Joumal of Music Therapy, 50(3), 2013, 198-242

© 2013 by the American Music Therapy Association

A Systematic Review on the Neural

Effects of Music on Emotion Regulation:
Implications for Music Therapy Practice
Kimberly Sena Moore, MM
University of Missouri-Kansas City

Background: Emotion regulation (ER) is an internal process through

which a person maintains a comfortable state of arousal by modulating
one or more aspects of emotion. The neural correlates underlying ER
suggest an interplay between cognitive control areas and areas involved in
emotional reactivity. Although some studies have suggested that music
may be a useful tool in ER, few studies have examined the links between
music perception/production and the neurai mechanisms that underlie ER
and resuiting implications for clinical music therapy treatment. Objectives
of this systematic review were to explore and synthesize what is known
about how music and music experiences impact neurai structures
implicated in ER, and to consider clinical impiications of these findings
for structuring music stimuli to facilitate ER.
Methods: A comprehensive electronic database search resulted in 50
studies that met predetermined inciusion and exciusion criteria.
Pertinent data reiated to the objective were extracted and study
outcomes were analyzed and compared for trends and common
findings.
Results: Results indicated there are certain music characteristics and
experiences that produce desired and undesired neurai activation
patterns impiicated In ER. Desired activation patterns occurred when
listening to preferred and famiiiar music, when singing, and (in musicians)
when improvising; undesired activation patterns arose when introducing
compiexity, dissonance, and unexpected musicai events. Furthermore,

Kimberly Sena Moore, MM, Conservatoiy of Music and Dance, LFniversity of

Missouri-Kansas City.
This research was supported in part by a Graduate Assistance Fund award from
the University of Missouri-Kansas City Women's Council. The author would like to
thank Mirna Herrera and Brittany Slaughter for their assistance as coders, and Dr.
Deanna Hanson-Abroraeit for her guidance and mentorship with this project. This
project was completed in partial fulfillment of a doctoral degree.
Address correspondence concerning this article to Kimberly Sena Moore,
Conservatory of Music and Dance, University of Missouri-Kansas City, Kansas City,
MO 64119-2229. Email: [email protected]
Vol. 50, No. 3, Fall 2013 199

the connection between music-influenced changes in attention and its

link to ER was explored.
Conclusions: Implications for music therapy practice are discussed and
preliminary guidelines for how to use music to facilitate ER are shared.
Keywords: music; emotion regulation; neuroscience, amygdala

Self-regulation is a complex process of self-directed change. It is the

abiUty to implement processes and acdons that allow one to effectively
control and manage multiple levels of experiences: cognitive,
emotional, behavioral, and physiological (Bandura, 1991; Blaustein
& Kinniburgh, 2010; Karoly, 1993; Larsen, 2000; Smith-Donal, Raver,
Hayes, & Richardson, 2007). Self-regulation is considered a centred
developmental milestone in early childhood (Liebermann, Gies-
brecht, & Müller, 2007) that has lifelong implications for one's
emotional, cognitive, social, and mental health. An essential
component of self-regulation is emotion regulation (ER) (Diamond
& AspinwaU, 2003; Geva & Eeldman, 2008) and the development of
ER is considered an early marker for the development of appropriate
self-regulation (Cole, Dennis, Smith-Simon, & Cohen, 2009).
There has been a significant increase in the past 25 years in
exploring the neural correlates underlying a phenomenon; ER is
no exception. In addition, there has been increased interest in the
music neurosciences and in studying the neural correlates
underlying music perception and cognition. Although it has long
been considered that music influences emotions, there has been
little attention given to understanding how music affects emotion
regulation. Eor the music therapist, an understanding of this
phenomenon has therapeutic implications for a variety of clinical
populations that find it a challenge to control and manage their
emotional experiences. Thus, the major goal of this review was to
explore what is known about how music and music experiences
impact neural structures implicated in emotion regulation, and to
consider possible clinical implications of these findings.
Emotion Regulation
Emotion regulation is an internal process through which a
person is able to maintain a comfortable state of arousal by
modulating one or more aspects of emotion (Blaustein &
Kinniburgh, 2010; Diamond & Aspinwall, 2003; McRae et al..
200 Journal of Music Therapy

