-person consolation from a par-
ent is more effective at reducing stress than consolation over
the phone, which is more effective than having no parental
consolation at all. However, oxytocin measurements revealed
different results. After the stressor, the control group exhib-
ited no change in oxytocin, but oxytocin levels increased sub-
stantially in both experimental groups. In fact, one hour post-
stressor, the phone-consolation group exhibited significantly
higher oxytocin levels than the in-person-consolation group.
These results imply that vocal contact (even in the absence
of live contact) affects release of both cortisol and oxytocin.
In other words, cortisol and oxytocinrespectively related to
stress and trustare subject to changes from auditory commu-
nication. Thus, decreased cortisol and increased oxytocin may
represent biological mechanisms involved in the development
and efficacy of the client-therapist relationship.
Although the results of Seltzer etal. (2010) can be applied
to talk therapies as well as music therapy, other research has
demonstrated a unique relationship between music and neu-
roendocrine hormones. Dai etal. (2012) used a music-based
experimental protocol to investigate oxytocin and vasopres-
sin levels in participants with Williams syndrome. People with
Williams syndrome often exhibit much more trust in strangers,
likely related to dysregulation of trust hormones. Dai et al.
measured baseline hormone levels and hormonal responses to
different stimuliincluding music. These measurements were
compared with healthy controls. As expected, the participants
with Williams syndrome exhibited higher levels of both hor-
mones throughout the entire study. But increases in oxytocin
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Music Therapy Perspectives (2015), Vol. 33
and vasopressin were also evident in the control group after
music stimuli, suggesting that music may have triggered the
release of these trust-related hormones.
In another study (Ukkola-Vuoti et al., 2011), researchers
found a positive correlation between music listening habits
and a gene for a vasopressin receptor. However, the same
gene was not correlated with musical aptitude. As the authors
point out, their results imply a genetic connection between
social affiliation and interest in music listening, irrespective
of musical aptitude. This could also help explain why some
people are more drawn to music than others.
Outside mental health settings, oxytocin and cortisol have
been examined following music interventions. For instance,
Nilsson (2009) measured oxytocin levels in patients who lis-
tened to relaxing music during their bedrest. These patients
exhibited significant oxytocin increases, even an hour after
music listening. Decreases in cortisol have been found in
medical patients following drum circles (Bittman etal., 2001),
group music therapy (Burns, Harbuz, Hucklebridge, & Bunt,
2001), and the Bonny Method of Guided Imagery and Music
(GIM) (Burns, 1999). Healthy adults have also exhibited
cortisol reductions following Bonny Method GIM sessions
(McKinney etal., 1997).
Overall, the above literature suggests that music can medi-
ate hormones related to stress and social affiliation. These bio-
logical mechanisms help music foster a trusting client-therapist
bond and minimize client stress. Furthermore, the literature
implicates auditory stimuli (including speech) as a key hormo-
nal trigger. This is particularly meaningful for music therapists
planning interventions early in the therapeutic process, because
it places an emphasis on music and speech in the therapeutic
relationship. This interpretation might be extended to suggest
that therapists should pay special attention to vocal tone, musi-
cal timbres, acoustics, word choice, and background sounds
during the first few sessions with a new client. In other words,
the auditory components of the client-therapist communica-
tion may be the cornerstones of trust development.
If music can promote a trusting client-therapist relation-
ship via hormonal mechanisms, it is possible that the same
mechanisms are capable of achieving other therapeutic goals
in mental health treatment. This could be especially true in
populations with below-average oxytocin levels at base-
line. For instance, individuals with schizophrenia exhibit
less trust-related oxytocin release than healthy controls (Keri
etal., 2009). Oxytocin administration has also been shown to
reduce amygdala hyperactivity in PTSD patients (Olff et al.,
2014). Although more research is needed, music therapy may
be capable of improving overall social functioning in these
populations by boosting baseline hormone levels.
