Prior to initiation of recruitment or data collection procedures, this study received ethical approval from Concordia University’s Human Research Ethics Committee (protocol #30000163) and Comité d’éthique de la recherche conjoint destiné aux CRDITED (CÉRC-0143).

A convenience approach to sampling was employed. Participants had to be at least 18 years of age, English speaking, have a diagnosis of high-functioning autism or Asperger’s Syndrome,⁹ and have the legal capacity to provide their own informed consent. Eligible participants were informed about this study via recruitment procedures initiated by two social services organizations. Twelve potential participants contacted the researcher by telephone or e-mail to inquire about the project. Eight of these individuals (2 females, 6 males; 21–38 years old [M = 26.88, SD = 5.77]) decided to participate for various reasons (see Table 1).

All participants identified as Canadian though some indicated other cultural connections including South American, Peruvian, Russian, Chinese, German, Italian, and Ukrainian. Six participants did not indicate having a religious affiliation. One identified as a born again Christian and another identified as a Pagan (e.g., observed holidays on the Pagan calendar). Participants were not explicit about their sexual orientations, although one participant spoke openly about involvement in gay pride events and another male participant spoke about having a date with a female. Although all participants had support systems in place, four participants lived independently whereas four lived with one or more family members. The participants also had diverse musical backgrounds, preferences, and dislikes; some had sound sensitivities or other hearing issues. See Table 2 for an overview of this information.

This exploratory study employed a mixed methods concurrent transformative design, which is “useful for giving voice to alternative perspectives, advocating for research participants, and better understanding a phenomenon that may be changing as a result of being studied” (Hanson, Creswell, Plano Clark, Petska, & Creswell, 2005, p. 229). Theoretically, this aligned well with the purpose of this research (presented above). Qualitative data were collected throughout all phases of the research process and quantitative self-report type data were collected via individual meetings that happened before and after the singing group period (see procedures below). The use of open and closed questions, conversation, and Likert-type scale questions provided participants with different options through which they could express their perspectives. Given the small sample size, the explicit advocacy lens (i.e., neurodiversity and CoMT), and the exploratory nature of the research, priority was given to the qualitative data. Descriptive statistics were embedded into the qualitative results, which helped to verify, challenge, and elucidate some of the qualitative interpretations. This could also be considered as a component of trustworthiness (i.e., validity).

Prior to initiating the singing group sessions, I met privately with each participant to discuss the project and gather preliminary data. Each individual completed a form (with support from me as needed), that gathered information on: demographics, motivations for participating in the singing group; and music background, preferences, dislikes, and hearing/sound issues. These interviews were audio recorded to gather information that emerged in conversation and not captured via the form. In addition to gathering demographic and background information, Likert type questions (5-point scales) were used to capture participants’ attitudes on the importance of music in their daily lives, how they felt about their singing voices, their level of comfort with social situations, their mood and level of anxiety in their daily lives, and how they felt in general about themselves (i.e., their self-esteem) in their daily lives. They were also asked to indicate what they liked most and least about their lives.

All of this information helped me and three graduate research assistants (certified music therapists enrolled in advanced music therapy training) to create a flexible singing group format that was adapted as needed to accommodate individuals’ implicit and explicit needs, potentials, and goals as they manifested within a particular session and over the duration of the group. This format included: a brief verbal check-in, breathing, vocal, and body warm ups (incorporated improvisatory components); one or more opening songs (chosen by the music therapist facilitators; varied according to participants’ overall mood, level of energy, anxiety, etc.; often incorporated improvisatory components; sung a cappella or accompanied by a music therapist facilitator on guitar or piano); singing participants’ song requests and practicing selected songs arranged for a group CD project (this project was not preplanned and emerged as part of the group process); a closing song (participants voted based on 2-3 songs suggested by music therapist facilitators; suggestions varied according to participants’ need for relaxation, energy, and review or closure of issues that arose during the session; accompanied by a music therapist facilitator on guitar or piano; one participant (Nancy) sometimes played a drum).

Twelve, 1.5-hour, group singing sessions were held over a 10-week period. ¹⁰ Two of the graduate research assistants and I took turns leading the various group singing experiences. When not leading, we each provided musical and personal support for participants. The third research assistant monitored the video and audio equipment used to record the sessions (for analysis purposes) and also provided personal support to participants as needed.