2010). It involves using strategies and processes designed to create a

new emotional response or change a current one (Gyurak, Gross, &
Etkin, 2011; McRae et al., 2010; Ochsner & Gross, 2005) that can be
explicit (e.g., effortful or conscious) or implicit (e.g., automatic or
unconscious) (Diamond 8c Aspinwall, 2003; Gyurak et al., 2011).
Generally, successful emotion regulation strategies either alter the
way an individual attends to a situation, interprets the meaning of
a situation (McRae et al., 2010), or changes the situation itself
(Diamond & Aspinwall, 2003). Difficulties with emotion regulation
can have a life-long impact on an individual's mental health and
well-being (Saxena, Dubey, & Pandey, 2011). Many researchers
consider appropriate emotion regulation to be a marker of mental
health as it allows a personfiexibilityin how he or she responds and
reacts to situations and moments of distress (Cole et al., 2009;
Gyurak et al., 2011; McRae et al., 2010). There are many disorders
and syndromes in which difficulties with emotion regulation can be
a challenge, including Attention Deficit/Hyperactivity disorder.
Autism and Asperger syndrome (Masao, 2004), Post-Traumatic
Stress Disorder (PTSD), and trauma (Ehring & Quack, 2010).
The neural correlates underlying emotion regulation suggest an
interplay between frontal lobe areas involved in cognitive control
and areas involved in emotional reactivity (Gyurak et al., 2011).
More specifically, cognitive control areas include the lateral
prefrontal cortex (Gyurak et al., 2011; McRae et al., 2010; Ochsner
& Gross, 2005), the orbitofrontal cortex (Masao, 2004; Ochsner &
Gross, 2005; Rempel-Glower, 2007; Schore, 2001), and the anterior
cingulate cortex (Gyurak et al., 2011 ; McRae et al., 2010; Ochsner &
Gross, 2005). The amygdala is the primary structure implicated in
emotional reactivity (Gyurak etal., 2011; Masao, 2004; McRae etal.,
2010; Ochsner & Gross, 2005). In general, emotion regulation is
characterized by increased activation in the cognitive control and
monitoring areas—the anterior cingulate cortex, orbitofrontal
cortex, and lateral prefrontal cortex—^which leads to decreased
activation in the amygdala (Gyurak et al., 2011; Ochsner & Gross,
2005; McRae et al., 2010; Rempel-Glower, 2007).
Music and Emotion Regulation
Music has long been thought to infiuence emotions and
emotion control. In his seminal book The Anthropology of Music,
Merriam (1964) wrote about music's role as a producer of
Vol. 50, No. 3, Faii 2013 201

emotions. It has also been noted that mvisic can evoke emotions in
listeners (Sloboda & Juslin, 2010) and may be an effective mood
induction technique (Thaut & Wheeler, 2010). However, mood
induction is different than emotion regulation; moods are
affective states lower in intensity than emotions (Juslin & Sloboda,
2010). Furthermore, evoking emotions is a general concept
whereas emotion regulation is geared towards the specific goal
of maintaining a comfortable state of arousal (Blaustein &
Kinniburgh, 2010; Diamond & Aspinwall, 2003; McRae et al.,
2010). More recent research has focused on the neural basis
underlying music-evoked emotions, finding that music does
indeed impact neural areas implicated in emotion processing
(Blood & Zatorre, 2001; Koelsch, 2010; Trainor & Schmidt, 2003).
However, much in the literature is from the music neuroscience
field and focuses on the neural mechanisms underlying music
listening, playing, or improvisation. There is little that explores
the connection between music processing and clinical treatment;
as such, there is httle in the way of chnical implications relevant to
the music therapy clinician. Therefore, the purpose of this
exploratory review was to synthesize findings from studies that
reported on the effect of music and music-based experiences on
neural structures implicated in ER, and to create preliminary
clinical considerations based on this synthesis.
Description of the Condition
For the purposes of this review, ER was defined as an internal
process through which a person is able to maintain a comfortable
state of arousal by modulating one or more aspects of emotion
(Blaustein & Kinniburgh, 2010; Diamond & Aspinwall, 2003; McRae
et al., 2010). It is characterized by the involvement of the amygdala
(Gyurak et al., 2011; Masao, 2004; McRae et al., 2010; Ochsner &
Gross, 2005), the anterior cingulate cortex (Gyurak et al., 2011;
McRae et al., 2010; Ochsner & Gross, 2005), the orbitofrontal
cortex (Masao, 2004; Ochsner & Gross, 2005; Rempel-Clower, 2007;
Schore, 2001), and the lateral prefrontal cortex (Gyurak et al., 2011;
McRae et al., 2010; Ochsner & Gross, 2005). There are cases where
"emotion regulation" has the same meaning as "affect regulation"
(Schore, 2001), although there are times when affect regulation
refers to a set of intervention techniques (Verheugt-Pleiter, 2008) ;
the latter did not fit the intent of this review.
202 Journal of Music Tiierapy

Description of the Stimulus

For the purposes of this review, "music" referred to any acoustic
stimulation provided by a complex, organized sound. As long as the
studyfitother criteria for this review, "music" also included musical
properties, such as rhythm, musical interval, harmony, and pitch,
and music experiences, such as listening to music, playing an
instrument, improvising, or composing. The literature lists "music"
most often, with occasional references to terms such as "acoustic
stimulation," "music therapy," and "complex musical sound
stimuli." Research using rhythm that was associated with circadian
rhythm, cardiac rhythm, respiratory rhythm, dietary rhythm, and
other nonmusical references to rhythm were excluded.