Neurobiology, Psychotherapy, and Mental Health
While most of the neural mechanisms of psychotherapy
have not been fully established, there is ample evidence to
support its influence on neural functioning in mental health
treatment. In most cases, specific techniques have been exam-
ined, such as the use of cognitive behavioral therapy (CBT)
to treat phobias or behavioral therapy for people with obses-
sive compulsive disorder (Roffman, Marci, Glick, Dougherty,
& Rauch, 2005). As another example, free association seems
to result in more widespread cortical activation than focused
 On The Neural Mechanisms of Music Therapy in Mental Health Care
memory recall (Roffman et al., 2005). Even though referen-
tial music appears to be most effective at inducing emotions
(Baumgartner et al., 2006; Eldar et al., 2007), the abstract
emotional qualities unique to music may allow it to stimulate
widespread neural regions similar to free association.
It is also worth mentioning that individuals with the same
mental health diagnoses do not necessarily exhibit the same
neural changes upon successful treatment. For instance, in
McGrath etal.s (2013) study of adults with major depression,
participants underwent pretest neuroimaging and were ran-
domly assigned to treatment with either escitalopram (an anti-
depressant medication) or CBT. Strangely, the results showed
that hypoactivity in the right anterior insula was associated
with responsiveness to CBT and poor response to escitalo-
pram, while hyperactivity in the right anterior insula was asso-
ciated with responsiveness to escitalopram and poor response
to CBT. This implies that different individuals may be best
suited to different kinds of treatments, even if they have the
same mental health diagnosis. Most music therapists in mental
health settings have probably worked with some clients who
simply responded less to music therapy; this is fully expected
based on individual differences.
Other researchers have investigated the effects of psy-
chotherapy on EEG correlates, especially FAA (more fron-
tal alpha activity in the right side, a predictor of depression
and response to negative emotional stimuli). In a rare neuro-
physiological investigation of music therapy in mental health,
Fachner, Gold, and Erkkil (2013) examined FAA of depressed
clients in a three-month psychoanalytical music therapy pro-
gram, which consisted of instrumental improvisation and
verbal processing. Surprisingly, FAA from pretest to posttest
became even more asymmetrically right sided (normally asso-
ciated with increased negative affect) despite lower scores on
a depression inventory. According to these results, it is pos-
sible that music therapy could actually restructure emotional
networksleading to an alternative neural pattern of emo-
tional health.
However, in another FAA study incorporating a music-
based intervention (listening to uplifting songs), depressed
adolescents exhibited less posttest FAA, consistent with simi-
lar FAA changes after other forms of therapy (Jones & Field,
1999). While these results seem to conflict with the 2013
investigation by Fachner et al., some differences may be
attributable to subject age, intervention style, and length of
treatment. Clearly, however, more research is needed to clar-
ify the role of music therapy in FAA. This could help establish
music therapys neurobiological mechanisms in treatment of
depression.
In another EEG study, participants undergoing an acute psy-
chotic episode listened to self-selected music. Their diagno-
ses consisted of schizophrenia, schizoaffective disorder, and
bipolar disorder. Results revealed diffuse decreases in delta
and beta waves during the music, which likely correspond
to favorable outcomeshigh delta waves often signal schiz-
ophrenia, and high beta waves are often present in bipolar
disorder (Galderisi, Mucci, Volpe, & Boutros, 2009; Boutros,
Galderisi, Pogarell, & Segmiller, 2011). Further research
is needed to explore effects of music on brain wave activ-
ity for persons with psychosesin particular, the use of live
music that is based on the clients personal preference and
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137
delivered by a music therapist in the context of a therapeutic
relationship.
Literature regarding the neural correlates of psychotherapy is
rare, and neurobiological research on music therapy in mental
health is even rarer. Until this is addressed, a complete under-
standing of music therapys role in mental health from a neu-
robiological perspective is out of reach. Still, a combination of
qualitative accounts, quantitative behavioral evidence, and neu-
roimaging evidence from other fields all suggest that music ther-
apy is equally capable of affecting neural network changes when
compared with other psychotherapeutic approaches. Moreover,
music therapy in mental health treatment may affect neural net-
works in ways that are distinct from other forms of therapy.
