The Role of Music in Psychedelic-Assisted Therapy: A Comparative Analysis of Neuroscientific Research, Indigenous Entheogenic Ritual, and Contemporary Care Models

Abstract

Music is deeply rooted in the human experience as well as a fundamental part of psychedelic-assisted therapies (PAT) and entheogenic ceremonies. Although a large body of research exists highlighting the importance of music from rehabilitative, psychological, neurobiological, anthropological, religious, and sociological contexts, there is limited scientific literature regarding the specific relevance of music in PAT and indigenous entheogenic ritual as a means of enhancing clinical outcomes. As demand for mental health services continues to grow and awareness of the medicinal benefits of psychedelic substances to treat mental and neurological conditions increases, a new wave of interest has emerged to support the development of care models, including how music is used during PAT. Music is a reliable cornerstone in therapeutic and ritualistic spaces using psychedelics, however there is still an immense opportunity to cultivate PAT models with interdisciplinary, evidence-informed perspectives and thoughtful analysis of music use in treatment. To contribute to this development, this review evaluates neuroscientific, psychological, and anthropological research on the neural and cognitive underpinnings of music as well as music use with psychedelics both in modern research settings and indigenous entheogenic ceremonies. In addition, personalized approaches to music protocols in PAT, how music use in traditional rituals may help inform best practices, and the need for researchers to specify music protocols in treatment models are detailed. Consideration of carefully respecting the bridging of indigenous practices and current medical models is discussed to highlight areas for future development.

Introduction

Studies dating back to the 1950s have found that music is a central component of physical and spiritual healing in ceremonies using psychedelics.¹ Similarly, individuals who experience psychedelic-assisted therapies (PAT) often describe music as a significant influence in their overall experience² and will use music to process emotions and recall feelings in the post-PAT integration process.³ Music has been found to help create a safe and supportive environment during both PAT sessions and entheogenic ceremonies,⁴ facilitating emotional processing, self-reflection, and influencing sustained changes in behavior.⁵ Research shows that psychedelics are critical modulators of emotions evoked through music listening⁶ and can concurrently enhance perceived meaningfulness of music.⁷ Furthermore, those who create music in ceremonial environments are traditionally revered for their imperative value and influence in the therapeutic process.⁸

As the use of psychedelics for health care, particularly mental health treatment, continues to grow in the Global North, researchers and clinicians are evaluating evidence and historical practices to form current treatment models. Within the expansion of this work, focus is being brought to each part of the therapeutic experience, including the careful cultivation of music and how it influences neurobiological, psychological, emotional, and social aspects of treatment and ongoing care. On a granular level, this involves the analysis of musical structures and characterizations of music that are supportive during a psychedelic experience.⁹ There is also more consideration of music use by indigenous cultures that have used psychedelics in entheogenic and healing contexts for thousands of years.

Although PAT does not refer to a single therapeutic framework, listening to music is often one of the most consistent features in this clinical setting. During PAT, patients lie down and are asked to listen to a specific music playlist throughout their session, as music is believed to facilitate and enhance the therapeutic experience.¹⁰ Legal psychedelic medications are often given to participants in conjunction with pre- and post-treatment protocols (e.g., neuropsychological questionnaires, post-PAT integration), various forms of psychotherapy (e.g., cognitive behavioral therapy, dialectic behavioral therapy), carefully cultivated settings (e.g., dim lighting, soft bedding), and musical interventions (e.g., specific melodies and tones to evoke deep emotional responses).³ Given that music continues to be recognized as a reliable cornerstone in current PAT research and traditional ceremonies, it should be considered as an imperative part of the therapeutic process and evaluated thoroughly for proper integration into PAT best practices.

Overview of Psychedelic Treatments for Mental Health

Psychedelics are plant, plant-derived, and chemical psychoactive substances that produce profound perceptive, cognitive, and mood-altering experiences. These substances have been tested and used to treat a range of mental health symptoms and disorders, including depression,¹¹ obsessive compulsive disorder,¹² post-traumatic stress disorder (PTSD),¹³ anxiety,¹⁴ alcohol misuse,¹⁵ nicotine addiction,¹⁶ and cancer-related psychological distress.¹⁷ Increased awareness of medicinal benefits along with an easing of research restrictions has created a shift in current views on how psychedelics are used in society. In religious or ritualistic contexts, psychoactive materials such as psychedelics can also be referred to as “entheogens” or sacred medicines with meaningful cultural ties to enhancing well-being and connecting with internal/external environments through visionary practices that have been passed down through generations.¹⁸

