The 54 participants in the program resided in the community and were considered “healthy” as reported by self-administered questionnaires. Based on these questionnaires, inclusion criteria were a health condition without a self-reported diagnosis of chronic diseases, psychiatric issues, or a cognitive or functional decline. Participants included 48 women and 7 men (ages ranged from 60-93; mean age 71.07). The participants were recruited from social clubs for older adults and attended the meetings independently. Most of them were women (87%), with high school or academic education (82.6%), most reported as having a good health condition (77.2%), as financially well off (93.3%), and with no previous musical background (92.5%).

Following a pilot group facilitated by the first author (a music therapist), which included five sessions conducted once a week with 10 community-dwelling older adults, a preliminary protocol was formatted. The protocol was based on two senior music therapists’ clinical experience in conducting music therapy groups with adults. Based on the positive findings of the pilot, including improvement in self-efficacy, self-esteem, and in mental well-being measures, an intervention led by the same protocol was delivered to the 54 participants mentioned above. The protocol included 12 weekly continuous sessions for three-months.

Each session lasted 90 minutes. There were six intervention groups, each containing 8-10 participants (54 participants in total). Two music therapists co-conducted each of the six groups, which took place at the first author's university. The music therapists attended weekly supervision meetings with a professional music therapist throughout the intervention.

The format and musical material were pre-planned according to the participants’ musical preferences, which were elicited during the pre-focused group interview. Each session included the following activities:

There were six pre- and post- intervention focus groups (FG). Each included 8-10 participants. The focus group interviews were conducted by the music therapists who co-facilitated the intervention. Focus group data allow rich information to emerge from the interaction between participants during the discussion. The researcher encourages participants to share their thoughts and respond to other members in the group (Acocella, 2012).

The discussion in the focus groups included questions such as:

These questions helped to promote a group discussion. While the music therapists were often not required to intervene, they tried to encourage all group members to engage. Qualitative content analysis revealed that group members engaged in an open dialogue and that the therapists had very few interventions in this dialogue.

The data was analyzed through a systematic qualitative content analysis (Kohlbacher, 2005) collected from the six groups on two occasions: pre-intervention (session number 1), and post-intervention (session number 12). A systematic process of step-by-step categorization was conducted. During the initial coding stage, the researchers marked word fragments, lines, segments, and incidents of the participants’ experiences. The researchers aimed to remain open to all possible directions indicated by the data. In the second coding stage, these textual parts were conceptualized into more salient categories, using the most common codes which were previously marked during the initial stage, with the aim of condensing the previous codes into general categories. This systematic process enabled us to focus on the main themes concerning the participants' attitudes and feelings regarding the vocal group experience.

The music therapists who guided the intervention also conducted the focus groups. One of the music therapists was also the researcher (the first author). These dual roles created more concerns regarding the aims of the intervention and its efficiency according to the expected results of the research and according to the opened responses of the participants. The dual expectations as a researcher and as a therapist were managed by receiving thorough supervision from an experienced music therapist throughout the intervention, striving to separate these potentially conflicting roles by focusing on the aims of the group itself and not on the expectations of the research (Bourdeau, 2000; Conneeley, 2002). Moreover, for the sake of credibility, and due to “the challenges of dealing with the researchers’ preconditions and consequences of research focusing on (social) critique, usefulness, relevance and ethics” (Stige et al., 2009, p. 1504), an experienced music therapist with expertise in working with older adults served as an external examiner, reviewed 80% of the data and commented on the reports from the content analysis.

To the authors’ knowledge, this is the only published study that uses vocal group improvisation in healthy older adults as a means to change their views on their voices and thereby to improve their self-esteem. As previously reviewed in the introduction, studies in this field mostly focused on populations of older adults with medical and psychiatric problems. The findings of this research indeed demonstrated that the participants experienced a significant and a positive emotional process due to the group work. This process began by them playing an active role in a new experience that has led them to improve their attitude about their voices. Moreover, the participants were involved in self-exploration and reported an improvement in their self-beliefs concerning their voice and interpersonal capabilities, as well as an observable positive change in behaviors in the group, such as self-expression and in regard to reported behaviors like the initiation of new activities in their daily lives.