Limitations and the Necessity for Future Research
Although neurobiological research is becoming common in
health care, more research is needed to understand the neural
mechanisms of music therapy, particularly in mental health
treatment. The vast majority of aforementioned experiments
including those focusing on receptive listeninghave exam-
ined either professional musicians or healthy adult partici-
pants. If musicians and non-musicians have different neural
responses to music, one might expect other neural differences
among various subpopulations in mental health. Aclearer pic-
ture of the neural mechanisms behind these differences will
provide further insight for future music therapists.
Neuroimaging studies also have limitations. Most modern
neuroimaging technology is capable of localizing mental pro-
cesses only on a macroscopic level. In contrast, the micro-
scopic mechanisms behind emotion and cognition are extraor-
dinarily complex and poorly understood. Thus, any attempt to
study larger neural circuits assumes that such processes can be
understood macroscopically. Beyond that, each neuroimaging
technique has several unique limitations in spatial/temporal
resolution, possible research methods, safety, and generaliz-
ability (refer to Hunt and Legge (this volume) for a lengthy
discussion of each method).
Concluding Remarks
The body of literature referenced here sheds light on several
relationships between music therapy methods, the neurobiol-
ogy of emotions, and the therapeutic relationship. This evi-
dence suggests several potential neural mechanisms contrib-
uting to the efficacy of music therapy. Many of these possible
mechanisms, along with relevant implications for music ther-
apy in mental health treatment, are summarized in Table1.
Musics capacity to stimulate emotional centers in the brain is
well established and involves several factors, including harmonic
changes, simultaneous referential stimuli, familiarity, autobio-
graphical memories, and musical training. Although less stud-
ied, active music-making and musical creativity processes are
also capable of activating emotional centers, and likely involve
different types of neural strategies depending on the individual
and/or nature of the music listening process. Overall, music-
induced emotions are associated with neural activity in many of
the same networks involved in non-musical regulation of mood
and emotion. Many of these networks are also dysregulated or
dysfunctional in mental health disorders. By incorporating a
neurobiological perspective, music therapists working in mental
health settings may be able to target and rewire dysfunctional
 138
neural networks implicated in specific mental health disorders.
Several successful psychotherapeutic techniques, including
music therapy, have been linked to changes in relevant neural
emotional centers. Finally, both music and speech affect hor-
monal responses involved in social affiliation and trust, which
play a critical role in the client-therapist relationship. Despite a
need for future research and careful interpretation, these findings
suggest that efficacy of music therapy in mental health settings
is related to musics unique neurobiological influence on emo-
tional circuitry and social behaviors.
From a clinical perspective, the findings presented here
offer several areas for guidance and further consideration
(refer to Table 1). Vocal communicationthrough both
singing and verbal processingmay be critical to building
a trusting therapeutic relationship supported by hormonal
changes. Unpleasant or sad music, while potentially helpful
later in therapeutic process, may be contraindicated early
in music therapy for populations with hyperactive amgada-
lae (depression, bipolar disorder, PTSD [Drevets, 2000;
Lanius et al., 2006; Zhang et al., 2011]). Evidence shows
that negative music-induced emotions are related to more
than dissonance (Green etal., 2008). During improvisational
interventions, the use of musical structures familiar to cli-
ents may be most effective at activating prefrontal brain areas
associated with self-reflection. This is supported by neuro-
imaging results of jazz pianists improvising over a known
chord structure (Limb & Braun, 2008). When paired with
music, concrete referents such as images may be capable of
maximizing emotion processing through multisensory-based
enhancement of neural activity in brain areas critical to emo-
tion (Baumgartner et al., 2006; Eldar et al., 2007). Finally,
harmonic changes from autobiographically relevant music
are likely to promote reminiscence through neural memory
networks, which can be correspondingly activated along
with the auditory cortex (Janata, 2009). The above clinical
suggestions (and others mentioned throughout the present
article) all warrant further exploration and confirmation.
However, they also represent the important clinical concepts
that can be developed through a neurobiological, evidence-
based approach to music therapy.
Acknowledgments
The author gives special thanks to Lillian Eyre and Benedikte
Scheiby. Additional thanks to Andrea McGraw Hunt, Jeremy
Love, the Loyola University Music Therapy Department, and
Gordon Legge.
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Glossary
Amygdala (plural amygdalae): Two neuroanatomical struc-
tures located deep within temporal lobes (one on each
side). The amygdalae are associated with processing of
emotional stimuli.