Approximately four weeks after the singing group sessions ended, I again met privately with each participant. I began by presenting each individual with their copy of the CD project (described in the Results section) and asked them to choose a selection that we could listen to together. After listening, we chatted about their chosen selection––why they chose it, what they liked or did not like about it, and what they were thinking as they listened to it. Each individual then completed a form (with support from me as needed), that gathered information on: what they liked and disliked about the singing group, things that made them feel comfortable/uncomfortable, what they learned (if anything), if they would choose to participate again (if given the opportunity), and any other feedback/questions they had. These interviews were audio recorded to gather information that emerged in conversation and not captured via the form. As was the case in the pre-singing group interviews, Likert-type questions (5-point scales) were used to capture participants’ attitudes on various issues (outlined previously). Four more Likert-type questions were added to help understand participants’ level of comfort with the social aspect of the singing group; what they generally perceived their mood and anxiety levels to be during the singing group; and how they felt about themselves as a person (i.e., their self-esteem) during the singing group. Again, participants were asked to indicate what they liked most and least about their lives.

One of the graduate research assistants and I reviewed the audio-video recordings of the group singing sessions and created concise summary descriptions of what happened before, during, and after each singing experience––she completed five summary descriptions and I completed seven. I then reviewed all of the videos, highlighting salient points, quotes, and occurrences on the summary descriptions. I listened back to the pre and post singing group interviews, reviewed my session notes as well as qualitative data from the interview forms, and extracted relevant data (i.e., related to participants’ needs, potentials, quality of life) from these sources. Using all of this material, I conducted a directed qualitative content analysis using a pre-determined coding framework wherein I gradually pared the material down to create concise descriptions of how quality of life variables appeared to manifest for participants in this singing group context. Sample quotes from participants were incorporated into these descriptions, which contained both objective observations and subjective interpretations. The coding framework was based on domain and sub-domain headings contained within a Quality of Life (QoL) Model conceptual framework developed by researchers at the University of Toronto (Raphael, Brown, & Renwick, 1999; The Quality of Life Model, n.d.). These domain and subdomain headings were a good fit for the present study as they were developed from a holistic biopsychosocial perspective (defined above) and could be conceptualized specifically in accordance with participants’ needs and potentials, as they emerged or were revealed within the singing group context. ¹¹ I also added three musical sub-domain headings to this framework based upon the CoMT concept of health musicking, which suggests that there are multiple ways in which a music practice (i.e., group singing) may serve as a contextually situated health resource (Stige, 2012). See Table 3 which outlines the predetermined coding framework. As an overarching concept, QoL was defined as the ways in which participants expressed, enjoyed, and found meaning through realization of their individual and collective potentials.

QoL variables conceptualized within this framework were considered as components and potential determinants of participants’ health and wellbeing within the singing group context and in their everyday lives. Research suggests that enhancing various QoL domains rather than an exclusive emphasis on symptom-focused interventions will lead to better life outcomes for Autistic persons (Jennes-Coussens, Magill-Evans & Koning, 2006; Renty, & Roeyers, 2006).

Quantitative self-report data gathered in the pre and post singing group individual interviews were analyzed using descriptive statistics and paired samples t-tests. Notable results (including relevant examples of individual participants’ scores) were integrated into the descriptive framework, which helped to verify, broaden, and elucidate some of the qualitative results and interpretations.

This study demonstrated credibility through the use of triangulation (i.e., multiple sources of data such as pre and post interviews and audio-visual recordings). Although member checking was not used per se (addressed further in the Discussion section), participants did have the opportunity to provide additional perspectives in the post singing group session interviews. They were also sent a summary of preliminary results via e-mail or post (according to their stated preference) and invited to respond; none did. This study contains elements of transferability via the use of thick descriptions thus potentially helping music therapists or others to readily adapt components of the singing group format, process, and results to suit other singing group contexts for Autistic adults. Dependability and confirmability were addressed through: triangulation (described above), debriefing meetings held with the three graduate music therapy research assistants and me where we discussed our collective observations about the group; I referred to session plans and notes to help audit my interpretations; and I continuously reflected upon my beliefs, values, perspectives, and assumptions (through analytic memos, professional supervision, etc.) some of which were summarized at the beginning of this paper.