Exploring their voice through vocal improvisational group work introduced the participants to a new experimental activity, one that helped them to free inner boundaries and discover new modes of expression. Their vocal exploration has led them to an intimate experience. The music therapists provided vocal means for exploring sounds and aimed to improve their capacity to release sounds and primitive vocal expressions, helping them to reconnect with their primal nature, access intense feelings, and give voice to the inexpressible and to their entire range of personality (Loewy, 2004). In this respect, this vocal exploration helped the participants express themselves, but also voiced emotions and feelings that were out of their awareness.

The mechanisms by which the vocal improvisation has served as an outlet for these emotions, validated them, and provided them with new meaning can be deduced from the participants’ reports. The participants reported feeling understood by the other group members and the therapists. They said that vocalizing and improvising together was meaningful, and made them feel more secure and a greater sense of belonging than before their participation. This is in line with previous clinical evidence demonstrating that exploring and voicing repressed primitive sound forms of self-expression (screams, sobs, etc.) helped to reclaim aspects of people that have been silenced or inhibited by their families and society (Loewy, 2004). This evidence is also consistent with the participants’ experience regarding cultural influences which characterize people of their generation in which it was common to be silenced. Some of them reported that from childhood and throughout most of their adulthood they had to internalize their wishes, desires, and feelings. Due to their old age, the participants reported that they gave up any hope they would ever express those repressed feelings. Not being able to express oneself as a child might lead to repressed feelings, insecurity, and anxiety in adulthood. Someone who has been silenced in the past might not even recognize or understand these negative feelings and how they are related to the current wish for self-expression (O'Loughlin, 1995).

Producing sounds and exploring one's voice play a larger role than just freeing hidden emotions. It is the key to accepting one’s voice regardless of training or background (Oddy, 2011). Therefore, perhaps using their voice as a channel for emotional expression helped the participants not just to accept their voice as it is, but also to accept themselves.

Another possible explanation for the evident change in the participants' self-acceptance was the impact of vocal expression as a physical experience. Finnegan (2012) has argued that music is experienced directly in and through the body, as it enhances one’s sense of self and better familiarizes a person with their own personality. Moreover, Bojner-Horwitz (2018) argued that music also increases contact with embedded emotions and develops empathy. A renewed contact with the self and an improved mood can change a person’s perception and, consequently, their well-being (Robertson & Monaghan, 2012; Seidler, 2007).

Vocal improvisation can also serve as an outlet for experiencing a wide range of emotions. The participants reported that improvising together led them to experiencing and expressing contradictory emotions. Music engagement offers what Seidler (2007) refers to as an “emotional space,” where it is socially accepted to experience a wide range of different emotional and affective states. Moreover, a vocal improvisation group work might aid in reinforcing the capacity to differentiate between positive and negative feelings. In some vocal exercises the participants testified that they not only learned how to express emotions in general but also to express contradictory emotions. This is notable due to cultural influences which characterize their older generation. Through vocal improvisational group work they expressed feelings that were sometimes contradictory (such as joy and sadness, etc.). Thus, as Ong and Bergeman (2004) argued, the participants reinforced their capacity for emotional complexity, which seems to improve in later life (Bodner et al., 2012; Carstensen et al., 2000; Ready et al., 2006; Ready et al., 2008). As the group provided a safe space for the participants to vocally express their emotions, it enabled them to use this ability.

From childhood, the self-perception of one’s voice is strongly connected to others’ opinions, which is why vocal exploration requires safe and non-judgmental environments. A safe environment makes it possible to share private experiences and serves as a venue for personal discoveries (Loewy, 2004). Indeed, the participants in this study reported that they experienced the group as a safe place.

In this regard, the term a “field of play,” coined by Kenny (2014), can be used. A field of play is a musical space where one feels secure and is free to engage in play. It is a space where there is a new openness, freedom, and a joyful sense of discovery, experimentation, and energy. According to this term, in one’s playfulness one may find authenticity, innovation, enjoyment, pleasure, and joy (Kenny, 2014). As can be seen from the qualitative data, the participants shared the notion that the group served as a safe and containing place for expressing their emotions. Some participants even testified that the group has inspired them with such a sense of confidence in expressing their feelings they had never evidenced before. They also reported that the atmosphere of the group enabled them: to feel free to play with their bodies and voices; to openly express various types of vocal expressions, such as a child’s voice or an authoritative voice; and to express their thoughts. The participants testified that this new experience enabled them later to transform this reassuring and safe atmosphere to their play with their grandchildren.