Anterior cingulate cortex (ACC): Frontal (anterior) portion of
cingulate cortex, a medial section of the cerebral cortex.
The ACC is involved in many functions, including regula-
tion of amygdala responses to emotional stimuli.
Basal ganglia: A subcortical structure composed of many
groups of cells with various neural connections and a wide
range of functions.
Blood-brain barrier: A physical barrier, composed of tightly
joined cells, that separates circulating blood from brain tissue.
Blood-oxygen level dependent (BOLD): A method used in
fMRI for determining spatial locations of oxygen delivery
to the brain.
 140
Brain waves: Oscillations of neural activity, often classified
according to frequency.
Brocas area: A region on one side of the frontal lobe (typically
the left side) that plays a key role in production of language
and speech. Damage to Brocas area causes expressive
aphasia.
Cerebral cortex: The outermost layer of the brain, involved
in many important mental processes. The cortex is divided
into four major lobes: frontal, temporal, parietal, and occip-
ital. The word cortex can also be used to describe each
lobe (e.g., frontal cortex).
Cortisol: A steroid hormone produced by the adrenal gland
and released in response to stress. Cortisol promotes higher
levels of blood sugar (glucose).
Default mode network: A network of neuroanatomical struc-
tures associated with introspective emotional process.
Deoxyhemoglobin: One of two states of hemoglobin, the pro-
tein that carries oxygen in red blood cells. Deoxyhemoglobin
is the state of hemoglobin without oxygen attached.
Dopamine: A neurotransmitter involved in many important
processes, including the reward system.
Dorsolateral prefrontal cortex (dlPFC): The dorsolateral
(upper and outermost) portion of the prefrontal cortex. The
dlPFC is involved largely in executive functions. It is also
associated with cognitive tasks related to emotional percep-
tion of external stimuli.
Early right anterior negativity (ERAN): An event-related
potential (detectable via EEG) exhibited when subjects hear
harmonically inappropriate chords.
Endogenous opioids: Refers to any opioids produced in the
body; they play a key role in the reward system, mediating
the perception of pleasure.
Event-related fields (ERFs): Characteristic magnetic field
changes, detectable in MEG recording, which are associ-
ated with responses to specific stimuli.
Event-related potentials (ERPs): Characteristic voltage
changes, detectable in EEG recording, which are associated
with responses to specific stimuli.
Fissure: A deep groove that separates portions of the brain,
such as the longitudinal fissure, which separates the two
hemispheres.
Frontal alpha asymmetry (FAA): An EEG pattern characterized
by more right-sided frontal activity in the alpha frequency
band. FAA is typically seen upon exposure to negative stim-
uli. It can also be an indicator of depression if detected at
baseline.
Frontal midline theta (FMT): An EEG pattern characterized by
more activity in the theta frequency band along the brains
midline. Increased FMT is associated with fewer anxiety
symptoms.
Glial cells (a.k.a. glia): Cells that are part of nervous system
tissue and mainly serve to support neurons. Glia are crucial
for healthy neural functioning, but do not actually partici-
pate in the electrochemical communication characteristic
of neurons.
Gyrus (plural gyri): The top and outermost portion (ridge) of a
fold in the cerebral cortex. Folds (a.k.a. convolutions) allow
a larger cortical surface area within the skull.
Hippocampus (plural hippocampi): Two neuroanatomical
structures located within the temporal lobes (one on each
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Music Therapy Perspectives (2015), Vol. 33
side). Part of the limbic system, the hippocampi are critical
for memory and spatial navigation.
Hormones: Signaling molecules that are transported in the
bloodstream and interact with many organs, including the
brain. Hormones are typically classified as either peptide or
steroid, depending on their composition.
Hyperscanning: A combined recording technique to examine
EEG changes in multiple subjects at the same time.
Insular cortex (a.k.a. insula): A region of cerebral cortex that
is located within a deep fold separating the temporal, fron-
tal, and parietal lobes. It is sometimes considered to be a
separate lobe.
Limbic system: A collection of neuroanatomical structures
involved in many functions, including emotions and memory.