Objectives
1. To explore and synthesize results examining the effects of
music on neural structures implicated in emotion regulation.
2. To create preliminary clinical considerations for structuring
the music stimulus when facilitating emotion regulation.

Methods
Search Strategies
The search and analysis processes used in this review were
consistent with those outlined by Cooper (1998) and Khan, Kunz,
Kleijnen, and Antes (2011). Studies considered for this review
were published through April 2012 and identified through a
comprehensive search in the following electronic databases:
MEDLINE, PsycINFO, CINAHL, SIGLE, National Institute for
Health Research, Current Controlled Trials, ClinicalTrials.gov,
and CAIRSS for Music. Electronic databases were searched using
the following keyword phrases: "music and amygdala," "music
and orbitofrontal cortex," "music and anterior cingulate," and
"music and prefrontal." Search results generated from the "music
and prefrontal" keyword phrase were scanned and included for
consideration if they included the words "dorsolateral," "ventro-
lateral," or "lateral."

Article Inclusion Criteria

1. The article was a primary research study.
Vol. 50, No. 3, Fall 2013 • 203

2. Participants were typically-developing humans, with no

restrictions as to age, gender, ethnicity, or type of setting.
3. Music was the primary stimulus, regardless of how it was
implemented (e.g., singing, listening, improvising, etc.), the
genre of music, or the music instrument(s) incorporated.
4. Study results reported on the impact of music on one or
more of the following neural structures: amygdala, anterior
cingulate cortex, orbitofrontal cortex, and lateral prefrontal
cortex.
.5. Articles were published in English.
6. Articles were published in peer-reviewed journals.
Article Exclusion Criteria
1. The article was a review study or theoretical paper.
2. Participants had a disorder, brain damage (such as lesions
and excisions), or a syndrome.
3. The study of rhythm was associated with circadian rhythm,
cardiac rhythm, respiratory rhythm, dietary rhythm, and
other nonmusical references to rhythm.
Data Collection and Analysis Process
The author and two research assistants independently extracted
pertinent information from the included studies related to the
first objective. This included, as applicable, information about
participant characteristics (i.e., number of participants, sex
distribution, average age, age range, and musical ability), study
design (i.e., primary research question, neural measurement tool
utilized, and other behavioral and neuropsychological tools
utilized), characteristics of the music and/or music experience
utilized (i.e., type of music experience, music characteristic
studied, music instrument used, and genre of musical stimulus),
and study outcomes (i.e., general outcomes of the study and
netiral structure-specific outcomes). Pertinent data related to the
objective were extracted and study outcomes were analyzed and
compared for trends and common findings. Differences in data
extracted were discussed and results agreed upon for data
analysis. Initial interrater reliability among the three coders was
75.5%. When controlled for typographical errors and updates to
the coding sheet that occurred as a result of discussing differences
in data extracted, final inter-rater reliability was 83.6%.
204 Journal of Music Therapy

Results of the Search

The comprehensive electronic database search resulted in 319
articles that were evaluated for inclusion according to the
inclusion and exclusion criteria listed above. Of those initial
studies, 103 met the criteria. Eorty-four (44) studies were
duplicates, which led to the inclusion of 59 unique studies.
During the coding process, an additional nine studies were
excluded for the following reasons: the neural structures were not
activated as a result of music stimulation (Dehaene-Lambertz et
al., 2010; Schulze, Zysset, Mueller, Eriederici, & Koelsch, 2011;
Sluming et al., 2002), music was not used as the intervention
(Blasi et al., 2011; Haslinger et al., 2004; Milton, Solodkin,
Hlustik, & Small, 2007), the study was a dissertation (Chapin,
2010), the study offered preliminary data that was reported in a
second study (Zarate & Zatorre, 2005), and the study did not
report information clearly enough for data extraction (Bodner,
Muftuler, Nalciogly, & Shaw, 2001). Thus, this review included 50
research studies.

