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Monday, January 23, 2006

Summary: A look at the many disciplines working with voice over the past 50 years is provided from the perspective of a speech-language pathologist (SLP). Some of the earliest collaborations between medicine and speech-language pathology were seen in the management of cleft palate and velopharyngeal inadequacy problems and observed, also, in laryngectomee rehabilitation. The earlier concern of the SLP for the emotional and psychological aspects of patients with voice disorders appeared replaced with the rise of symptomatic therapy. Dramatic improvement in instrumentation assisted by computer analyses increased our awareness and understanding of both normal and disordered phonation. Although instrumentation today allows for many forms of visual feedback in voice training and therapy, this may be often at the expense of providing needed kinesthetic-proprioceptive and auditory feedback. Particular voice therapy approaches (cognitive, gestalt-holistic, imagery, resonant therapy, muscle training, and symptomatic therapy) used today are described. Suggestions are given for improving educational requirements and clinical experience in voice for SLPs.

Key Words: Voice Disciplines--Collaboration--Instrumentation--Feedback--Therapy--Training.



In 1961, I met the President of the American Speech and Hearing Association (ASHA) by a chance seating in the coffee shop of the Sherman Hotel in Chicago. This friendly, accessible human being invited me to sit with him for breakfast. That man was Paul Moore. That was 40 years ago, and he and I have had the good fortune of developing an ever-growing mutual friendship along with our families and spouses over those years. For about 20 years, we liked to have breakfast together, often with our friend Doug Hicks, at either an ASHA meeting or at the annual Voice Foundation Symposium. Many of us in the room have had our career heroes. G. Paul Moore is mine. He is brilliant, yet humble, and always comfortable with himself. This has allowed him to reach out to students and to voice newcomers, as well as to the more established and sometimes opinionated members of our lot. When he is with other people, he has the knack of making them feel important, feeling good about themselves. For me to be asked to present this lecture, named for a person so dear to all of us, is indeed a personal and professional challenge at this late stage of my career.

My topic today concerns fostering communication and understanding between various voice disciplines, a topic that was needed more one half a century ago than it is today. A meeting like this one, the Voice Foundation's 30th Annual Symposium: Care of the Professional Voice, could not have been held 50 years ago. There was no unity among our diverse professions. We were further apart than we are today. We had performers, actors, and singers. We had professional users of voice like teachers and preachers. There were singing teachers and vocal coaches. There were voice scientists and speech pathologists. There were dentists and physicians, such as plastic surgeons and laryngologists. I have searched for an all-inclusive word for such a collection of specialists. Tentatively, I am using the word "smorgasbord" for this presentation. The origins of the Swedish word "smorgasbord" were for naming a collection of appetizers and other tasty foods in one setting; the word has emerged in the English language as a noun for naming a "widely varied assortment or collection." (1) The professional use and care of the voice has been practiced by a diverse group of individuals with very little training beyond their own specialty. Indeed we were a smorgasbord with sparse communication between individuals. When people crossed over the threshold beyond their particular specialty, they were viewed as an amateur or invaders of a turf for which they had no training. The remnants of this kind of thinking still interfere with our attempts at professional cross-fertilization and our acceptance of the views of people trained differently than we were. In the 30 years of the Voice Foundation's annual symposiums: Care of the Professional Voice, there has been remarkable growth in acceptance of our professional diversity. Although we may unnecessarily guard our turf, we listen more and are more accepting to those among us with different backgrounds.

My look at our vocal smorgasbord begins in 1951 when I first began as a professional speech pathologist, working at that time with a Bachelor's degree in an aphasia center at the Veteran's Hospital in Long Beach, California. Obviously, at that time with a scant education and limited clinical training, I was deservedly low in the hierarchy of other professionals at this renowned aphasia center. Like many of us early in our careers, I was unaware of what I did not know. However, this unawareness that we experience early in our careers, which hopefully diminishes with experience and time, probably enables us to function in our particular discipline. For example, as one develops more awareness of other treatment alternatives, it may become more difficult to be comfortable with a particular treatment regimen one may be using. After 5 years of doctoral training and increased clinical experience, I found that education was in part becoming aware of what one does not know. It has been wisely said that, "the more one knows, the greater awareness of what one doesn't know." In this context of being unaware, it is my belief that many of us today do not fully appreciate the knowledge base, competency, and experience of voice professionals in other disciplines. Or the specialist within a particular profession may not appreciate the competence and clinical worthiness of a colleague who practices in an entirely different area within that profession, ie, the present-day speech-language pathologist (SLP) who is a specialist in swallowing disorders may not appreciate the clinical genius of the SLP who successfully reduces vocal hyperfunction in children with vocal nodules.