Although the Quality of Life Domains and Subdomains framework was predetermined (see Table 3 and rationale outlined above), the data analysis process was inductive in that each Subdomain was conceptualized specifically in accordance with participants’ needs and potentials, as they emerged or were revealed within the singing group context.

Prior to the present study, no research had been conducted on the potential benefits of group singing for Autistic adults. The process and results of the present inquiry indicate that these participants realized a range of QoL benefits, some of which are similar to those previously identified for the general adult population at large. These included observed and reported instances of: enhanced posture and voice quality (Clift & Hancox, 2001; Subdomains I a., d., & III d.); reduced feelings of stress/anxiety (Judd & Pooley, 2014; Linnemann, Schnersch, & Nater, 2017; Subdomain I b.); increased feelings of relaxation and heightened feelings of energy (Livesay et al., 2012; Mellor, 2013; Vaillancourt et al., 2018; Subdomains I a. & b.); new learning (Livesay et al. 2012; Subdomains III c. & d.); enhanced self-awareness (Mellor, 2013; Subdomains I a., b., c., & d.); meaningful social and musical connections made with others (Faulkner & Davidson, 2006; Stewart & Lonsdale, 2016; Vaillancourt et al., 2018; Subdomains II b. & d.); feelings of belonging (Judd & Pooley, 2014; Livesay et al., 2012; Mellor, 2013; Stewart & Lonsdale, 2016; Subdomains II b., c., & d.); enhanced feelings of self-confidence, self-esteem, personal growth, and accomplishment (Busch & Gick, 2012; Livesay et al., 2012; Vaillancourt et al., 2018; Subdomains I b., III c., & d.). Additionally, participants expressed pleasure and excitement when they felt that they sounded good (Subdomains I b., d., III. b., and d.).

Although needs of Autistic adults are unique to their circumstances and context and keeping the neurodiversity stance of this paper in mind, it is important to note that benefits of group singing experienced by the participants in this study overlapped with some benefits experienced by other adult cohorts who may face similar challenges (e.g., anxiety, social isolation, social stigma, etc.) albeit for different reasons. For example, previous research (Dassa & Amir, 2014; Lesta & Petocz, 2006) indicates that group singing in music therapy contexts has helped persons living with dementia to experience: feelings of accomplishment (Subdomains I b., III c., & d.) and belonging (Subdomains II b. & d.); enhanced social and musical interactions (Subdomains II b. & d.); reduced feelings of anxiety (Subdomain I b.); and enhanced feelings self-esteem and improved mood (Subdomain I b.). It is beyond the scope of this paper to compare and contrast the results of the present study with all studies that examine the benefits of group singing in clinical or CoMT contexts for the wide range of implicated adult cohorts. However, future studies could make these types of detailed comparisons which in turn, could aid in the formulation of population and context specific singing, health, and well-being best practice guidelines. A model of voicework in music therapy proposed by Baker and Uhlig (2011), does not explicitly include a CoMT philosophical orientation, and these guidelines could also contribute to further development of that model. Best practice guidelines on how to facilitate CoMT singing groups for Autistic adults (developed through further research) could also partially address the identified need for more training in music therapy service provision for these individuals (Kern, Rivera, Chandler, & Humpal, 2013).

Group singing appeared to have multiple benefits for the participants in this study that fulfilled and went beyond their original motivations for joining the singing group (see Table 2). Some participants also asked questions about how they could improve their singing skills and seemed to appreciate vocal tips. Although we did incorporate some aspects of vocal improvisation into the group (in the warm ups and opening songs), it would be interesting to explore in subsequent research how participants’ unique vocal expressions might be further developed within a wider range of improvisatory and compositional frameworks, and better understand what the associated benefits or contraindications might be.

