Chinese five-tone music therapy

1. Introduction

Version followed: the Chinese clinical form set out in the Chinese Research Hospital Association group standard T/CRHA 036—2024, 五行音乐疗法应用护理规范 (Nursing standard for the application of five-element music therapy, issued 20 Feb 2024). It is receptive listening to music written in the five pentatonic modes, using a five-element music library. Timing and dose details come from the 2025 consultation draft 睡眠障碍五行音乐疗法技术规范 (Technical specification for five-element music therapy for sleep disorders), proposed by Xiangya Hospital, Central South University. Where the "counteracting-emotion" mapping tabulated by Kwon, Kim & Kim (2024) differs, this guide says so. [source: T/CRHA 036—2024; Xiangya draft standard 2025; Kwon et al. 2024]

What it is. Chinese five-tone music therapy (五音疗法, also called 五行音乐疗法, five-element or five-phase music therapy) comes from Traditional Chinese Medicine (TCM). The five tones of the Chinese pentatonic scale are 宫 gong, 商 shang, 角 jue/jiao, 徵 zhi and 羽 yu. In TCM theory each tone, and the musical mode built on it, belongs to one of the five phases (Earth, Metal, Wood, Fire, Water). Each phase is in turn linked to a zang organ and an emotion. The idea goes back to the Huangdi Neijing. The Lingshu chapter 邪客 (Xie Ke) says "天有五音，人有五藏" ("Heaven has five tones; people have five zang organs"). [source: Lingshu, Xie Ke (ctext); T/CRHA 036—2024 §6, App. A]

How change happens, according to the tradition. Music in a mode matched to a person's constitution, emotional pattern or affected organ is said to regulate qi and to settle the emotions (调畅情志). In China it is used for health maintenance, emotional regulation and as an adjunct in disease care. [source: T/CRHA 036—2024 §6; Xiangya draft 2025 §3.1]

How to treat the theory. The links between tones, elements, organs and emotions are the tradition's own theory and have not been validated empirically. Kwon et al. (2024) note that the five tones are classified "mainly based on subjective judgment" and have not been defined objectively. Present the correspondences to clients as part of a cultural and medical tradition, not as established physiology. Never present five-tone music as a treatment for physical disease. [source: Kwon et al. 2024]

In psychotherapy terms, the active ingredients you can reasonably rely on are:

• guided relaxation and breathing;
• regulated, focused attention;
• a predictable, culturally meaningful routine;
• the chance to explore emotions the music evokes. [synthesis]

What kind of method this is. It is a TCM-derived receptive music-listening protocol, not a stand-alone psychotherapy. In mainland China it is mostly delivered by TCM nurses and physicians on a physician's order, and often self-administered with recordings. [source: T/CRHA 036—2024 §1, §7.2; Yu & Sun trial registration]

Other versions you may meet:

• Counteracting-emotion mapping. One version tabulates which emotion each tone "evokes" and "inhibits", following the controlling cycle of the five phases. [source: Kwon et al. 2024]
• Korean Han Ak (韓樂). This variant maps instrument families, not modes, to organs: metal/bell to the liver, drum to the heart, stone chimes to the spleen, strings to the lung and bamboo winds to the kidney. [source: Lim et al. 2017]
• Vibroacoustic delivery. An immersive, multi-speaker version adds a vibrating treatment bed. [source: RFEMI protocol, NCT07653113]

Professional frame.

• In China. T/CRHA 036—2024 is written for registered nurses and requires training in both TCM and music therapy. The 2025 draft asks for a degree in music therapy or a related field, a practice certificate from a professional association or government body, and knowledge of five-phase and zang-fu theory. [source: T/CRHA 036—2024 §1, §4; Xiangya draft 2025 §4.2] No separate state-regulated credential for five-tone therapy is documented. [uncertain]
• Elsewhere. "Music therapist" is a protected or credentialed title in many countries, for example HCPC registration (with BAMT as the professional body) in the UK, and the CBMT MT-BC credential (with AMTA) in the US [uncertain: general knowledge].
• What a psychotherapist without these qualifications can do. You can use prescribed receptive listening as a relaxation and emotion-work adjunct within your own scope. Do not describe it as music therapy. Do not make TCM pattern diagnoses unless you hold TCM licensure. Refer to a TCM practitioner for pattern-based prescription, and to a credentialed music therapist for active music-making with clinical goals. [synthesis]

2. Framework

T/CRHA 036—2024 sets out the process as a nursing sequence, with ongoing ("dynamic") reassessment and records kept throughout. [source: T/CRHA 036—2024 §4, §7]

Phase 1: Assessment and plan (§7.1, §4).