Results
Characteristics of Included Studies
Participant characteristics. There were a total of 811 partici-
pants in the studies (M = 25.1 years; SD = 6.2 years, range: 12-
60 years), 757 adults and 54 adolescents. Over half of the
participants were male (54.7%) and the rest were female (45.3%).
Studies used an average of 16 participants (range: ()-49
participants). Almost half of the studies used musicians as
participants or a combination of musicians and nonmusicians
(44.4%) and the remainder either used nonmusicians or authors
were not specific in the reporting (Table 1).
Characteristics of study design. Erequency information, related
to study design characteristics of the included studies, is reported
in Table 1. The two most common neural measurement tools
used were functional Magnetic Resonance Imaging (fMRI)
(65.5%) and Positron Emission Tomography (PET) (18.2%).
Other techniques used included electroencephalography
(EEG), event-related potentials (ERPs), magnetoencephalogra-
phy (MEG), and a brain oxygen measurement tool called an OT
system. Studies included in this review incorporated a variety of
Vol. 50, No. 3, Fall 2013 205 ^

musical experiences. The majority of studies (69.6%) used

listening to recorded music as the experience, followed by
singing, instrument playing, and improvisation. The most
common musical instrument used, when specified, was piano
(41.7%) followed by voice (18.3%), and the most common
musical genre used, when specified, was tonal. Western instru-
mental music (43.1%), followed by popular or current music, jazz
or improvisation, and nonwestern music. Almost half of the time
(49.1%) researchers were not investigating a particular musical
element (i.e., rhythm, pitch, harmony, etc.). If they did, harmony
was investigated the most frequently (21.8%), followed by rhythm,
melody, pitch, timbre, and pitch interval.
Synthesis of Results
A summary of pertinent chsiracteristics and outcome measures of
individual studies is reported in Table 2 and a synthesis of the main
findings is reported in Table 3. Anterior cingulate cortex activation
was reported and/or described the most frequently (32.9%),
followed by lateral prefrontal cortex activation, amygdala activation,
and orbitofrontal cortex activation (Table 1). Results will be
presented in a bottom-up fashion, from the deepest neural structure,
the amygdala, to the most superficial area, the prefrontal cortex.
Amygdala. Multiple studies reported that the amygdala was
activated when listening to minor, dissonant, negative, or
unpleasant music (Koelsch, Fritz, Cramon, Müller, & Friederici,
2006; Lerner, Papo, Zhdanov, Belozersky, & Hendler, 2009;
Pallesen et al., 2005). Amygdala activation occurred during an
unexpected event (e.g., hearing an irregular chord) and its
activity could be modulated by a single chord change (Koelsch,
Fritz, & Schlaug, 2008). One study reported that the amygdala was
activated during music listening regardless of consonance or
dissonance (Ball et al., 2007). Amygdala activation increased when
listening to music with eyes closed (Lemer et al., 2009) and was
activated more strongly when music was paired with visual stimuli
as compared to no visual stimuli (Baumgartner, Lutz, Schmidt, &
Jäncke, 2006; Eldar, Ganor, Admon, Bleich, & Hendler, 2007).
One study noted a lateralization effect, reporting that the right
amygdala was activated more strongly during an audiovisual
condition than the left amygdala, and its activity increased with
exposure over time (Dyck et al., 2011). The right amygdala in
206 Journal of Musió Therapy

TABLE 1
Frequency of Participant and Study Characteristics

N'limber Relative frequency

Music training of participants

1. Nonmusicians only 15 30%
1. Musicians only 13 26%
1. Not specified 13 26%
1. Both musicians and nonmusicians 9 18%
Neural measurement tools used
1. fMRI 36 65.5%
1. PET 10 18.2%
1. Electroencephalography (EEC) 5 9.1%
1. Event-related potentials (ERP) 2 3.6%
1. Magnetoencephalography (MEG) 1 1.8%
1. Event-related potentials (ERP) 1 1.8%
Type of music experience
1. Music listening (recorded music) 39 69.6%
1. Singing 8 14.3%
1. Instrument playing 5 8.9%
1. Improvisation 4 7.1%
Music instrument(s) utilized
1. Piano 25 41.7%
1. Voice 11 18.3%
1. Instrumental (orchestral) 8 13.3%
1. Instrumental (electronic) 5 8.3%
1. Not specified 4 6.7%
1. Instrumental (accompaniment) 3 5.0%
1. Instrtimental (solo) 2 3.3%
1. Instrumental (nonwestern) 1 1.7%
1. Other 1 1.7%
Genre of music
1. Western tonal instrumental music 22 43.1%
1. Not specified 13 25.5%
1. Popular/current music 6 11.8%
1. Jazz/improvisation 4 7.8%
1. Nonwestern music 3 5.9%
1. Western tonal vocal music 2 3.9%
1. Other 1 2.0%
Music element studied
1. Not specified 27 49.1%
1. Harmony 12 21.8%
1. Other 6 10.9%
1. Rhythm 3 5.5%
1. Melody 2 3.6%
Vol. 50, No. 3, Fall 2013 207