In future reiterations of this singing group, individualized vocal coaching sessions and a broader spectrum of singing experiences might help some participants to further realize their unique vocal potentials (in traditional and non-traditional ways), which in turn could contribute to the overall creative energy and musical aesthetic of the group. From both practical (Subdomain III a.) and intrapersonal (Subdomain I b.) perspectives, literature suggests that increased vocal strength and flexibility has potential to enhance one’s feelings of control and sense of identity (Warnlock, 2011). It should also be noted however, that increased awareness of how one’s own voice actually sounds can be quite surprising or even upsetting, as was the case for River when he heard a recording of his vocal solo (which incidentally, sounded fine to the music therapists). Although we were able to work through this issue, this potential sensitivity must be kept in mind when doing voicework with individuals whose sense of self may be somewhat fragile due to life experiences (previous and ongoing) of feeling unaccepted or like they do not belong.

There are additional factors pertaining to singing and performance that must be considered. Given the exploratory nature of the research and the short duration of the singing group, this project did not include a public performance component, which within a CoMT approach, may serve as a platform for promoting equal rights and social justice (Vaillancourt, 2012). Public performance as a vehicle for self-advocacy, empowerment, creative self-expression, community connection, and public education is a central component of the Sensory Friendly Concerts (SFCs) initiative (described previously and discussed further below; Shiloh & Lagasse, 2014). Brandalise (2015) illustrated how incorporating theatre performance into a CoMT approach helped to meet the psychological, cultural, and social needs of a group of young Autistic adults (aligns with Subdomains I b., c., & II b., respectively). Some participants in the present study (River and Sean) expressed a desire to perform and future singing groups for Autistic adults could consider this option. However, having been involved in various types of CoMT singing groups (e.g., Young, 2009; Young & Pringle, 2018), it has been my experience that some individuals benefit first and foremost from participation in the group singing experience in and of itself and do not necessarily want to perform in a public forum. These individuals need access to group singing contexts where participation in performance is not required. Additionally, there are situations where vocal performance may be contraindicated (e.g., the amount of anxiety elicited negates potential benefits; Young & Nicol, 2011). Finally, in a study that examined negative experiences of amateur choral society members, Kreutz & Brünger(2012) found that perceived demands of public performance lead some individuals to form negative associations with choral singing. This is an important finding to consider, especially if the fundamental purpose of a singing group is to promote feelings of well-being.

In the present study, the CD project recording process could be considered as a type of performance, wherein participants worked together to achieve uniquely tailored renditions of each selection, which they could later share with family and friends if they chose to do so (Subdomains II b. & c.). This type of project (which emerged out of the group process and was not pre-planned) could serve as a viable alternative for or adjunct to community/public performance depending upon the individual and collective needs or goals of a particular singing group.

This research was motivated in part by my belief that a singing group conceptualized within a CoMT approach could provide Autistic adults with a creative and supportive forum wherein individual neurodiverse participants could realize their unique potentials. As this belief aligns with the philosophy of Sensory Friendly Concerts (SFCs; Musical Autist/About, 2018; Shiloh & Lagasse, 2014), it is relevant to highlight similarities and distinctions between these two initiatives. It is also important to note that the identified distinctions are not contradictions but rather different ways in which the subdomains contained in the present study’s QoL framework may be realized and supported.

Like SFCs, we made accommodations to support the sensory needs of our participants (see Table 3; also aligns with Subdomain III a.). Although we did not have access to noise cancelling headphones/ear buds ¹⁵ (which I would definitely use in the future), our participants did have access to foam ear plugs, which one participant (Gabriel) used regularly. If anyone became overwhelmed or overly anxious, it was understood that they could leave the room and sit quietly in an adjacent room until they felt ready to return (SFCs have a designated sensory calm room). One of our group facilitators would accompany that person and check on them as needed; and provide musical and personal support when they returned. For very valid reasons (e.g., auditory processing disorders/sensitivities, loud, startling sounds; disconcerting effects of surround sound, etc.), SFCs do not use a house Public Address (PA) system. However, in this research project, we did use a microphone attached to a speaker (via a soundboard) for individuals who performed solos or other special parts on the group CD project. For some, singing into and holding a microphone appeared to be an empowering experience (as evidenced by body stance, gestures, facial expressions, comments, etc.; Subdomains I a., b., c., & d .), and it was very helpful for participants with soft voices who wanted to sing and record a solo part (Subdomain III a.). It also enhanced group awareness (i.e., group members watched and listened to the soloist more intently; Subdomains II b. & d.) and clarified musical roles (i.e., created an inherent structure wherein soloists and backup singers naturally assumed these roles; Subdomains I d. & II d.). The music therapist leading particular rehearsal/recording activities sometimes wore a headset microphone to provide vocal support/direction as needed for both group and solo parts. We did have one incident where feedback from our amplification system greatly startled Clare who was rehearsing a vocal solo for the CD recording. Although the group members demonstrated notably enhanced musical and personal support (Subdomains II b. & d.) toward her as a result of this incident (their previous interactions with her had been somewhat limited/strained), it also clearly demonstrated potential contraindications for use of amplification. I recommend considering this issue with great care and caution, taking the needs of each group and individual as well as the particularities of each singing group context into account. It is also very important that the intricacies of the equipment be well understood, if it is to be used.