Among the 1859 members of ASHA (2) in 1951, the clinical membership, members who provided speech and voice therapy, was outnumbered slightly by the speech-voice scientists and teachers of speech pathology in the universities. From these universities, a clinical voice literature emerged in the 1950s with more focus given to cleft palate and velopharyngeal inadequacy (VPI) than to the remediation of symptoms related to vocal abuse and voice misuse. Velopharyngeal problems were one of the first clinical treatment areas that blended the skills of the voice scientist, the speech pathologist (designated name before 1978), and the dentist or medical surgeon. Perhaps one reason for the early prominence in correcting velopharyngeal incompetence was that particular dimensions of the problem, such as air volumes and pressures, were measurable. Physical defects like cleft palate or velar insufficiency were clearly observable with the measuring equipment of the day. Furthermore, the problem could often be corrected through prosthodontic or surgical treatment followed by speech/voice therapy. Finally, treatment success could be measured by pretreatment and posttreatment comparisons.

Another area of developing cooperation in the early 1950s between speech pathology and otolaryngology was in the postsurgical rehabilitation of the laryngectomy patient. In Detroit, 1952, the International Association of Larynectomees (IAL) was founded, primarily through the efforts of Julius McCall, otolaryngologist, and Warren Gardner, speech pathologist. The early focus of the IAL was on incorporating lay patient visits for the new laryngeal cancer patient who was usually facing a total laryngectomy. These preoperative visits, arranged jointly by the surgeon and a speech pathologist, coupled the new patient with a previously operated patient who could demonstrate good esophageal voice. In the early years of the IAL, less favorable reaction was given for using the artificial larynx (pneumatic or electronic) rather than using functional esophageal speech. The IAL went on to become a program of the American Cancer Society (3) with a continuing focus on providing local support group and rehabilitative services for the patient surviving laryngeal cancer after successful partial or total laryngectomy.

Both the literature and my personal recollection of speech pathology in the early to mid-1950s is that voice therapy was more focused on voice problems secondary to organic pathologies related to cancer, dysarthria, and organic resonance deviation than it was on functional voice problems. In addition to working with organic voice pathologies, the speech pathologist was active in the evaluation and treatment of articulation disorders, stuttering, aphasia and children's language disorders, and motor speech problems. There was in the 1950s a growing concern that many voice problems were but symptoms of an underlying personality disorder. The book, The Voice of Neurosis, (4) by Paul Moses was widely accepted by both the medical and speech pathology communities, presenting the view that it was the voice patient's anxieties and unresolved personal conflicts that were not only the cause of the dysphonia, but also often the reason voice symptoms continued. Voice therapy was only treating symptoms. It was, therefore, no accident that those of us in the 1950s in doctoral training in speech pathology with an interest in voice disorders chose doctoral minors in clinical psychology. We coordinated our voice therapy closely with the services of practitioners in psychiatry and clinical psychology.

From the perspective of a speech-language pathologist in the year 2001, I see occasional reference that voice and resonance are two separate entities. Resonance is part of voice. In this particular presentation, I view voice (as most of us assembled here do) as a product of phonation and resonance combined. Phonation coming from vocal fold vibration is continually influenced by changes in the force and volume of the airstream with continual resonance variation related to changes in laryngeal, pharyngeal, nasal, and oral postures.

Looking at phonation and resonance historically, we can briefly summarize what we were doing in our voice evaluations prior to 1960, as shown in Table 1. All voice evaluations included audiometric and respiratory data as a prelude to acoustic testing and the examination of the vocal mechanisms. The better diagnostic-evaluation clinics at that time were in the universities and not in physician's offices or medical centers. Visualization of the larynx was accomplished by mirror examination, sometimes supplemented by stroboscopic viewing. The evaluation typically ended with stimulability testing to determine if application of a particular therapy technique, such as imitating an acoustic model, would help the patient produce better voicing. We call this today a "diagnostic probe."

Most of the university and college voice clinics had consulting neurologists and otolaryngologists. In the 1950s, if it had been determined that an organic or physical problem was the origin of the voice disorder, the primary management of the patient belonged to the physician. If all organic factors could be eliminated as causal factors, the diagnosis of functional dsyphonia was usually made. Patients with diagnoses of functional dysphonia were often sent for psychological testing followed by possible psychotherapy. The voice therapy literature was sparse for what to do with functional voice problems (see Table 2).