TABLE 1
Continued

Category Number Relative frequency

1. Pitch 2 3.6%
1. Timbre 2 3.6%
1. Interval 1 1.8%
Neural structure reported on
1. Anterior cingulate cortex (ACC) 24 32.9%
1. Lateral prefrontal cortex (lateral PFC) 21 28.7%
1. Amygdala 12 16.4%
1. Orbitofrontal (OFC) 9 12.3%
Note. Some studies incorporated multiple types of neural measurement tools, music
experiences, music instruments, music genres, studied multiple music elements,
and reported on multiple neural structures. These numbers are reflected in the
reported frequencies.

particular was recruited during "sad" music (Mitterschiffthaler,

Fu, Dalton, Andrew, & Williams, 2007), is implicated in early
neural responses to chord violadons (James, Britz, Vuilleumier,
Hauert, & Michel, 2008), and exhibited chord-dependent
responses (Pallesen, Brattico, Bailey, Korvenoja, & Gjedde,
2009). The left amygdala had consistently similar activation
patterns, with increased activation reported when listening to
music rated with a higher negative emotional valence (Dyck et al.,
2011). The amygdala was deactivated during music improvisation
(Limb & Braun, 2008) and when listening to pleasant music
(Blood & Zatorre, 2001; Koelsch et al., 2006). A long-term
habituation effect was noted, perhaps due to the amygdala's role
in evaluating salience (Mutshuler et al., 2010). To summarize,
amygdala activation and deactivation patterns changed based on
the type of music experience, the characteristics of the music
stimulus, and perceived valence of the music.
Anterior cingulate cortex (ACC). The ACC was activated during
voluntary pitch correction (Zarate, Wood, & Zatorre, 2010),
discrimination tasks (Brown & Martinez, 2007), when listening to
chord violations (James et al., 2008), and when monitoring
performance errors (Ruiz, Jabusch, & Altenmûller, 2009). In
addition, listening to familiar music activated the ACC (Janata,
2009) as did, in musicians, listening to dissonant chords (Foss,
Altschuler, & James, 2007). ACC activation increased during both
singing (Perry et al., 1999) and music listening tasks (Menon &
208 Journal of Music Therapy

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230 Journai of Music Therapy

Levitin, 2005; Nakamura et al., 1999) and it was more pronounced

in musicians compared to nonmusicians (Pallesen et al., 2010;
Zarate & Zatorre, 2008). ACC activation was correlated with
overall song likability (Berns & Moore, 2012) and increased in
individuals who disliked a song,' yet were sensitive to the song's
popularity; the researchers attributed this ACC activation to a
mismatch between individual and societal opinion (Berns, Capra,
Moore, & Noussair, 2010). Reports of activation patterns based on
musical modes are mixed, with studies reporting increased
activation when listening to happy music or music that elicits
chills (Blood & Zatorre, 2001; Mitterschiffthaler et al., 2007),
when listening to music in a minor mode as compared to a major
mode (Green et al, 2008), or when listening to music in either a
major or minor mode (Mizuno & Sugishita, 2007). Different
activation patterns were reported when listeners perceived
ascending and descending melodic contours (Lee, Janata, Frost,
Hanke, & Granger, 2011) and when processing musical phrase
boundaries (Knösche et al., 2005). In addition, the ACC was
activated during both overt and imagined singing (Kleber,
Birbaumer, Veit, Trevorrow, & Lotze, 2007) and during singing
improvisation (Brown, Martinez, & Parsons, 2006). The left ACC
was activated during rhythm- and melody-based working memory
tasks, though more strongly for rhythm Qerde, Childs, Handy,
Nagode, & Pardo, 2011) and when listening to favorable or
energetic music (Brown, Martinez, & Parsons, 2004), whereas the
right ACC was activated during a free generation task (de
Manzano & Ullén, 2012). Finally, there was increased activity in
the ventral ACC when listening to music compared to the dorsal
ACC (Green et al, 2008). To summarize, ACC activation occurred
when listening to preferred music, when engaged in an active
music-making experience, and when attending to specific
characteristics of the music stimulus.
Orbitofrontal cortex (OFC). The OFC was activated when
listening to preferred music (Menon & Levitin, 2005) and in a
separate study was more strongly activated when listening to music
as compared with listening to speech (Callan et al., 2006). OFC
activation related to emotional valence were mixed, with studies
reporting that listening to unpleasant or negative music activated
the OFC (Flores-Gutiérrez et al., 2007) as well as listening to
pleasant music (Blood & Zatorre, 2001). Several studies reported
Voi. 50, No. 3, Faii 2013 231

activation patterns related to attending to musical characteristics.