• Goal: set a main therapeutic aim and write an implementation plan.
• Assess general condition, past and present illness, cultural background, lifestyle, music preferences, mental state and ability to communicate.
• In the standard, the plan is built from the physician's order and this assessment (§7.2).

Phase 2: Tone and music selection (§6).

• Goal: choose a mode and pieces. The basis depends on the purpose:
  • health maintenance: the five-phase constitution;
  • emotional regulation: the emotion type found by TCM pattern differentiation;
  • disease care: the organ involved.
• Adjust for culture, habits and preference.

Phase 3: Preparation (§5, §7.2).

• Room, equipment and client preparation.

Phase 4: Implementation sessions (§7.3).

• Each session runs: guided relaxation and breath-matching, then low-volume listening, then 5–10 minutes' rest.
• Watch for adverse reactions throughout.

Phase 5: Evaluation and adjustment (§7.4).

• Compare blood pressure, pulse and subjective state before and after each session.
• Adjust the plan based on the results.

Phase 6: Health guidance and follow-up (§8).

• Give lifestyle and emotional guidance.
• Encourage completing the course and attending follow-up on schedule.

Session length, frequency and course. T/CRHA 036—2024 sets no numbers. Published versions differ:

[source: Xiangya draft 2025 §5.1.2–5.1.3; NCT07653113; Zhang & Li 2021; Lyu et al. 2025; ACTRN12622001528741p]

Format. Usually individual, in a quiet room or by the bed, or self-administered at home. The draft standard specifies single-person headphones. The RFEMI protocol uses room speakers. [source: Xiangya draft 2025 §4.4; NCT07653113]

Moving between phases. The sources give only general criteria:

• move to sessions once the plan and environment are ready;
• after each session, reassess and adjust;
• complete the full course, then follow up;
• the sleep draft names a target of a PSQI total of 5 or less after treatment (§7.1.1). [source: T/CRHA 036—2024 §7–8; Xiangya draft 2025 §7]

Suggested decision points [synthesis]:

• If, after 3–5 sessions, the client finds the chosen mode unpleasant or arousing, re-select (see 4.2–4.4).
• At the end of one course (about 20 sessions or 3–4 weeks), review your agreed outcome measure. Then continue, change the mode, or stop.
• Stop sooner if adverse reactions recur (see Section 5).

3. Guiding principles

• Individualise the choice (辨证施乐). Match the mode to the person's pattern, constitution or dominant emotion, not to the diagnosis label alone. In practice: do not give everyone the same playlist. [source: T/CRHA 036—2024 §6; Xiangya draft 2025 §5.2.1]
• Preference and culture count as much as theory. Selection must take account of the client's culture, habits and taste. In practice: if the theory points to a mode the client dislikes, pick another piece in that mode or change the mode. [source: T/CRHA 036—2024 §6, §7.1; Xiangya draft 2025 §4.1.1] A pilot was designed to test whether familiarity with Chinese culture changes response. [source: ACTRN12622001528741p]
• Attribute the theory; never promise physical cure. In practice: say "in Chinese medicine, this mode is linked with…", not "this music heals your liver". [source: Kwon et al. 2024; synthesis]
• Adjunct, not replacement. The standards place five-tone music inside medical and nursing care (the physician's order; "adjunctive" in RFEMI). In practice: never let it displace medication, medical care or evidence-based psychotherapy. [source: T/CRHA 036—2024 §7.2; NCT07653113]
• Keep volume low and controlled. In practice: start very quietly, raise only on request, and stay within the ranges in 4.8. [source: T/CRHA 036—2024 §7.3; Xiangya draft 2025 §4.4.1]
• Protected, comfortable setting. In practice: quiet room, soft light, warmth, a reclining position, no interruptions. [source: T/CRHA 036—2024 §5; Xiangya draft 2025 §4.3]
• Listen attentively, unless sleep is the aim. In practice:
  • daytime sessions: ask the client to stay awake and attend to the music and the body (T/CRHA §8 advises against falling asleep);
  • bedtime protocols: sleep onset is the goal (Lyu et al. 2025; Xiangya draft).
  • The versions differ on this point; follow the one that fits your goal. [uncertain]
• Vary the material. In practice: do not loop one track. Rotate pieces and mix modes. [source: Xiangya draft 2025 §5.2.2]
• Assess dynamically and record. In practice: note state before and after every session and adjust the plan. [source: T/CRHA 036—2024 §4, §7.4]
• Combine with psychological work. The draft standard recommends combining TCM emotion theory with modern psychotherapy. In practice: use the listening as material for reflection, not as a substitute for therapy. [source: Xiangya draft 2025 §6.1.2]
• Voluntary, stoppable at any time. In practice: agree a stop signal, and pause or end the session for any discomfort. [source: NCT07653113]
• Trauma- and hearing-aware. Music can trigger memories. Headphones and long daily exposure carry hearing risk. In practice: screen for both (see 4.1 and Section 5). [synthesis]

4. Intervention inventory

The published method is receptive: the client listens. No protocol for active singing or playing of the five modes is given in the sources. An adjacent vocal practice is noted in 4.15. Example language throughout is illustrative wording written for this guide.