Some of the most commonly known and studied psychedelics are psilocybin mushrooms, 3,4-methylenedioxymethamphetamine (MDMA), lysergic acid diethylamide (LSD), and dimethyltryptamine (DMT).¹⁹ Scientific literature evaluating the mechanisms of action of psychedelic substances in the brains of humans and rodents find activation of the 5-HT_2A receptor, a subtype of the serotonin receptor family, to be the main influence causing intense alterations in perception experienced upon consumption.²⁰ Research continues to develop on how classical psychedelics (classified for their chemically similar activation of receptors, including 5-HT_2A), impact additional receptors, including 5-HT_1A (serotonin), dopaminergic, and glutamatergic pathways. There is also evidence of neuroplasticity and increased neural connections among a host of different areas of the brain upon consumption of psychedelic substances,^21,22 findings that merit ongoing exploration for neurodegenerative conditions where cortical atrophy is prevalent.²³

For over 30 years, the main medications offered to treat mental health symptoms have been antidepressants, mood stabilizers, antipsychotic drugs, and certain off-label medicines for those who do not respond to traditional pharmacological options. Although these medications have brought assistance to millions of people globally and demonstrate efficacy in controlling symptoms relative to placebos,²⁴ they are known to come with serious side effects (e.g., changes in cognition, fatigue, sexual dysfunction, extrapyramidal symptoms) and toxicity when used in the long term.^25,26 Longitudinal research also shows inconsistencies in effective dosing,^27,28 lack of improvement in long-term health-related quality of life,²⁹ and evidence of degradation of medication efficacy over time;³⁰ hence, there is a large unmet need for alternative medications. Psychedelics offer an avenue for enhancement in the field, where new compounds can be studied and used in wider populations as additional treatments for mental and behavioral health. These compounds are especially known for their low toxicity, dependence, and public harm profiles relative to other common drugs and psychiatric medications, as well as side effects that are perceived to be manageable through adequate clinical and integration support.³¹

PAT for the treatment of mental health symptoms is currently confined to research protocols with a limited number of participants studying conditions, such as depression,³² anxiety,³³ PTSD,³⁴ alcohol use disorder,³⁵ eating and body image disorders,³⁶ and neurological³⁷ and chronic pain conditions.³⁵ Initial studies have been promising and are opening avenues for alternative treatments in a field where medications have remained largely unchanged for over three decades. For example, research has found that psychotherapy together with classical psychedelics such as LSD demonstrates improved outcomes in anxiety reduction as well as usefulness in treating alcohol use disorders.^38,39 For PTSD, MDMA in conjunction with psychotherapy has been found to be two times more effective than psychotherapy alone and four times more effective than selective serotonin reuptake inhibitors (SSRIs).⁴⁰ Psilocybin has been used effectively for treatment-resistant depression, and research highlights the importance of psychiatric support together with psychedelic administration so that patients can experience meaningful uninterrupted inner dialogs and other emotional processing.⁴¹ In a study with hallucinogen-naive adults, psychedelics used among 36 healthy volunteers showed marked improvements in mental well-being and optimism and, in 14-month follow-ups, was framed by participants as some of the most spiritually meaningful experiences of their lives.⁴²

Although these findings are extremely promising, there is still a need to formalize evidence-based standards on best practices when facilitating psychedelic treatments. Recent shifts in cultural awareness and regulatory expansion for meaningful use are slowly opening doors for this to occur. In the United States, New York, California, Michigan, Colorado, and Illinois, among others, are pursuing regulatory frameworks for psychedelics use,⁴³ and in 2020, the Oregon Psilocybin Services Act (Measure 109) was created as the first regulatory framework for psilocybin health services.⁴⁴ Oregon was reportedly influenced by Portugal’s decriminalization of the acquisition, possession, and public and private use of all drugs in 2000, as long-term benefits have been seen in overdose death reduction as well as lower crime rates.⁴⁵ The Netherlands allows for the legal sale and administration of truffle mushrooms,⁴⁶ and in 2023, Australia’s Therapeutic Goods Administration formally changed the classification of psilocybin and MDMA to enable prescribing by authorized psychiatrists.⁴⁷ Furthermore, new professional organizations, such as the American Psychedelic Practitioners Association, The American Association of Psychedelics, Psychedelics EUROPE, and Psychedelic Access and Research European Alliance, have emerged with an aim to legitimize professional frameworks, continuing education, and evidence-based care models.

