Background <p>The experience of pleasure in music therapy has been underexplored. This paper examines the possibility that pleasure might mediate the effectiveness of music therapy interventions, particularly for individuals experiencing anhedonia (diminished ability to experience pleasure). We theorise this proposition by exploring music therapy processes and findings from two case studies involving people with anhedonia.</p> Methods <p>An interpretive case study approach was employed to generate explanations for observed outcomes. Following ethics approval, three participants meeting clinical criteria for anhedonia were recruited. Over four months, they engaged in tailored daily independent music activities focused on eliciting pleasure, supported by a music therapist. Multiple data sources were collected, including standardized anhedonia measures, daily ratings, interviews, and therapist observations.</p> Results <p>All three participants showed improvements in anhedonia scores, with two moving into the normal range by study completion. Qualitative data revealed the importance of: 1) accessible and intentional pleasure-focused music activities; 2) therapeutic alliance providing guidance, psychoeducation and motivational support; and 3) participants' existing relationship with music as a historical source of pleasure. Specific therapeutic principles that facilitated outcomes are outlined.</p> Conclusions <p>Findings suggest musical pleasure may be an important mediator of positive outcomes in music therapy, particularly for anhedonia. By overtly targeting pleasure through tailored music activities and therapeutic support, participants reconnected with musical pleasure, which generalised to improved hedonic capacity. Interacting dimensions of pleasure-focused musicking, the pleasure experience, and therapeutic scaffolding are proposed as key mechanisms. Implications for music therapy practice and future research are discussed.</p>