It should be noted that at the same time, they also expressed some reservation, stating that the outside world (their family members), might judge their behavior as unsuitable for their old age. The positive atmosphere had evolved through the workshop and enabled the participants to experience the "field of play." They explored new ways of expression, released repressed emotions, and freed themselves from their old beliefs by exploring new territories. They no longer felt that their voices are ugly and expressed the feeling that they are capable and allowed to play despite their old age.

This finally led them to change their beliefs and behaviors and to more strongly believe in their ability to sing in front of other people, join community choirs, write songs, and plan new activities in their daily life, such as learning new academic skills or going on vacation. In this regard we can conclude that the participants in the group had personal resources that could enable them to achieve such benefits from the vocal improvisation group, and this conclusion justifies the investment of music therapists in groups of healthy older adults.

Self-esteem is defined by Harter (2006) as an overall feeling of self-worth, which is essential in promoting emotional well-being (Mann et al., 2004; Rogers, 1961). Feelings of self-worth can act as a psychological engine that propels us toward positive health and adaptation. Criticism, on the other hand, deeply questions our self-worth (DuBois et al., 2009).

The effect of vocal expression on the participants' self-esteem may have created a bi-directional process, whereby the vocal expression improved these self-perceptions, which subsequently enabled better vocal self-expression, and vice versa. The participants reported that they better recognized themselves: My voice is who I am (Rivka, post-FG4); and they felt more confident in managing their everyday lives. Some even reported a change in their behavior, such as initiating new things they never had the courage to do before, despite the ageist belief that “you can’t teach an old dog new tricks.” The safe and non-critical vocal improvisation group work enabled the participants to self-explore, make new self-discoveries and strengthened their self-esteem and well-being.

Engaging in music provides emotional rewards for people, such as being in touch with one's emotions (Juslin & Sloboda, 2010). Being in touch with one’s emotions is important since it “lies at the heart of our capacity to experience meaning” (Johnson, 2007, p. 53), and meaning is one of the central elements of well-being (Batt-Rawden et al., 2005; Ruud, 2013). As people understand, recognize and acknowledge new parts of themselves and their uniqueness, they find new meaning in their lives, which promotes positive psychological well-being (Zika & Chamberlain, 1992), including being more adept at dealing with life's challenges (Krok, 2015; Park & Folkman, 1997). As stated before, older adults face many challenges in their daily lives, which may evoke a mix of undefined negative emotions which may undermine their sense of meaning. As demonstrated in this study and in line with other current studies that showed the value of musical involvement in old age (e.g., Lindblad & de Boise, 2019), the improvised vocal group work offered a variety of experiences of emotional expression that may alleviate the challenges and physical impairments that accompany the aging process and provide new meaning to the participants.

Our findings are also consistent with other studies showing that music engagement in old age reveals hidden parts of older adults’ identity, provides them with a sense of meaning and stability, and strengthens their sense of self (Lindblad & de Boise, 2019, Volgsten, 2012; Volgsten & Pripp, 2016). The participants in this study experienced new modes of expression through vocal exploration, which helped them to discover new and dormant elements of their self-identity. This may have helped them deal with the challenges they encounter in old age, such as loss of meaning in life, social status and networks, and their sense of identity, factors that tremendously impact their well-being (Jackson, 2016; Russell, 2004). The vocal improvisation group provided a safe environment to explore their identities by expressing themselves vocally and improvising in the here and now freely, leaving prior self-judgments behind.

Everyday use of music in old age is a “provider of vitality – that is, emotional stimulation and expression; tool for developing agency and empowerment; resource in building social networks; and a way of providing meaning and coherence in life” (Ruud, 2013, p. 10). All these advantages of music engagement are in accordance with the participants’ experiences regarding their new sense of capability that empowered them not only during the group work but, most importantly, in their daily lives. The participants shared their plans to join local choirs and to perform at social gatherings, they talked about new plans for vacations, reported new friendships, and even decided to register to academic programs. In addition to their change in behaviors, this emotional process via the vocal improvisation group work has led the participants to a changed attitude toward their voice, as well as to a change in their self-beliefs concerning their voice and interpersonal capabilities. As they wrote in one of their songs: We are older people, 60 years old, experiencing how to smile and how to have fun, learning how to create more fun from within ourselves, fun that until now was hidden (from concluding song, group number 2).