Music’s Influence on Neurobiological and Psychological Processes

Music is forged in primal human instincts and undeniably intertwined with our biological existence. It has been evaluated from many biological and sociological perspectives,⁴⁸ as well as compared with language evolution and the behavior of animals that use musical components in their daily activities of living (e.g., birds, apes, dolphins).⁴⁹ From a neurobiological lens, music has been found to activate various regions of the brain such as the auditory cortex, motor cortex, prefrontal cortex, and limbic system, including the amygdala, hypothalamus, hippocampus, and orbitofrontal cortex.^50,51 On a fundamental level, the auditory cortex processes sound and pitch, the motor cortex is involved in music production, and the limbic system and the prefrontal cortex coordinate emotional responses to music. Research across a range of age-groups has found that creating and consuming music can also influence improvements in executive functioning,⁵² including decision making, planning, complex reasoning, problem solving, and emotion regulation that is mainly mediated by the prefrontal cortex.⁵³

Neuroimaging studies evaluating music listening have found enhanced functional connectivity between important perceptual–cognitive, attentional, and reward networks, including the mesolimbic and orbitofrontal reward circuits, the auditory cortex, and the prefrontal cortex.^54,55 In fMRI studies evaluating personally meaningful music listening, participants demonstrated increased connectivity between auditory and reward-related brain regions, including interplay between the nucleus accumbens, ventral tegmental area, and dopaminergic system.^56,57 Analysis of bold data through tonality tracking has shown that signaling through 5-HT_2A receptor activity changes neural processing of music, impacting areas related to music perception, memory, emotional response, and senses of connection and meaning derived from music.⁵⁸

In pediatric research, a systematic review of 29 studies across 5,468 participants (2,693 intervention, 2,775 control) evaluating music training in executive functioning found improvement in children’s inhibitory control, working memory, and cognitive flexibility.⁵⁹ In older adults with dementia and Alzheimer’s disease, a host of studies have concluded that various music techniques can be used to improve behavior, cognition, distress, and socialization, which can, in turn, help with improved quality of life and mental health outcomes.^60–62 In sleep literature, there are attempts to delineate music-related variables responsible for music’s effects on sleep quality (e.g., rhythm, emotional salience, entertainment).^63–65 In addition, Indigenous peoples have used music for thousands of years to connect with and promote health among their communities. For example, physical, mental, spiritual, emotional, and perceived quality-of-life benefits have been researched in Aboriginal women’s hand-drumming practices, promoting physical energy, body relaxation, tension release, meditative states, and expression of emotions to achieve transpersonal awakening and a greater connection to natural elements.⁶⁶

Today, music therapy is appreciated as a clinical practice with more than two decades of research exploring many facets of therapy protocols and use cases, including how music can be used in complex care. For example, a systematic review of 25 studies involving music therapy for neurological patients with conditions such as stroke, Amyotrophic Lateral Sclerosis, Parkinson’s disease, and Multiple Sclerosis found positive effects on mood, emotion, and behavior, as well as decreased depressive and anxiety symptoms in the majority of the literature.⁶⁷ The activation of various brain regions through music therapy may also be a contributing factor to improved mental health outcomes such as reducing stress, anxiety, and depression.⁶⁸ In pediatric populations, music therapy has been found to improve communication and self-esteem in youths with emotional and developmental difficulties⁶⁹ and enhance reading abilities in children with dyslexia.⁷⁰ Furthermore, a global survey of 2,495 professional members of the World Federation of Music Therapy cites over 40 specific conditions that can benefit from music therapy treatment.⁷¹

Music Use and Expansion in PAT Care Models

Music listening is frequently and persistently used within study protocols and treatment models involving the use of psychedelics for health care. Recent research evaluating music in PAT reports beneficial impacts on emotion processing,⁷² meaning making,⁷ mental imagery,⁷³ and tolerability of treatment.⁷⁴ Similarly, studies dating back to the 1970s find that music listening during PAT creates a safe environment for participants to relinquish control, promoting transformative self-exploration and an ability to structure and direct the experience.^75,76 Music has also been found to promote mystical encounters,⁷⁷ a predictor of long-term therapeutic outcomes when paired with PAT. Furthermore, the dichotomy of music as a simultaneous anchor and propeller of emotional elicitation during PAT creates a unique antipodal influence,² promoting exploration of various thoughts and feelings while patients remain in what is perceived to be a grounded state.

Challenging effects of intense music in some PAT studies are reported as welcomed by participants despite the evocation of grief or sadness.^78,79 As found in Socrates’ famous accounts of the tragedy paradox, negative emotions elicited by music are viewed with openness and as helpful in allowing participants to express inner psychological concerns that can then be addressed⁸⁰; however, their therapeutic potential may diminish when music is “dissonant with the unfolding experience.”⁶ Interestingly, in a study of psilocybin-based PAT, it was the “welcome” or “unwelcome” experience of music and not the intensity of the compound that predicted reduced depressive symptoms in the week following treatment.⁸¹ Indeed, perception of music is an important factor to consider both in terms of “set” and “setting” and how musical stimuli can impact inner processes and therapeutic dialog during PAT treatment.⁸²