Lingual gyrus: A portion of the occipital lobe associated with
complex visual processing and visual memories (named
lingual due to its tongue-like shape).
Medial prefrontal cortex (mPFC): The medial (middle) portion
of the prefrontal cortex. The mPFC is involved with inter-
nally oriented emotional processing.
Motor cortex: A portion of the frontal lobe with neural pro-
jections directly to the spinal cord. The motor cortex is the
primary brain area in control of movement.
Neuroanatomical structures: Anatomical structures of the
nervous system, which can be classified based on location,
function, and/or appearance.
Neurotransmitters: Chemicals that are transmitted from one
neuron to another across the synapse. They are involved in
almost all neuron activity.
Neurophysiological: Pertaining to neurophysiology, a branch
of physiology concerning the nervous systemespecially
the electrical activity of neurons and the types of electrical
or chemical connections between neurons.
Nucleus acumens (NAc): A part of the ventral striatum in
the basal ganglia. The NAc plays a key role in the reward
system a mediator of dopamine-mediated opioid release,
which results in the sensation of pleasure.
Oribitofrontal cortex: The ventromedial (lower and middle)
portion of the prefrontal cortex. The orbitofrontal cortex is
associated with decision-making cognitive processes.
Oxyhemoglobin: One of two states of hemoglobin, the protein
that carries oxygen in red blood cells. Deoxyhemoglobin is
the state of hemoglobin with oxygen attached.
Oxytocin: A hormone involved in trust and intimacy, as well
as other functions.
Parahippocampal gyrus: A region of cerebral cortex surround-
ing the hippocampus, involved in memory.
Prefrontal cortex (PFC): A portion of the cerebral cortex, the
PFC is the frontmost part of the frontal lobe.
Pregenual anterior cingulate cortex (pregenual ACC): The
portion of the ACC directly in front of the genu (another
structure). The pregenual ACC may be involved in mediat-
ing emotional processing in the amygdala, which is situated
nearby.
Premotor area: A portion of the frontal lobe adjacent to the
motor cortex and involved in many processes, including
planning movement.
Reward system: A collection of neuroanatomical structures
and neurotransmitters involved in reward-seeking behaviors
and reward-based pleasure.
 On The Neural Mechanisms of Music Therapy in Mental Health Care
Serotonin: A neurotransmitter involved in many neural net-
works, including the reward system. Serotonin is associated
with feelings of happiness and pleasure.
Spatial resolution: The sharpness of images, often used in neu-
roimaging to describe the smallest space distinguishable via
a given imaging technique.
Subcortical: Pertaining to brain structures deeper than (below)
the cerebral cortex.
Subgenual anterior cingulate cortex (subgenual ACC): The por-
tion of the ACC directly below the genu (another structure).
The subgenual ACC may be involved in mediating emotional
processing in the amygdala, which is situated nearby.
Substantia nigra: A subcortical brain structure that is largely
involved with dopamine neurotransmission. It plays impor-
tant roles in reward pathways and movement.
Sulcus (plural sulci): The bottom and inner portion (groove)
of a fold in the cerebral cortex. Folds (a.k.a. convolu-
tions) allow a larger cortical surface area within the
skull.
Temporal resolution: The precision with which a device
detects events on the basis of time, often used in
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neuroimaging to describe the maximum frequency at
which an imaging machine can produce quality images
of a target.
Thalamus: A single neuroanatomical structure that serves as
a relay station between the cerebral cortex and other sites.
The thalamus is crucial in sensory and motor signaling.
Vasopressin (a.k.a. antidiuretic hormone): A hormone largely
involved in regulation of blood pressure and diuresis, but
also with other functions, including trust.
Ventral pallidum: A part of the basal ganglia implicated in
craving and substance abuse.
Ventral stratium: A part of the basal ganglia and key compo-
nent of the reward system. The ventral striatum includes the
nucleus accumbens, in addition to other structures.
Ventrolateral prefrontal cortex: The ventrolateral (lower and
outer) portion of the prefrontal cortex.
Visual cortex: A portion of the occipital lobe involved in pro-
cessing visual information. The visual cortex is one of the
most well-understood parts of the cerebral cortex; specific
functions have been determined for several specific compo-
nents of the visual cortex.