The OFC was activated when attending to a single musical
component, such as a melodic line (Satoh, Takeda, Nagata,
Hatazawa, & Kuzvihara, 2001), when detecting phrase boundaries
(Knösche et al., 2005), when processing types of chords (Fujisawa
& Cook, 2011), and when responding to syntactical irregularities
(James et al, 2008). OFC activation is reported to be related to
song likability (Berns et al., 2010; Berns & Moore, 2012), with
increased activation for nonliked songs (Berns & Moore, 2012).
The right OFC may be implicated as a link between affective and
cognitive neural systems that are engaged during music listening
(Menon & Levitin, 2005). Its activation is negatively correlated
with chord instability (e.g., dissonant chords) (Fujisawa & Cook,
2011) and it showed increased activation compared to the left
OFC when processing emotionally-salient music (e.g., either
unpleasant/negative music or pleasant music) (Blood & Zatorre,
2001; Flores-Cutiérrez et al., 2007). To summarize, OFC activation
occurred when listening to preferred music, when listening to
familiar music, and when attending to specific characteristics of
the music stimulus.
Lateral prefrontal cortex (PFC). The majority of studies that
reported on prefrontal cortex activity focused on either the
dorsolateral prefrontal cortex (dlPFC) or the ventrolateral
prefrontal cortex (vlPFC). Those that reported on the lateral
PFC noted enhanced activity during a music-based working
memory task (Pallesen et al., 2010), stronger activation in
response to negative music paired with visual stimuli, but not
without visual stimuli (Eldar et al., 2007), and activation that was
correlated with song likability (Berns et al., 2010).
Dorsolateral prefrontal cortex (dlPFC). The dlPFC was activat-
ed during the observation and motor preparation of nonpracticed
chords (Vogt et al., 2007), when listening to Mozart music (Suda,
Morimoto, Obata, Koizumi, & Maki, 2008), and when listening to
music with eyes open, but not closed (Lerner et al., 2009).
Increased activation was noted when synchronizing to tempo
changes during a motor-rhythm synchronization task (Thaut et
al., 2009) and mixed results were reported when exploring dlPFC
activation during a music improvisation task, which either caused
activation of the dlPFC (Bengtsson, Csíkszentmihályi, & UUén,
2007) or deactivation (Limb & Braun, 2008). The impact of music
232 Journal of Music Tiierapy

training on dlPFC activation also had mixed results, with one

study noting that musicians had stronger dlPFC activation (Ohnisi
et al., 2001) and another reporting that college-aged music majors
had stronger dlPFC activation than laypersons, but not profes-
sional musicians (Kleber, Veit, Birbaumer, Gruzelier, & Lotze,
2010). The right dlPFC was activated during singing (Jeffries,
Fritz, & Braun, 2003), and during music discrimination tasks
(Brown & Martinez, 2007; Hugdahl et al., 1999). The left dlPFC
was activated during a free generation task, i.e., a music
improvisation task (de Manzano & Ullén, 2012).
Ventrolateral prefrontal cortex (vlPFC). The vlPFC was activat-
ed when listening to musical triads (Mutshuler et al., 2010) and it
may be implicated in processing syntactical violations in music
(Janata, 2009). In addition, vlPFC activation occurred during an
imagined singing task, but not when overtly singing, perhaps
reflecting its role in emotional recall (Kleber et al., 2007).
To summarize, lateral PFC activation occurred when listening
to preferred or familiar music, when engaged in an active music-
making experience, and when attending to specific characteristics
of the music stimulus.

Discussion
The purpose of this exploratory review was to examine the
effects of music on neural structures implicated in emotion
regulation and to create preliminary clinical considerations based
on this synthesis. Although the impact of music on emotion
processing has long been of interest, this is the first attempt to
systematically review and synthesize research specifically investi-
gating the neural effect of music on emotion regtilation. Results
indicated that there are certain musical characteristics and
experiences that produce desired neural activation patterns
implicated in emotion regulation. From a clinical perspective,
understanding this link between musical elements and the target
goal—in this case, emotion regulation—helps the music therapist
make informed decisions about the Therapeutic Function of
Music (TFM). Hanson-Abromeit (2013) defmes the TFM as "the
direct relationship between the treatment goal and the explicit
characteristics of the musical elements, informed by a theoretical
framework and/or philosophical paradigm in the context of a
client" (p. 130). In other words, having an explicit understanding
Vol. 50, No. 3, Fall 2013 233