The evaluation and management of resonance disorders, particularly related to velopharyngeal inadequacy (VPI), moved out of the university speech clinics and into the hospitals. The University of Iowa, for example, became prominent in the literature for nasal resonance research and in provision of management and therapy for VPI resonance problems. The message that emerged in the 1950s was that successful management of nasal resonance problems first required establishment of structural adequacy. Voice therapy would not be effective until velopharyngeal closure adequacy had been established. This message still needs to be repeated today. Also, the speech-voice scientist reminded us that we were dealing with two functions, air emission and sound-wave resonance, both related but traveling separately through the nasopharynx and nasal cavities, contributing to coexisting problems of speech articulation and voice. After structural adequacy of the velopharyngeal mechanism had been established through prosthodontia or , beginning therapy efforts often focused on articulation rather than on problems of nasalance (see Table 3).

Graduate courses in speech pathology in the 1950s and early 1960s put more emphasis on speech and voice science than on voice remediation: The first emphasis was on voice science followed by psychological aspects, then resonance defects, and with minor emphasis given to voice therapy. The voice science curriculum included anatomy and physiology, acoustics, respiratory physiology, instrumentation, and the ASHA required course of phonetics. Landmark research in the 1950s by Moore and von Leden (5) employed high-speed cinematography to look at laryngeal function and vibratory characteristics of the vocal folds under different conditions. Thus, viewers were able using high-speed film to see vocal fold adductory patterns like we had never been able to see before. This was 20 years before the common use of both flexible and rigid fiberoptic endoscopy, which has so revolutionized our understanding and treatment of voice disorders. In the 1950s, through the use of the phonellogram and spectrogram, we were able to isolate fundamental frequency and the relative positioning of formants. Some of our brethren ask today, "why was there so much focus on pitch and optimum pitch thirty years ago?" One simple answer could be that it was one of the few parameters of voice that we were able to measure.

Clinical voice courses put emphasis on such organic problems as laryngectomy, cleft palate and other nasalance problems, and motor speech disorders. As mentioned earlier, both undergraduate and graduate students in audiology and speech pathology were exposed to a number of psychology courses. We learned to appreciate the coloring of the voice as an expression of emotions, developing an appreciation of the voice as an instrument of beauty, sadness, fear, or agony. We studied the effects of the cry and the laugh and their contribution to the human condition. Our background in psychology coupled with a growing exposure to semantics helped us realize that the speaking voice was capable of shadings that could lead to different meanings for the same single word. How the word was said might carry more meaning than what was actually said. In our voice improvement efforts, we not only looked at vocal technique, but we looked at the person behind the voice. In the 1950s and 1960s, graduate training in speech pathology included more student exposure to the normal voices of professional users of voice, such as actors and singers. Such performers would demonstrate the control and unusual power of their voices. They would discuss the need to keep their vocal techniques under control under varying conditions, such as singing without amplification before a large audience in a noisy outdoor tent theater. Theater amplification was just beginning. If you wanted to be heard, you knew what to do in respiration and projection.

Over the years, the various voice disciplines have used these feedback systems in voice therapy and vocal training: visual feedback, tactile/kinesthetic/proprioceptive feedback, and auditory feedback. In the early days, the mirror was used heavily for visual feedback by vocal trainers and singing teachers; as film and videotaping became more available, clients were able to study body and head posturing on visual playback. Most measuring devices that produced visualization of a function, either by numerical data or some kind of pictorial display could serve as visual biofeedback, providing the client ongoing feedback about a particular voice component. Auditory feedback equipment like the Phonic Mirror (6) and the Language Master (7) provided auditory feedback for the voice patient who could compare his or her production with target voice models. In the 1960s, much more emphasis was given to auditory feedback in voice therapy than is provided in therapy today.

Perhaps the greatest achievement in any kind of feedback was the emergence of videoendoscopy. In the 1960s, the early videoendoscopic voice tapes recorded by the laryngologist using the rigid endoscope revolutionized the understanding of the larynx and its multiple functions. Lack of portability of early videotaping equipment with its 2-inch tapes required the services of a video technician to permit video playback in the clinic or the classroom. As equipment became smaller and more portable, playback equipment was available for real-time or delayed feedback in any setting. With the advent of VHS recording systems, all of the voice disciplines were able to show endoscopic or stroboscopic playback recordings. In time, the laryngologist was working with the speech pathologist and the voice scientist in developing endoscopic skills, enabling these disciplines to perform endoscopy as may be needed in the voice clinic. Video playback for the patient today is part of many therapy sessions, probably providing some patients with more visual knowledge than they are able to absorb. The playback capabilities of our instrumentation today focus on the visual image: We can see the vocal folds in action, or we can follow the real-time playback of some aspect of phonation on a monitor. Today, our extensive use of visual feedback in therapy may be coming at the expense of not using kinesthetic-proprioceptive feedback and auditory feedback. For many patients in therapy, it can be a giant leap to change a production of one's voice from visual information provided on a screen, particularly if that information is not accompanied by auditory feedback.