Although research on the use of music in PAT has grown in recent years, optimized protocols and standards of care need to be developed. Although guidebooks dating back to the 1950s have described music as “virtually essential” within therapeutic spaces in psychedelic trial settings,⁸³ there is still an immense opportunity to cultivate models with interdisciplinary, research-informed perspectives and careful analysis of music use in treatment. Given that music listening causes affective and physiological reactions linked to esthetic and eudaimonic evocations of meaning, self-fulfillment, and self-improvement,⁸⁴ these influences are particularly interesting to consider as adjuncts to mental health treatment, as utilization of stimuli that promote self-exploration, emotional processing, and goal setting can be complementary to the therapeutic process.⁸⁵ Contrasts of visceral responses, such as states of heightened body sensations described as “warm” and “cold” when listening to thrilling or moving music,⁸⁴ may also create a unique introspective environment in therapy to uncover psychosomatic connections.

Learnings from music therapy research on techniques as well as the production, reception, and reproduction of music may help inform practices in certain PAT care models. For example, a meta-analysis evaluating 39 music therapy randomized controlled trials found that recreative music therapy and guided imagery with music show superiority in reducing depression compared with other music therapy methods.⁸⁶ Music listening, which is most likely to be the method applied in PAT, has been found to reduce depressive symptoms in adults, with the magnitude of effect depending on the music genre’s alignment with the preferences of the listener.⁸⁷ Reproducing music (e.g., singing or playing familiar songs, learning musical skills), which can potentially be suited for postsession integration, has been found to foster the development of relational competencies in individuals aiming to enhance interpersonal and social skills,⁸⁸ and improvised music creation has led to significant reductions in MADRS scores in depressed adults.⁸⁹ Considering these findings, evaluation and testing of specific music therapy modalities for mental health treatment within PAT settings could be beneficial in cultivating evidence-based care models that utilize music for specific patient needs.

Historical and Current Convergences of Music and Psychedelics

Traditional and indigenous contexts

Music is deeply rooted in traditional entheogenic ritual and shamanic practice. When used in these environments, music has been described as a “centripetal force enabling the convergence of the visual, olfactory, and other kinds of discourse composing the rites”⁹⁰ and, in certain traditional contexts, as an essential requirement to facilitate an entheogenic ritual or religious ceremony. For example, in the Santo Daime religion, rituals are organized around the drinking of daime or ayahuasca (a brew made from a mixture of plants, namely the Psychotria viridis shrub containing DMT and the Banisteriopsis caapi vine containing harmine, an inhibitor of DMT breakdown in the digestive system),⁹¹ along with a musical performance of ritual hymns called hinos. This occurs in a sacred space called the salão where musical intervention acts as a central pillar and necessary conductor of the ceremony, levitating memories, emotions, and cognition through sound.⁹²

In Indigenous Peruvian communities, the Icaros, or regular, rapid rhythms of limited melodic variations with two or three repetitive phrases, are one of the healer’s (also known as curanderos) primary tools for healing.⁹³ They are structured as monophonic sounds—single melodies without accompanied harmonies—that healers sing, hum, or whistle,⁹⁴ together with a frequency of rattling and rapid vibrational sounds that cohesively create modular building blocks assembled into an enclosed container of music. Icaros are used in ayahuasca ceremonies to facilitate and deepen the medicinal trance by attuning to a person’s subconscious emotions, visions, and patterns. In a study on the use of Icaros during ayahuasca ceremony, participants reported that the music created a sense of safety to explore their challenging memories and emotions in addition to eliciting experiences of healing and learning about their addictions.⁸

Interestingly, the structure of the Icaros parallels the rhythms that produce theta waves, neural oscillations in the brain that are also associated with deep states of relaxation, meditation, dreams, memory retention, concentration, and the patterns of the unconscious.⁹⁵ Of the five rhythms reported in electroencephalogram (EEG),—alpha, beta, delta, gamma, and theta—theta waves produce a 4–8 hz frequency band, tend to modulate the medial prefrontal and anterior cingulate cortex, and demonstrate a neural indication of inner processes requiring self-management.⁹⁶ A study using EEG to investigate the brain activity of participants while listening to Icaros found that the music induced a theta-dominant EEG pattern and increased the synchronization of brain activity in the frontal and parietal areas.⁹⁷ Theta phase synchronization, particularly in right frontotemporal regions for unfamiliar music and interhemispheric temporoparietal regions for familiar music, is positively associated with music-evoked pleasantness.⁹⁸

Theta wave activity increases during mindfulness meditation practice and auditory mindfulness activities such as sound bathing, as well as relaxed conditions such as drowsiness and sleep.⁹⁹ Studies have also found that Icaros can activate the default mode network (DMN) and the salience network, which are similarly activated during mindfulness meditation.¹⁰⁰ The modulation of the DMN by psychedelics reveals disruptions in resting-state connectivity within the DMN and increased functional connectivity between canonical resting-state networks during the psychedelic experience.^101,102 These findings highlight the potential for classical psychedelics to alter brain network dynamics, which may underlie therapeutic effects reported by users. However, some findings using EEG in ayahuasca ceremonies observed a decrease in theta-band activity,¹⁰³ challenging the assumption that increased theta activity is universally beneficial. Alterations in alpha-band activity marked by desynchronization are more characteristic of the psychedelic state,^104,105 suggesting a different neural basis for the effects of psychedelics compared with meditation alone.