Like the SFCs initiative, this research singing group context also provided “a safe and understanding environment where different responses to music [were] respected” (Shiloh & Lagasse, 2014, p. 118). Behaviours such as hand flapping, rocking, or spontaneous vocalizations were not discouraged. Improvised dancing, moving to music, or walking around were considered as natural forms of musical and self-expression (Subdomains I a., b., c., & d.). Songs for the CD project were arranged to showcase the unique musical, personal, and cultural expressions, strengths, and preferences of individual participants (also see Tables 2 & 6).

Unlike SFCs, we did not integrate community musicians into our group. The four certified music therapists involved in the project (three certified music therapist graduate research assistants and I) provided both musical and personal support. Musically, we brought a range of clinical and performance skills (including vocal knowledge and experience) to the project which helped us to accommodate traditional and non-traditional aesthetic needs and potentials of participants. Our therapy training and experience helped us to understand and navigate complex group processes and individual challenges that emerged as well as provide individualized support to help promote the realization of unique personal resources. However, this does not preclude the inclusion of community musicians in future reiterations of singing groups for Autistic adults. This could potentially expand the scope of music experiences offered (i.e., unique genres, instruments, vocal approaches, languages, etc.; aligns with Subdomains I c., d., & III d.), enhance individuals’ understandings about autism, and strengthen reciprocal connections between community members and Autistic culture (Subdomains II c. & d.)

Although I did have a few brief interactions with parents/other caregivers (via phone, e-mail, or in person) they did not observe sessions nor were they invited to be part of the singing group as they are at SFC gatherings. Initially, this decision was made for two reasons: (a) to have a clearly defined group of research participants (i.e., include verbal Autistic adults only), and (b) an identified lack of programming that catered specifically to the needs of Autistic adults. Research has indicated that difficult transitions from supportive youth services to limited or no services for adults has left young Autistic adults and their families feeling concerned about their potential to live a meaningful life (Milen & Nicholas, 2017). This small singing group consisted of eight diverse individuals who had experienced social isolation and stigma because of their autism, even though (and sometimes because) they had caregivers who had tried to protect them. Throughout the research process, participants implicitly and explicitly indicated their desire to live their own lives and find their own way (Subdomains III a., b., c., & d.). For this particular age cohort (and perhaps for older Autistic adults), this type of delimited singing group format may serve as an empowering forum or transitional space where Autistic individuals can discover, accept, and celebrate unique aspects of themselves. The inclusion of caregivers (and others) as part of a singing group format would potentially have other benefits. For example, parents and caregivers who participate in the SFCs initiative experience an environment where autistic behaviours are accepted as the norm, they learn about neurodiversity, and they are able relax and enjoy the music at whatever level they desire to participate (Shiloh & Lagasse, 2014). Possible benefits of singing groups that include parents/caregivers/others as well as the potential for adaptation/modification of relevant components of existing inclusive community chorus models (e.g., Carpenter, 2015) should be further explored in future research.