of why and how music affects a desired change informs the

intentional, therapeutic use of music in clinical practice. For the
purposes of this study, it involves having an explicit understanding
of what musical characteristics and experiences impact a person's
ability to regulate his or her emotions and how.
Emotion regtilation is characterized hy increased activation in
the cognitive control and monitoring areas—the anterior cingulate
cortex (ACC), orhitofrontal cortex (OFC), and lateral prefrontal
cortex (PFC)—which leads to decreased activation of the amygdala
(Gyurak et al., 2011; Ochsner & Gross, 2005; McRae et al., 2010;
Rempel-Clower, 2007). Overall, results indicated that there are
certain music characteristics and music experiences that produce
such activation pattems. For example, listening to music considered
pleasant or happy activated the AGG (Blood & Zatorre, 2001; Brown
et al., 2004; Mitterschiffthaler et al., 2007), the OFC (Berns & Moore,
2012; Berns et al., 2010; Berns & Moore, 2012; Blood & Zatorre,
2001; Flores-Gutiérrez et al., 2007), and decreased activation in the
amygdala (Blood & Zatorre, 2001; Koelsch et al., 2006). Similar
activation pattems were found when listening to music, regardless of
emotional meaning for the listener (Gallan et al., 2006; Menon 8c
Levitin, 2005; Mizuno & Sugishita, 2007; Nakamura et al., 1999) and
when singing (Kleber et al, 2007; PeiTy et al., 1999). These pattems
were also reported when musically-trained individuals were impro-
vising (Bengtsson et al., 2007; Brown et al, 2006; Limb & Braun,
2008). It should be noted, though, that one study reported
deactivation in the dlPFG during improvisation, which the authors
attributed to its role in providing a framework for goal-directed
behaviors, a role not needed when improvising (Limb & Bratin,
2008). Although it is premature to make direct clinically-based
generalizations unül future research is conducted, these results
provide preliminaiy evidence supporting the use of music listening,
singing, and improvisation to facilitate emotion regulation.
In addition to desired neural activation patterns for emotion
regulation, there can also be undesired activation patterns.
Results of this review indicated certain musical characteristics
and experiences that produced increased activation patterns in
the amygdala, namely listening to music that was minor,
dissonant, negative, or unpleasant (Koelsch et al., 2006; Lerner
et al., 2009; Mitterschiffthaler et al., 2007; Pallesen et al., 2005)
and changing chords (Pallesen et al., 2009), especially in an
234 Journal of Music Therapy

unexpected way, as with chord violations (James et al., 2008;

Koelsch et al., 2008). In addition, listening to music with eyes closed
increased the amygdala's activity (Lemer et al., 2009) as did
providing a more complex sensory stimulus by pairing music with a
visual stimulus (Baumgartner et al., 2006; Dyck et al., 2011; Eldar et
al., 2007). A primary function of the amygdala is to assess
emodonally-salient sensory information. If the sensory information
is determined to be unthreatening, amygdala activity decreases.
The fmdings from this review are congruent with this primary
function, as they indicate that the amygdala is processing and
assessing music stimuli that is new, (e.g., chord changes),
unexpected (e.g., chord violations), or complex (e.g., simultaneous
aural and visual input). Thus from a clinical perspective, research
also indicates characteristics of music and music experiences that
should be avoided when trying to help a person regulate and shift
his or her physiological and emotional state. Based on this review,
these include avoiding music that is minor, dissonant, or
considered unpleasant, as well as avoiding unexpected musical
events (e.g., sudden dynamic changes), frequent chord changes,
and listening to music with eyes closed. It should be noted that this
process implies musically-facilitating a shift to a comfortable state of
arousal, back to homeostasis. There may be times when it is
clinically indicated to maintain or increase amygdala activation,
thus maintaining or intensifying the emotional experience. This
may involve the incorporation of music and music experiences that
are considered unpleasant, with frequent chord changes and
unexpected musical events. Future research and systematic reviews
are recommended to explore and address this phenomenon.
The roles of the cognitive control and monitoring areas are
more complex than that of the amygdala; therefore, their
activation patterns associated with music characteristics and
experiences are less straightforward. Results indicated that, for
the most part, all the music experiences produced diffuse
activation in those three areas. However, unlike findings related
to amygdala functioning, they provided no indication of the types
of music and experiences to use or avoid when facilitating
emotion regulation. One possible explanation for this lack of
clarity is that those structures are implicated in other tasks. For
example, the ACC is thought to be involved in processing
uncertainty and conflict (Brown & Martinez, 2007; Mizuno &
Vol. 50, No. 3, Fall 2013 235