Similar to theta wave frequencies, Peruvian Icaros and Santo Daime hinos music creates tension and emotional response by building up to a climax, much like a crescendo, whereas the repetitive rhythms and melodies can create a sense of familiarity, promoting relaxation and cathartic effects.¹⁰⁶ The theory of musical activation of theta waves can also be observed in Iboga ceremonies in Gabon (using Tabernanthe iboga, a shrub native to Central Africa), where it has been proposed that the repeated use of polyrhythms, together with the use of specific instruments that induce possessional trances and visions, increases the effect of the drug and could potentially generate these frequencies if read through EEG.¹⁰⁷ This research suggests that, during the trance induced by iboga, the increase in rhythmic changes stimulates the cerebellum and hippocampus like the substance itself, augmenting the effects of the medicine. This is also found in research on shamanic trance, a state of consciousness experienced by the ceremony facilitator that is characterized by a heightened sense of awareness and altered perception influenced by increased activity in the parietal and prefrontal cortex as well as decreased activity in the DMN.¹⁰⁸

Within the Indigenous Maxinéri communities of Brazil, Bolivia, and Peru, ritualistic chants used during ayahuasca ceremonies speak of natural spirits and animals accompanying the mother spirit of ayahuasca. According to the Maxinéri, each animal and plant has its own song, a similar belief held in Peruvian Amazonia cosmology. If someone learns this particular song while under the trance of ayahuasca, they can receive teachings as well as protective medicines and spells through the animal or plant spirits.¹⁰⁹ To this effect, while conducting fieldwork and studying the music of the Suyá in the Brazilian Amazon, Virtanen proposed that “music transcends time, space, and existential levels of reality” by effecting “humans, spirits, animals, and those hard-to-imagine beings in between.”¹¹⁰ Similarly, in Colombia, it is believed that the places “visited” by participants during a yagé ceremony are constructed by the taitas, or healers’ temporary modulation of music and sound, anchoring participants to a sense of “placeness” in nonverbal sounds that index to traditional Amazonian soundscapes, such as rivers, wind, and animals.¹¹¹

For the Wixárika people of the Sierra Madre occidental mountains of North-Central Mexico, music is an important part of their experience with the peyote cactus, a small entheogenic plant that has been medicinally studied for over a century.^112,113 Once a year when men and women take a pilgrimage to San Luis Potosí, the land of peyote’s origin, a shaman chants to evoke uniform hallucinogenic visions of the spirits of snakes and jaguars, animals that are similarly present in Maxinéri ceremonies. Peyote and the chants that provoke visions according to the melodic patterns during the quest are a large part of the Wixárika’s journey toward healing and attaining the sacred.¹¹⁴ Peyote continues to be used extensively in indigenous ceremonies in Mexico, North America, and South America and has also been found to alleviate muscle and joint inflammation while producing mild antibiotic properties when used topically.¹¹⁵

How traditional methods have informed current practice

Traditional shamanic music and its repertoire within Indigenous groups are now evolving as young people are increasingly living in urban centers. For example, the Maxinéri have begun to incorporate guitar instruments as an accompaniment to the tromba (an instrument of a bow and string), flute, and drums that are used traditionally to create ceremonial music.¹¹⁰ Musical performances during ayahuasca rituals are also being learned in interethnic contexts involving a number of different Indigenous groups that would typically perform ceremonies separately. Therefore, entheogenic music is being taught and learned not only in a traditional sense from the forest and spirits but by and from people who act as channels for those spirits in their own communities and with modern influences.