4.1 Intake assessment for five-tone work

• Purpose / when. Before any listening. The aim is to set the goal, gather what you need to choose a mode, and screen for risks. [source: T/CRHA 036—2024 §7.1]
• Steps.
  1. Take the usual history:
     • general health and past and present illness;
     • mental state, including current risk;
     • ability to communicate and follow instructions with eyes closed. [source: T/CRHA 036—2024 §7.1]
  2. Ask about cultural background, daily routine and music preferences. Include familiarity with Chinese traditional music and instruments (guzheng, erhu, dizi bamboo flute, guqin). [source: T/CRHA 036—2024 §7.1; Lyu et al. 2025]
  3. Identify the main emotional target. The tradition names five emotions: 思 pensiveness or worry, 悲 grief, 怒 anger, 喜 joy or over-excitement, 恐 fear. Use the client's own words alongside these. [source: T/CRHA 036—2024 App. A]
  4. If a TCM practitioner has made a pattern diagnosis (for example liver-qi stagnation), record it. Do not make one yourself unless you are TCM-licensed. [source: T/CRHA 036—2024 §6, §7.2; synthesis]
  5. Screen for:
     • hearing loss, tinnitus or sound sensitivity;
     • bipolar disorder (hypomania risk);
     • active suicidality;
     • psychosis or dissociation with eyes closed;
     • trauma linked to music, places or periods (see Section 5). [source: NCT07653113 exclusions and stopping rules; synthesis]
  6. Agree a measurable outcome, for example sleep quality (PSQI), anxiety or depression self-report (SAS, SDS, GAD-7), or a daily 0–10 tension rating. [source: Xiangya draft 2025 §7; NCT07653113]
• Example language (illustrative).
  • "What kinds of music calm you, and which do you avoid?"
  • "Are there songs or instruments that bring back hard memories?"
  • "In Chinese medicine the emotions are grouped into five families. Which one feels most stuck for you right now: worry, sadness, anger, over-excitement or fear?"
• Watch for. Clients who expect the music to treat a physical illness (correct this gently). Clients from cultures where these instruments carry funeral, political or migration associations.

4.2 Choosing the mode: same-phase matching (standard version)

• Purpose / when. The default selection rule in T/CRHA 036—2024: choose the mode belonging to the client's dominant emotion, constitution or affected organ. [source: T/CRHA 036—2024 §6]
• Correspondences (the tradition's theory). [source: T/CRHA 036—2024 App. A; Xiangya draft 2025 §3.1, App. A]

• Steps.
  1. From 4.1, name the main emotion, or note the constitution or pattern a TCM practitioner has given.
  2. Look up the matching mode in the table.
  3. Offer 2–3 pieces in that mode. Let the client choose by short samples (30–60 seconds each). [source: T/CRHA 036—2024 §6 (preference); synthesis (sampling)]
  4. Record the mode and pieces chosen in the plan.
• Example language (illustrative). "In this tradition, music in the jue mode is linked with the Wood phase and with anger and frustration. Let's try two short pieces and see which one your body settles with."
• Watch for.
  • Signs it fits: slower breathing, lowered shoulders, the client reports "settling".
  • Signs it does not fit: restlessness, irritation, intrusive memories. If so, switch piece or mode.
  • The table is theory, not a diagnosis.

4.3 Choosing the mode: counteracting-emotion version

• Purpose / when. An alternative logic found in the literature: use a tone said to restrain an excessive emotion, following the controlling cycle of the five phases. Use it when the matched mode (4.2) seems to amplify the emotion rather than settle it. [source: Kwon et al. 2024, Table 1]
• Correspondences as Kwon et al. tabulate them.

[source: Kwon et al. 2024]

• Steps.
  1. Name the excessive emotion.
  2. Choose the tone listed as inhibiting it. Examples: shang for anger, zhi for grief, gong for fear, jue for worry, yu for over-excitement.
  3. Trial it as in 4.2, steps 3–4.
• Note. This mapping differs from 4.2, and the versions are not reconciled in the sources. Choose one rule per client and record which you used. [uncertain]
• Example language (illustrative). "Another way the tradition works is to balance a strong feeling with its opposite. For the anger you described, it pairs the shang mode, which is often described as clear and restraining. Shall we try it?"
• Watch for. Some clients find "counter" music invalidating, as if they are being told not to feel. If so, return to matching or to plain preference.