Sugishita, 2007; Pallesen et al, 2010), error monitoring (Ruiz et

al., 2009), and response inhibition and selection (de Manzano &
Ullén, 2012). Given that music is a complex stimulus, it can be
hypothesized that once it has been determined that the music
stimulus is not a threat—i.e., the emotion-processing aspect that
results in decreasing amygdala activity—these neural structures
attend to processing other aspects of the music stimulus.
Another possible explanation relates to their involvement in
another emotion regulation-related process, attention. More specif-
ically, this refers to their possible involvement in processing music-
influenced changes in attention that facilitate emotion regulation.
As indicated previously, a common process involved in emotion
regulation is the use of strategies that can create a new emotional
response or change a current one (Gyurak et al., 2011; McRae et al,
2010; Ochsner & Gross, 2005). Successful strategies either change
how we interpret the meaning of a situation or alter how we attend
to a situation (McRae et al., 2010). All three cognitive control areas
explored in this review are thought to be implicated in networks
involved in attention, a role reflected in the results of several studies
included in this review (de Manzano & Ullén, 2012; Jerde et al.,
2011; Knösche et al., 2005; Satoh et al., 2001). One common
denominator in those studies was that the pjirticipants were
instructed to focus on a specific cognitive task related to the music
stimulus, such as processing the melodic phrase structure (Knösche
et al., 2005) or attending to the melodic line and harmonic changes
(Satoh etal., 2001). In other words, the participants were instructed
to attend to the music stimulus in a different, more analytical way.
From a clinical standpoint, one emotion regulation strategy these
results suggest is to instruct the client to attend to a specific
characteristic of the music (e.g., the melodic line, a musical cue,
etc.), thus removing their focus from the emotional event. This
strategy is analogous to using music to reduce pain perception, a
common phenomenon reported in the medical literature (Fra-
tianne et al., 2001; Tan, Yowler, Super, & Fratianne, 2010), and
supports the use of effortful, explicit strategies when facilitating
emotion regulation (Gyurak et al, 2011).
Limitations
One major limitation of this review is the lack of intervention
reporting in the included studies, specifically that related to the
236 Journal of Music Therapy

music stimulus used. There has been a call in the literature to

include clear and detailed explanations of the interventions used
and why that intervention was selected (Robb, Burns, &
Carpenter, 2011). However, many of the studies included in this
review were not specific as to the type of music used, the names of
musical pieces, the structure and characteristics of the music
stimulus, whether the music was original or improvised, or the
instrument (s) that were used. This lack of explicit intervention
reporting is problematic for two reasons. One, it makes it difficult
to understand the mechanisms underlying the neural activations,
thus decreasing the reliability of the results. In other words, it
makes it difficult to explore and understand what characteristics
of the music stimulus are responsible for the desired activation
patterns. Two, without a clear understanding of the music
stimulus used, it is difficult to replicate the stimulus in future
studies, as well as in clinical practice.
There are other limitations in this review that affect the
generalizability of the findings. First, as the inclusion criteria
stipulated that study participants be typically-developing humans,
studies included in this review reflect a nonclinical population
and findings may not easily generalize to clinical populations.
Second, the majority of the studies utilized Western music as the
stimulus (Table 1), making it unclear how these findings might
generalize from a multicultural perspective. As such, the results
and clinical implications of this review should be considered
preliminary and should be interpreted with caution. Future
research can explore the effect music has on emotion regulation
in clinical populations and through a multicultural perspective.
Furthermore, clearer intervention reporting is needed in future
research to inform the translation of research to clinical practice.

Conclusions
This systematic review indicates that music experiences may
have an impact on emotion regulation. Furthermore, the results
provide preliminary guidelines for music characteristics and
specific strategies that might assist in the emotion regulation
process when using music as an intervention strategy. These
guidelines include using music considered happy and pleasant,
with predictable, consonant harmonies. In addition, the music
therapy clinician should be aware of multimodal implications.
Voi. 50, No. 3, Fall 2013 237

such as asking a client to close his or her eyes or pairing music

with a visual stimuli, as these might heighten the emotional
response. Music listening, singing, and improvisation may assist in
facilitating emotion regulation, as might instructing the client to
attend to another task related to the music stimulus, such as
focusing on noticing harmonic changes. As noted, these are
preliminary guidelines and more research is needed. Future
research can further explore the Therapeutic Function of Music,
teasing apart the different elements of music (e.g., pitch, rhythm,
harmony, melody, etc.) and studying their role, if any, on emotion
regulation (Hanson-Abromeit, in press). Following that, clinical
studies are needed to move this exploration from the theoretical
realm to functional, clinical use. This review provides preliminary
support for the use of music to facilitate emotion regulation, but
studies are also needed to explore the clinical efficacy of music
interventions on emotion regulation.

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