Although new musical characteristics are being added to ayahuasca ceremonies with novel rhythms, sounds, and prayers, there is still a distinct preparatory process for the ceremony. This is typically focused on creating an intentional ritual space that prepares the human body for the consumption of sacred psychedelic medicines and accounts for safe passage throughout the experience. The ceremony itself has had different levels of interconnectivity within religious practices, and this is continuing to evolve as historical traditions are shared (or carefully protected) for various reasons. For example, the Maxinéri have retained a level of separation from outside influences; however, in Mestizo populations of urban Peru and Ecuador, there is more openness to nonindigenous influences on ceremonial and musical practices.⁸⁹

Where sharing has occurred, music in entheogenic ritual has informed certain aspects of contemporary use of music in ceremonial and therapeutic practice. Many contemporary practitioners draw inspiration from indigenous cultures and rituals, incorporating elements such as indigenous instruments, rhythms, and vocal techniques into their compositions, facilitating therapeutic benefit and a sense of emotional openness.⁸ For example, it is suggested that using Icaros in cross-cultural environments may not depend on original cultural familiarity for achieving therapeutic efficacy as the music may convey universal therapeutic aspects of musical structure and instrumentation.⁴ As such, Icaros’ effectiveness outside of traditional settings in Peru prompts further investigation into which musical features are most conducive to therapeutic outcomes and if it is ethically appropriate to leverage them in nonentheogenic settings.

Acknowledging the ethical complexities of integrating indigenous musical practices into psychedelic research is crucial, and the full scope of such a topic is beyond that of this article. Yet, it necessitates a respectful and informed approach to ensure that any applications reflect cultural sensitivity and receive informed consent before use. Given their long-standing healing applications and use in spiritual attainment and emotional wellness, traditional indigenous practices and musical performances may provide enhancement of the therapeutic experience and improve outcomes for Indigenous and non-Indigenous people alike.¹¹⁶ For Indigenous individuals who live and receive health care in more modern settings, traditional practices can help create a sense of cultural safety and connection, aspects that are particularly important for those who may have experienced trauma and can benefit from meaningful cultural connections when receiving psychedelic medicines for health improvement. To advance PAT music protocols, initial empirical studies could prioritize the therapeutic efficacy of traditional music such as Icaros and Santo Daime hymns given their structured rhythmic patterns. Comparative research across musical traditions such as those used in iboga ceremonies and Wixárika peyote rituals may then elucidate the specific elements of music that potentially enhance therapeutic outcomes.

Considering the evidence of traditional music as a powerful healing tool, there may be flexibility to incorporate certain elements of this music within clinical, therapeutic contexts. However, to protect the indigenous music used in ceremonial ritual from extractive practices that reduce the culture to a commodified product, a bridging of both applications could be to develop new music compositions. These may include music developed from facilitator and participant feedback that is appropriately attributed to and inspired by, but not replicating, indigenous music, together with protocols that delineate the clinical versus ceremonial contexts in which music is played. However, any time that indigenous music is used outside of traditional ceremonial contexts, even as a basis to create new compositions, this should involve permission and input from Indigenous practitioners.

Within modern applications, it is imperative to apply cultural humility and respect when incorporating indigenous music and practices into psychedelic therapy models. Similarly, this approach is necessary when involving Indigenous practitioners and community members in the development and implementation of protocols, as unification of such practices require culturally accurate translations of indigenous knowledge within modern psychedelic research and therapy. Currently, there is a lack of scientific evidence and no large-scale efforts to translate such traditional protocols to therapeutic contexts. This is due to the historically extractivist nature of knowledge exchange and the general mistrust by Indigenous groups in sharing their wisdom without consultation.¹¹⁷ Hence, there is a distinct opportunity within the scientific community to establish ethical, respectful, and culturally informed models of exchange on methods of using psychedelics (and supporting tools such as music) for health improvement.

Future State of Music in PAT

Music curation and thoughtful pairing with specific medicines

The purpose of music in psychedelic experiences is to surface and process emotions surrounding both positive and challenging memories, thoughts, and behaviors. It is designed to support a specified set and setting that promotes beneficial therapeutic outcomes and helps to express a range of feelings that people may confront and, in cases of processing challenging issues, resolve.⁷⁶ Although the use of soothing and calming music is typical in trauma-focused therapy,¹¹⁸ oncology treatment,¹¹⁹ and palliative care models,¹²⁰ PAT music is designed to relay a narrative experience with its intensity adjusted by the clinician or facilitator at specified times to deepen or elicit emotional breakthroughs. This personalized musical journey can also be used by participants after a session to reconnect to their emotional states as a tool for integrating these experiences.

In contemporary practice, it is important that the facilitators pay particular attention to the energetic arc of musical accompaniment so that the onset, peak, and descent of a psychedelic journey are carefully curated according to the specific characteristics of the compound being used.¹²¹ At this time, these techniques are mainly informed through anecdotal evidence pointing to the specific phenomenological characteristics of different medicines paired with particular sounds and musical compositions. For example, ambient, ethereal music may be paired well with psilocybin-assisted therapy but may hinder the movement of an MDMA journey. Considering that psilocybin produces changes in neural activity that are associated with increased connectivity between different brain regions, it is possible that ambient music can complement these effects by promoting a sense of immersion and detachment from the external environment. In contrast, the movement-oriented experiences often associated with MDMA may be better paired with upbeat and rhythmic music that complement these effects and enhance a sense of movement.