4.4 Choosing the mode: "supplement the mother" or "drain the child" (补母/泻子)

• Purpose / when. The 2025 draft says practitioners may choose a supplementing-the-mother or draining-the-child mode according to the generating and controlling relations of the five phases. It gives no detailed rules. [source: Xiangya draft 2025 §4.1.3]
• What the tradition means. In five-phase theory each phase is "mother" to the next in the generating sequence. The mode of the preceding phase is said to support a weak phase. The mode of the following phase is said to drain an excessive one. Kwon et al.'s "evokes" column follows the same generating order (Wood→Fire→Earth→Metal→Water→Wood). [source: Kwon et al. 2024 Table 1; uncertain as to clinical application]
• Steps. Use only when a TCM practitioner has identified a deficient or excessive organ pattern and asks for this. Otherwise use 4.2 or 4.3. [synthesis]
• Watch for. This is a specialist TCM judgment. Do not improvise it.

4.5 Building the music library and choosing pieces

• Purpose / when. Before starting the course. The standards call for pieces from a five-element music library composed on Huangdi Neijing theory. [source: T/CRHA 036—2024 §6; Xiangya draft 2025 §4.1.1]
• Steps.
  1. Use a recognised five-mode collection. One widely used example is composer Shi Feng's 中国传统五行音乐（正调式） (Wuxing therapeutic music, zhengdiao), recorded by the Central Conservatory of Music Chinese Music Ensemble and published by China Medical Multimedia Press. [source: Lyu et al. 2025] Another collection in use is the "Tianyun Five Elements Music" CD, which has yin- and yang-rhythm pieces for each phase. [source: ACTRN12622001528741p] The draft standard's appendix lists recommended pieces; I did not reproduce them. [uncertain]
  2. Prefer uncompressed or undistorted audio files on a dedicated player. [source: Xiangya draft 2025 §4.4.2]
  3. Have several pieces per mode, so you avoid repeating a single track and can mix modes. [source: Xiangya draft 2025 §5.2.2]
  4. Consider timbre. One study made versions of the same five-mode melodies on erhu, guzheng and bamboo flute, and compared them. Ask which instrument the client prefers. [source: Lyu et al. 2025]
  5. Check each piece's length against the session plan. Lyu et al. cut each mode to a 3-minute core and combined five into a 15-minute track. [source: Lyu et al. 2025]
• Example language (illustrative). "Some people prefer the bowed sound of the erhu, others the plucked guzheng or the flute. Which of these feels easier to be with?"
• Watch for. Poor-quality streaming copies with adverts or sudden volume changes. Recordings with lyrics or strong associations for the client.

4.6 Room and equipment set-up

• Purpose / when. Before each in-clinic session. [source: T/CRHA 036—2024 §5, §7.2]
• Steps.
  1. Room: a separate, quiet room of roughly 12–20 m² with sound-absorbing surfaces. Adjustable, glare-free light.
  2. Climate: about 18–22 °C and 50–60 % humidity, with no draughts.
  3. Furniture: a reclining chair or bed. Simple decoration, plants or a mural.
  4. Speakers: the standard asks for players arranged by five-element directions. This is a tradition-specific feature and optional outside TCM settings. [source: T/CRHA 036—2024 §5; synthesis on optionality]
  5. Equipment check: confirm it works and that the volume is preset low.
  6. Headphones: single-user headphones are preferred, cleaned between users. [source: Xiangya draft 2025 §4.3–4.4; synthesis on cleaning]
  7. Afterwards: ventilate and clean the room daily. [source: T/CRHA 036—2024 §7.3]
• Watch for. Trip hazards from cables. Getting up too fast from a recliner, especially in older clients.