As previously noted, research suggests that enhancing various QoL domains rather than an exclusive emphasis on symptom-focused interventions will lead to better life outcomes for Autistic persons (Jennes-Coussens, Magill-Evans & Koning, 2006; Renty, & Roeyers, 2006). The research process and results of the present study further reinforce this position and also indicate that a singing group conceptualized within a CoMT philosophical approach may serve as a forum for empowerment and self-actualization on individual and collective levels. However, more research is needed to understand various ways in which singing groups might be conceptualized for Autistic adults and what the contextually specific complexities and benefits might be. For example, aging well is becoming an increasingly popular concept in society yet there is limited research and knowledge on what this means for Autistic adults. In a qualitative interview study conducted with 15 Autistic adults and 9 carers of Autistic adults that explored this concept, Hwang, Foley, and Trollor (2017) found that being autistic was not viewed as a hindrance (i.e., aligned with a strengths-based, neurodiversity perspective) but that participants identified social and relational issues (Subdomain II b.) as well as societal attitudes (Subdomains II c.) as unique and key factors to aging well. Future inquiries could explore how these (and other) issues might be addressed via a CoMT singing group context for aging Autistic adults.

Autistic self-advocates do not support the traditional biomedical cure research agenda for autism and instead believe that research priorities should focus on areas that have the most potential to improve the daily lives of Autistic people (ASAN, 2018a). Music therapist researchers (in collaboration with a range of relevant stakeholders) need to find ways to legitimate QoL music therapy practices and produce accessible and practical findings without utilizing research methodologies that contribute to the disempowerment of participants (Metell, 2014). Throughout this research process, I became more consciously aware of how aspects of the biomedical model were subtly influencing what I considered to be my humanistic client/music centered therapy approach. Both music therapy students and professionals need to develop skills and understanding on how to navigate the current systemic realties of employment contexts without inadvertently contributing to the disempowerment and over-pathologization of their clients. This issue could be more consistently and directly addressed within the context of music therapy training programs, continuing education, and professional advocacy initiatives.

This study has limitations that must be acknowledged. All of the participants were verbal and highly capable in various aspects of their lives. Therefore, the research process, results, and implications may have limited applicability to Autistic persons who are non-verbal and whose challenges and strengths manifest in other ways. Additional research that explores how various individuals on the autism spectrum might realize their potential for wellbeing through musical self-expression (vocally or otherwise) is warranted.

Although I am able to share audio recordings of the group within presentation contexts, I unfortunately did not obtain participants’ consent to include audio excerpts in any related publications. In some instances, one can hear how particular subdomains contained within the overarching QoL domains are reflected in various singing experiences. These audio excerpts would have served to further validate the findings and well as provide concrete, practical, and thought-provoking examples for readers. Whenever possible, researchers should try and obtain permission to include audio examples in future similar research publications.

Some may view my dual role as researcher and lead group facilitator as problematic. Given the exploratory nature of this study, I felt that I needed to directly interact and develop relationships with the participants in order to identify and set aside my assumptions and make my best attempt to truly understand how QoL variables might be realized for this group in context. In the post singing group interviews (as compared to the pre singing group interviews), participants were generally more comfortable in sharing their perspectives (i.e., they talked more and were more forthcoming with their answers) because they had gotten to know me, which I believe ultimately enhanced the quality (i.e., authenticity) of the post session data.

I also decided not to use member checking. It took a long time to transcribe and analyze the data, and the passage of time may have affected participants’ perspectives in such a way that could have convoluted rather than clarified the results (McConnell-Henry, Chapman, & Francis, 2011). Furthermore, in getting to know the participants, I came to believe that a member checking process could evoke unnecessary anxiety for some individuals. In future studies, it may be more useful and appropriate to include [some or all] participants and other Autistic individuals as part of the research team to ensure that key stakeholder perspectives are an integral part of the process at every stage (i.e., use a participatory action research methodology). A current study being conducted on “Music in Everyday Autistic Life” (funded by the American Music Therapy Association Fultz Award) is utilizing a 6-member, neurodiverse research team for this very reason (K. Aigen, personal communication, February 13, 2018).

Finally, the Likert-type scale questions provided concrete choices for answers and this seemed helpful for some participants (i.e., less anxiety provoking than open ended questions or conversation). Additionally, examining individual participants’ quantitative data sometimes provided important information that either elucidated or validated some of the individual and group qualitative interpretations. However, some individuals expressed anxiety at having to choose an answer (that felt like it could be wrong) and felt that more context was needed (e.g., I am highly anxious in some social situations and not in others). Although the quantitative results have some potentially meaningful implications, they should be interpreted with caution. In future research studies, the inclusion of Likert-type scales may be most useful for the unique reasons outlined here, and their value as a measure of the general attitudes of a group of Autistic adults may be limited.