Incorporating personalized music therapy into PAT protocols by adjusting musical features such as tempo and rhythm to an individual’s preferred cadence and leveraging familiar melodies to evoke positive emotional and mnemonic responses may enhance the efficacy of PAT by aligning with the neural mechanisms of reward prediction and emotional regulation. Research on music perception’s neural underpinnings also emphasizes the importance of rhythmic synchronization and auditory–motor interactions, where neural resonance and predictive coding models highlight the potential of personalized music therapy in enhancing emotional regulation.¹²² Some early research has begun to evaluate how music preferences can affect the quality of a psychedelic experience⁴ as well as musical characteristics’ association with peak experiences, lead-up, and integration phases.¹ It has also been inferred that unwelcome music can result in feelings of fear⁵ or manipulation,¹²³ suggesting a possibility that if music diverges significantly from user preferences, this can heighten the risk of the unwelcome experience. However, under high doses of psychedelics such as psilocybin and LSD, individuals may become more receptive to unfamiliar music,⁸¹ suggesting the need for further research to understand the impact of cross-cultural music on different clinical populations.

Surveying and integrating participants’ perspectives on music preferences for different phases of PAT may help inform guidelines and genres for developing playlists, including using familiar or unfamiliar music, vocally comprehensible, incomprehensible, or music without vocals. Similarly, studying participant responses to music in conjunction with specific types and doses of medicine could open avenues to understand, for example, which genres and tempos are best paired with certain drugs or which musical styles are most useful for specific conditions or symptoms. To enhance PAT music protocols, empirical testing could help explore various strategies, including personalized playlists featuring autobiographically significant music, emotionally resonant musical styles, and tracks used by sound healers and therapists across clinical contexts.

Need for additional research and dissemination

At this time, accredited and accepted best practice standards for music in PAT have yet to be developed and brought into professional education systems. Early efforts to do this have begun mainly by therapists and researchers disseminating protocols developed in academic and clinical settings or through learnings obtained from grassroots programs. When evaluating current research protocols and newly created professional training curricula that have been derived from these methods, music facilitation is routinely present yet with limited details on real-world practices. It is evident that music is an integral part of all psychedelic and entheogenic experiences; however, far more studies are needed to illustrate music’s distinct effects and formulation within PAT frameworks.

For example, music is consistently noted in PAT practitioner training protocols such as the Multidisciplinary Association for Psychedelic Studies MDMA-assisted psychotherapy for PTSD manual¹²⁴ and the Yale Manual for Psilocybin-Assisted Therapy for Depression.¹²⁵ A search of completed Phase 2 & 3 MDMA clinical trial protocols for PTSD found that every entry mentions the use of a music program designed to support participant experiences, although there is no elaboration on how these musical interventions are created or applied. Public entries made on clinicaltrials.gov for research on PAT with psilocybin found similar results within their protocols. Despite mounting evidence of therapeutic benefit, the lack of specifics on music facilitation within PAT models should not be overlooked, and more specifications are clearly needed in clinical trial design to better inform holistically appropriate and effective protocols. Furthermore, scientific literature mainly covers data from individuals in Europe and North America, and roughly 80% of participants identify as non-Hispanic White males,¹²⁶ presenting a significant limitation to the cultural implications of music and psychedelic therapy. By enhancing diversity of participants and details on styles of music used in PAT, researchers can use richer data when analyzing music’s impact on clinical efficacy.

In the context of integration, no scientific research presently exists examining the therapeutic results of PAT with music when used as an integration tool postexperience. As outlined earlier and given the relevance of music across cultures as a healing tool, it is also necessary to examine music and its usefulness within postsession integration and through the lens of evaluating long-term outcomes. In the limited existing research that loosely associates PAT and postsession integration with music, the literature has yet to compare the differences between music used and types of psychedelic substances or how current treatment models relate to traditional entheogenic practice. As PAT and psychedelic medicines continue to gain traction in modern medical settings, this presents an exciting opportunity for research collaboration, protocol development, longitudinal studies on efficacy and usefulness, and enhancement of care models.

Discussion

Music is an essential part of the human experience. Its fundamental importance to humans is not just cultural and recreational but also highlighted in neuroscientific and biological literature, including more than 20 years of therapeutic research demonstrating relevant benefits for a multitude of populations, age ranges, and health statuses. Evidence of music utilization in ritual and entheogenic ceremony demonstrates the importance of music as a healing modality and necessary tool within individual and community-driven therapeutic processes. Music is now also being used in PAT and research applications, with protocols becoming better understood, highly evaluated, and more refined, albeit the design of specific musical implementations in these settings requires additional investigation. In this review, the authors have chosen to analyze the importance of music as a fundamental aspect of the psychedelic healing process given supportive evidence from interdisciplinary literature alongside gaps in details on how music can be best used for various populations, medicine types, and doses, as well as how and when traditional practices can be leveraged in modern care models.