4.7 Preparation: guided relaxation and breath-matching

• Purpose / when. The opening minutes of each session, to settle attention. [source: T/CRHA 036—2024 §7.3, App. B]
• Steps.
  1. Ask the client to remove hard objects and switch off phones and electronic devices. The standard's stated reason is electromagnetic interference; the practical benefit is fewer interruptions. Ask them to loosen clothing and settle comfortably. [source: T/CRHA 036—2024 §7.3; synthesis on practical benefit]
  2. Invite them to close their eyes, or to soften their gaze if eye-closing is uncomfortable. [source: T/CRHA 036—2024 §7.3; synthesis on the alternative]
  3. Give a short guided relaxation. The standard has eight guided-meditation scripts in Appendix B for use before listening. Write your own brief version rather than copying them. [source: T/CRHA 036—2024 App. B]
  4. Ask the client to let their breathing follow the rhythm of the music, notice bodily sensations, and let thoughts settle. [source: T/CRHA 036—2024 §7.3] The Yu & Sun protocol simply asks for a steady breathing rate. [source: ACTRN12622001528741p]
• Example language (illustrative). "Let your breath find its own pace with the music. You don't need to force anything. If your attention drifts, gently bring it back to the sound and to where your body touches the chair."
• Watch for.
  • Breath-holding or over-breathing: reassure, and drop the breath instruction.
  • Panic with eyes closed: open the eyes and use external grounding.

4.8 The receptive listening session

• Purpose / when. The core intervention, in every session of the course. [source: T/CRHA 036—2024 §7.3]
• Steps.
  1. Start playback and set the playing time.
  2. Volume. The two standards give different figures:
     • T/CRHA 036—2024 begins with about one minute of introductory music at roughly 25 dB, then allows adjustment within about 25–60 dB. [source: T/CRHA 036—2024 §7.3]
     • The sleep draft gives 40–60 dB through personal headphones, and below 35 dB for calming (安神) music. [source: Xiangya draft 2025 §4.4.1]
     • RFEMI says only "comfortable". [source: NCT07653113]
     • In all versions, keep levels at quiet-conversation level or below. [synthesis]
  3. Length: about 30 minutes is the common dose (15–30 minutes across versions). [source: Xiangya draft 2025 §5.1.2; NCT07653113; Lyu et al. 2025]
  4. Stay present and observe throughout: breathing, facial expression, restlessness, tears. [source: T/CRHA 036—2024 §7.3]
  5. Pause or stop for discomfort, dizziness, ear pain, agitation or a request to stop. [source: NCT07653113]
• Example language (illustrative).
  • "I'll start very quietly. Lift a finger if you'd like it louder or softer, and raise your hand if you want to stop."
  • "Just let the music be there. Notice whatever comes, without needing to do anything with it."
• Watch for.
  • Signs it is working: slower breathing, softer facial muscles, the client reports calm or an emotional shift.
  • Problems: fidgeting, clenched jaw, tears turning into distress, or no response at all. Adjust volume, piece or mode, or stop.

4.9 Timing by organ (time-of-day schedule)

• Purpose / when. The sleep-disorder draft recommends listening windows by mode, following TCM organ-clock reasoning. Use it when the client can listen at home and the mode is already chosen. [source: Xiangya draft 2025 §5.1.1]
• Recommended windows (draft standard).
  • jue (liver): 19:00–23:00
  • zhi (heart): 21:00–23:00
  • gong (spleen): during a meal or within an hour after it
  • shang (lung): 15:00–19:00
  • yu (kidney): 07:00–11:00
• Dose in the draft. 2–3 times a day, about 30 minutes each, with 20 sessions as one course. [source: Xiangya draft 2025 §5.1.1–5.1.3]
• Steps.
  1. Agree a realistic window with the client.
  2. Write it into the plan.
  3. Give a simple log sheet: time, piece, 0–10 tension before and after. [synthesis]
• Note. These timings are the tradition's rationale and are marked as recommended (宜), not required. Fitting the client's day matters more for adherence. [source: Xiangya draft 2025; synthesis]
• Example language (illustrative). "The tradition suggests late afternoon for this mode. If that doesn't fit your work, let's find the slot you can actually keep."
• Watch for. Rigid or anxious adherence to the clock, for example in clients with OCD traits. In that case, relax the rule.

4.10 Bedtime home-listening programme

• Purpose / when. For sleep problems or evening anxiety, as self-administered home practice. [source: Lyu et al. 2025; Xiangya draft 2025]
• Steps.
  1. Give the client one prepared track. Lyu et al. used a 15-minute sequence of all five modes; a single matched mode is also possible.
  2. Ask them to play it every night in bed for two weeks or longer, at low volume. [source: Lyu et al. 2025]
  3. Set up adherence support. Lyu et al. used a group chat with a supervising instructor, where participants logged each night's listening. A simple shared log works as well. [source: Lyu et al. 2025; synthesis]
  4. If using headphones, choose comfortable sleep headphones or a quiet bedside speaker with a timer. Calming music should be quieter than daytime listening (below 35 dB in the draft). [source: Xiangya draft 2025 §4.4.1; synthesis on equipment]
  5. Review sleep weekly, for example with the PSQI or a sleep diary. [source: Xiangya draft 2025 §7.1]
• Example language (illustrative). "Each night when you're in bed with the lights off, start the track. If you fall asleep before it ends, that's fine. Just tick the log in the morning."
• Watch for.
  • Ear discomfort from sleeping in earbuds.
  • Using the track to avoid winding-down routines.
  • Dependence on the track for sleep onset.
  • Pair it with standard sleep-hygiene or CBT-I work where indicated. [synthesis]

4.11 Post-session rest, monitoring and recording

• Purpose / when. At the end of every in-clinic session. [source: T/CRHA 036—2024 §7.3]
• Steps.
  1. Fade the music out.
  2. Ask the client to stay lying or sitting for 5–10 minutes before standing.
  3. Record before and after: blood pressure, pulse and subjective feelings, on a standard form. Nursing settings measure the vital signs; psychotherapists usually record a subjective rating only. [source: T/CRHA 036—2024 §7.3, §7.4; synthesis on psychotherapy adaptation]
  4. Note any adverse reaction and how it was handled. [source: T/CRHA 036—2024 §7.3; NCT07653113]
• Example language (illustrative). "Take your time coming back. Wiggle your fingers and toes, open your eyes when ready, and stay seated for a few minutes. On a scale from 0 to 10, how tense are you now compared with before?"
• Watch for. Light-headedness on standing. Drowsiness before driving. A lingering low or tearful mood that needs talking through (see 4.14).

4.12 Outcome evaluation and plan adjustment

• Purpose / when. After each session (brief) and at the end of each course (formal). [source: T/CRHA 036—2024 §7.4]
• Steps.
  1. Each session: compare pulse, blood pressure (in medical settings) and the client's subjective experience before and after. [source: T/CRHA 036—2024 §7.4]
  2. Each course: re-administer your agreed measures. The draft and trials use:
     • PSQI for sleep;
     • SAS, SDS and SF-36;
     • TCM syndrome scores;
     • heart-rate variability;
     • HAM-D, HAM-A and GAD-7 in RFEMI. [source: Xiangya draft 2025 §7; NCT07653113]
  3. Adjust: change the piece, the mode or the timing, or stop. [source: T/CRHA 036—2024 §7.4]
• Note. The draft standard's stated efficacy figures (overall response 80–90 %) are targets written into a consultation draft, not trial results. Do not quote them to clients. [source: Xiangya draft 2025 §7.4; synthesis]
• Example language (illustrative). "Over these three weeks your sleep score has moved from X to Y. Shall we keep this mode, try a different one, or put our time into other work?"
• Watch for. Improvement that tracks other changes (medication, life events). Attribute it cautiously.

4.13 Health guidance alongside listening

• Purpose / when. Throughout the course. [source: T/CRHA 036—2024 §8; Xiangya draft 2025 §6]
• Steps. Advise:
  • keeping emotions as steady as possible and limiting exposure to upsetting input before sessions;
  • listening attentively (in daytime sessions);
  • regular meals and daily routine;
  • appropriate exercise as medically advised;
  • completing the course and attending follow-up.
  • Staff report notable psychological changes to the treating doctor. [source: T/CRHA 036—2024 §8; Xiangya draft 2025 §6.2]
• Example language (illustrative). "The music works best on top of a steady day: regular meals, some movement your doctor is happy with, and a fixed bedtime."
• Watch for. "Keep emotions stable" can sound like suppression. Frame it as reducing avoidable stressors, not as forbidding feelings. [synthesis]

4.14 Integrating the listening into psychotherapy

• Purpose / when. The draft standard recommends combining TCM emotion theory with modern psychological therapy. This item gives one way to do that in a talking-therapy session. [source: Xiangya draft 2025 §6.1.2; steps are synthesis]
• Steps. [synthesis]
  1. Place a 10–15 minute listening segment (4.7–4.8) early or late in the session, depending on the aim:
     • before talking, to lower arousal;
     • at the end, to close down.
  2. After the music, ask open questions about bodily sensations, images, memories and emotions.
  3. Link what emerged to the client's current goals. Use your usual modality (for example emotion-focused reflection, a cognitive reappraisal, or a mindfulness debrief).
  4. Hand the track out as homework (4.9–4.10), and review the log next session.
• Example language (illustrative).
  • "What did you notice in your body while the music played?"
  • "You said the flute made you think of your grandmother's village. What feeling goes with that picture?"
• Watch for.
  • Grief or homesickness evoked by familiar pentatonic music, especially in migrant clients. This can be therapeutic but needs pacing.
  • Clients over-reading meaning into organ labels.