Psychedelics use is evolving from a regulatory perspective, and there is an expectation that health-related treatments (e.g., meaningful use) will be part of legal, therapeutic frameworks within the next 5–10 years.¹²⁷ With the emergence of such promising and powerful new tools for mental health care, there is great responsibility on the part of clinical, research, legislative, and advocacy communities to evaluate different aspects of PAT protocols, consider how medicine is being delivered to diverse groups, and formulate ways to optimize usage and safety for all stakeholders. Consideration should also be taken from regulators, policy makers, and payors of health services (e.g., insurance providers, health systems) to support music application as a necessary part of PAT treatment, ongoing postsession integration, and long-term care. Similar to policy reform and reimbursement of music therapy services and music use in neurorehabilitation, the use of music in PAT must be inclusive and not considered an ancillary part of treatment.

As the field is in infantile stages of developing clinical protocols, innovation will surely occur and many unanswered questions will require exploration. Can we ultimately determine what music works best with certain types of drugs, conditions, personality types, and individuals’ characteristics? Is there a further opportunity to use technological advancements to facilitate automatic adjustment of music dynamically in therapeutic spaces through artificial intelligence and personalized algorithms that modulate based on individual reactions during ceremony? Can neurofeedback techniques, real-time monitoring of skin galvanization, movement through sensors, or recognition of speech patterns facilitate the thoughtful creation of a truly personalized therapeutic environment? Is it possible for future advancements to allow for the setup of an entire digitally connected PAT space where video, sound, and motion capture provide insight into patient responses to medicine, the environment, and music, with the ability for practitioners to intervene by adjusting any or all of these areas?

There is an opportunity for research to be enhanced with real-world data, technology, and deeper evaluation of music regiments by distinct tones, resonance, and frequencies, categorized and tracked by indication and medicine type. As new modalities are created, diversity and equity of participants also feed into these protocols given that current trials tend to have a limited number of homogeneous participants. Considering that one type of music or playlist will certainly not be appropriate for all people, the inclusion of women, people of color, and various gender and sex identities will need to be prevalent to cultivate PAT and its musical accompaniment effectively within large populations. Furthermore, investigation into personalized music therapy and its applications within mental health care may be helpful to analyze for the purposes of furthering PAT research. These specifics should be included in research protocols and shared publicly with other investigators to provide an opportunity to replicate and innovate music usage in PAT, aspects we do not currently see in the evidence-based literature.

When assuming the role of traditional and indigenous music in therapeutic models of the Global North, music protocols in PAT must not culturally appropriate. Although there have been inquiries on how to leverage indigenous models for the benefit of current PAT cultivation, it is absolutely acceptable for Indigenous communities to not share their music and other entheogenic practices. There is no requirement for Indigenous peoples to do this, nor does the teaching of certain elements with non-Indigenous individuals mean that all practices must be included in this sharing. In accepting the sacredness of their traditions, modern supporters can review anthropological research, observe rituals, and understand firsthand accounts of practices while respecting the generosity coming from those communities choosing to share revered information. Owing to historic extractive and exploitative practices as well as a lack of current solutions to compensate, translate, and partner with communities that govern such traditions, there should not be any activities from modern facilitators that mimic traditional entheogenic ceremonies. Rather, novel and hybrid protocols can be continuously studied and refined to best understand usefulness and where practices may evolve to be suitable for modern medical treatment.

Psychedelic medicine given with the aid of music is a fundamental component of the healing process in both traditional and modern therapeutic applications. Neuroscientific research suggests that music can be highly beneficial for a range of health conditions in addition to eliciting activity in the brain during music consumption, creation, and therapy that contribute to improved mental health outcomes. Important considerations are still required for further investigation around the design of best practices in music use with PAT, including how to respect indigenous traditions that have inspired modern applications, how to effectively use specific medicines for certain diagnoses and individual needs, and how to leverage music in integration models. Given the full perspective of music outlined in this review, the authors hope that clinicians, researchers, advocates, and enthusiasts alike will be inspired to investigate these important concepts in more detail and acknowledge musical interventions as a fundamental part of the therapeutic process.

Authors’ Contributions

A.A.E.: Conceptualization (equal); Writing—original draft (equal); and Writing—reviewing and editing (equal). A.M.C.: Conceptualization (equal); Writing—original draft (equal); and Writing—reviewing and editing (equal). A.K.: Writing—reviewing and editing and Supervision.

Author Disclosure Statement

The authors declare that no conflicts of interest or competing financial interests exist.

Funding Information

This research received no external funding.