4.15 Vibroacoustic and immersive five-element delivery (medical-adjunct variant)

• Purpose / when. Used in an inpatient psychiatric trial as an add-on to usual care for depression in men. Five-element tracks matched to the TCM pattern were delivered through a multi-speaker playback system and a treatment bed with gentle vibration synchronised to the audio. [source: NCT07653113]
• Steps (as the protocol describes).
  • about 30 minutes, five times a week, for four weeks;
  • comfortable volume;
  • staff monitor comfort, tolerance and adverse events, and pause, adjust or stop as needed. [source: NCT07653113]
• Note. This needs a dedicated device and a medical or rehabilitation setting. Use it only as an adjunct within that care, not as a replacement for treatment. Outcome claims are those of the trial; its results are not reported here. [source: NCT07653113; uncertain on results]
• Watch for. Dizziness, ear pain, agitation and unstable vital signs (the protocol's own monitoring list). Discontinue if the client switches into mania. [source: NCT07653113]

4.16 Adjacent practice: the Six Healing Sounds (六字诀)

• What it is. A separate qigong breathing and vocalising practice, often mentioned alongside five-element music. It assigns an exhaled sound to each organ (for example xu to the liver, he to the heart). It is described as "a breathing technique to protect health". [source: Lim et al. 2017]
• Where it fits. It is not part of the five-tone listening protocols above, and no primary instruction source is drawn on for it. [uncertain] Do not teach it from this guide. If a client is interested in an active, voice-based practice, refer them to a qualified qigong teacher, or to a credentialed music therapist for clinical voice work. [synthesis]

4.17 Adapting for children and young people [synthesis]

None of the sources describe paediatric protocols.

• Consent and parents. Obtain parental consent and the child's own assent. Explain to parents that this is a relaxation and listening activity, not a TCM diagnosis or medical treatment.
• Dose and volume. Use shorter segments (5–10 minutes), keep eyes open if preferred, and use lower volume. Do not use earbuds at night.
• Engagement. Let the child pick the instrument sound. Use drawing or movement afterwards to talk about the experience.
• Safeguarding. Usual safeguarding and mandatory-reporting duties apply to anything disclosed during the reflection.

5. Handling problems

The standards say only to observe for adverse reactions and to adjust the plan. The RFEMI protocol adds monitoring and stopping rules. Everything else in this section is my own synthesis and is marked as such.

• Adverse physical reactions: dizziness, ear pain, discomfort, agitation, unstable vital signs.
  • Pause the music and lower the volume.
  • Sit the client up, open their eyes, and check pulse or wellbeing.
  • Resume only if the symptoms clear and the client agrees. Stop if they recur.
  • Record the reaction. [source: NCT07653113; T/CRHA 036—2024 §7.3]
• Mood switch or rising excitement in bipolar disorder.
  • RFEMI discontinues participants who switch to bipolar disorder. [source: NCT07653113]
  • Avoid long daily exposure to energising modes for clients with a history of hypomania, and monitor sleep and activity. [synthesis]
• Suicidality.
  • RFEMI excluded people with suicidal or violent tendencies. [source: NCT07653113]
  • Five-tone listening is not a crisis intervention. Do a standard risk assessment and safety plan first. Use listening only once the client is stable, and never as the main treatment for depression. [synthesis]
• Hearing safety. [source: T/CRHA 036—2024 §7.3; Xiangya draft 2025 §4.4.1; synthesis]
  • Keep within the standards' low ranges: start around 25 dB and stay at or below about 60 dB.
  • Prefer room speakers for clients with tinnitus or hyperacusis.
  • Ask about ear fullness or ringing after sessions.
  • Limit nightly in-ear use.
  • Clients with hearing aids may need speaker delivery and a check of the aid's settings.
• Musical trauma triggers. [synthesis]
  • Traditional Chinese instruments and pentatonic tunes can evoke funerals, illness, war, political campaigns, displacement or abusive caregivers.
  • If a piece triggers flashbacks or dissociation: stop the music, open the eyes, and ground the client with present-moment orientation (feet on the floor, naming objects in the room).
  • Afterwards, note the trigger and avoid that piece, instrument or mode.
  • Do not use eyes-closed listening with clients prone to dissociation until grounding skills are in place.
• Overwhelming emotion during listening (tears, grief). [synthesis]
  • Lower the volume and offer to pause. Stay with the client.
  • Leave enough session time to process (4.14). Do not send a client away in a raised state.
  • Shorten future segments.
• Client dislikes the music or finds it foreign. [source: T/CRHA 036—2024 §6; ACTRN12622001528741p; Lyu et al. 2025; synthesis]
  • Preference is a selection criterion in the standards.
  • Try another piece in the same mode, or a different timbre (erhu, guzheng, flute).
  • If it still does not land, drop the five-tone frame and use preferred relaxing music.
  • Do not push cultural "authenticity".
• Falling asleep in daytime sessions. [source: T/CRHA 036—2024 §8; synthesis]
  • The nursing standard advises against it.
  • Shorten the segment, sit the client more upright, or move listening to bedtime if sleep is the goal.
• Non-adherence to home listening. [source: Lyu et al. 2025; synthesis]
  • Agree a smaller dose, for example 10 minutes once a day, and tie it to an existing routine.
  • Use a log or check-in message. Lyu et al. used a supervised group chat.
  • Explore ambivalence: "What gets in the way on the nights you skip it?"
• Stuck: no change after a full course. [source: T/CRHA 036—2024 §7.4; synthesis]
  • Re-evaluate the selection rule (matching versus counteracting).
  • Check dose and timing, and look for maintaining factors such as untreated sleep apnoea, substance use or ongoing stressors.
  • Then step up to evidence-based treatment, or stop the music component.
• Client believes the music will cure a physical illness, or wants to stop medication. [source: Kwon et al. 2024; T/CRHA 036—2024 §7.2; synthesis]
  • Restate plainly that the organ correspondences are traditional theory, not proven medicine.
  • Say that the listening is an adjunct.
  • Coordinate with the prescribing doctor. Never endorse stopping treatment.
• Over-identification with organ or element labels (for example "my liver is angry"). [synthesis]
  • Treat the label as metaphor and return to the client's own experience and situation.
  • Avoid labels that feel like a diagnosis.
• Ruptures. [synthesis]
  • Signs: the client feels exoticised, tested on, or that "therapy has been replaced by a CD".
  • Name the rupture, explain why you suggested the music, and offer it as optional.
  • Re-centre the relational and talking work.
  • With clients of Chinese heritage, ask what this tradition means to them, rather than assuming affinity or rejection.
• Resistance to closing the eyes or lying down. Keep eyes open, sit upright, and lower the room lighting less. Safety and control come before protocol. [synthesis]
• Scope problems. [source: T/CRHA 036—2024 §4; Xiangya draft 2025 §4.2; synthesis]
  • The standards expect training in TCM and music therapy.
  • If you lack it, keep to receptive listening and refer for pattern diagnosis or clinical music therapy.
  • Do not advertise "five-element music therapy" as a service you deliver.
• Psychosis, severe agitation or cognitive impairment. [synthesis]
  • Use short, eyes-open, therapist-present segments.
  • Avoid unsupervised headphone use.
  • Stop if perceptual disturbance increases.

Sources

Sources:

• 五行音乐疗法应用护理规范 T/CRHA 036—2024 (Chinese Research Hospital Association, 2024)
• 睡眠障碍五行音乐疗法技术规范 (group standard, consultation draft, 2025; proposed by Xiangya Hospital, Central South University)
• Kwon C-Y, Kim H, Kim S-H (2024). The Modernization of Oriental Music Therapy: Five-Element Music Therapy Combined with Artificial Intelligence. Healthcare 12(3):411
• Huangdi Neijing, Lingshu, 邪客 (Xie Ke), Chinese Text Project
• Lyu P, Li X, Yao X (2025). An empirical study on the intervention of TCM five-element music in alleviating anxiety and depression among medical students. Frontiers in Psychology
• Adjunctive Resonance-Based Chinese Five-Element Music Intervention for Depressive Disorders and Anxiety Symptoms in Male Inpatients (RFEMI protocol, NCT07653113)
• Yu WY, Sun Y-T. Does the cultural context impact on mood and stress level? Pilot study on TCM five-phase music therapy (ACTRN12622001528741p)
• Lim D, Kim W, Kang S, Hong S, Ryu K (2017). The potential for Han Ak (Korean music) therapy based on the five phases theory. TANG 7(2):e6
• Zhang X, Li X (2021). 五行音乐疗法改善慢性乙肝（肝郁脾虚证）患者焦虑、抑郁症状的效果. 临床与病理杂志 41(12) (abstract only)
• 中医五行音乐疗法的研究进展, 中西医结合护理 2022 (DOAJ record, abstract only)

Recordings cited (further reading, not drawn on):

• Shi Feng (composer). 中国传统五行音乐（正调式）. China Medical Multimedia Press. Details as reported by Lyu et al. 2025; year [uncertain].
• Traditional Chinese Medicine Health Tianyun Five Elements Music (CD). As reported in ACTRN12622001528741p; publisher and year [uncertain].

Further reading (not drawn on):

• Suwen chapter 阴阳应象大论. The emotion–organ lines were not checked against the original text. [uncertain]