The vocal coach and singing teacher may use kinesthetic and proprioceptive feedback in their training sessions more than the SLP does. Although sensory feedback receptors are plentiful in the more anterior portions of the vocal tract, they become less available as we move back within the oral cavity. Our facial muscles and mandible joint moving muscles have fine sensory receptors as does the anterior-middle tongue. However, the velopharyngeal mechanisms have sparse kinesthetic receptors and proprioceptors, and in the oropharynx, they are almost lacking. The tactual sensitivities in the VP area permitting the gag-reflex are the exception. The intrinsic muscles of the larynx lack kinesthetic receptors. Even the laryngeal extrinsics that play a role in elevating or lowering the larynx give off very sparse information relative to laryngeal positioning. The plus side of this lack of posterior sensory information is that it permits the human to eat and speak simultaneously, requiring no cortical monitoring; the negative aspects are that in training the voice, our patients have little sensory information to guide them specific to various muscle movement requests. In voicing, however, the auditory system plays a very active role in guiding posterior oropharyngeal and laryngeal muscle movements.

The speech/voice trainer and singing teacher have always appreciated the importance of self-hearing. The ability of a mimic or voice impersonator to match a celebrity voice tells us there is some kind of "silent" prephonation set that unifies vocal components to produce a holistic vocal response. In discussing how singers can sing on request an exact note, being neither sharp nor flat, Wycke (8) wrote that the auditory system provides a "prephonatory tuning" with an "acoustic monitoring." Recent auditory research by Kawahara and Williams (9) document the auditory system's ability to make instantaneous corrections (within 120 to 180 ms) for subjects correcting pitch shift changes of their produced fundamental frequencies. Singers make these instantaneous corrections of frequency to stay on pitch. More amazing, after the presentation of a target pitch, the human larynx is able to provide the right amount of vocal fold tension required to produce the precise tone of that target pitch. It has been postulated (10) that the temporal lobe functions for the speaking and singing voice similar to how the premotor strip of the frontal lobe functions for skeletal muscle motor innervation.

There are two forms of auditory feedback that appear to be positive factors in voice production. One is real-time self-amplification: Hearing oneself through headphones when speaking or singing is commonly used in broadcasting and in recording studios. Voice quality is often improved with such real-time feedback. A second form of auditory feedback useful clinically in phonology training and voice therapy is immediate feedback of what was just said, such as can be heard with the solid-state loop feedback on the Facilitator. (11) The patients may profit from comparing their voice with a model. Clinically, there are two alterations of auditory feedback that can change performance. Delayed auditory feedback (DAF) has been demonstrated for over 40 years as an effective way of improving fluency among stutterers and inducing dysfluent speech in normal speakers. Or masking noise can be useful diagnostically: Beyond the reflex of speaking louder, what does the voice sound like when the speakers are unable to hear themselves speak? I have always used auditory feedback extensively in voice therapy with most of my voice patients wearing headphones, receiving real-time amplification.

In the United States, the specialists in our voice smorgasbord in the 1950s and early 1960s first of all included the otolaryngologist whose prominent role continues today. Voice scientists 40 years ago played a more pervasive role in the management of voice patients than they do today. The role of emotions and life-adjustment on the human voice as voiced by psychiatrists and psychologists, unfortunately, is all but silenced in today's voice clinics. The work of the vocal coach and speech trainer of the 1960s lives on today through the establishment of the Voice and Speech Trainers Association (VASTA). Over the years, singing teachers and performers often asked the speech-language pathologist and the laryngologist to demonstrate some facet of their work at the National Association of Teachers of Singing (NATS) meetings; however, I have witnessed far less invitations to members of NATS to demonstrate their work at meetings of speech pathologists or laryngologists.

Of all the professions in our collection of voice disciplines, speech pathology has grown the fastest over the years with dramatic changes in role, academic, and practicum requirements. In 1979, the name of ASHA was changed to accommodate a growing segment of the profession who worked primarily in language development and language disorders to the American Speech-Language-Hearing Association. By using hyphens instead of commas, the Association was able to preserve its established logo, ASHA. As an immediate Past President of ASHA in 1977, I argued the position of voice clinicians that if we were going to change the name of our professional association, let us represent the membership best by calling it the American Speech-Language Voice-Hearing Association. The debate over the name change lasted heatedly over 2 years. Once the name of the Association was changed, there was an immediate cry to change the name of the practitioner to speech-language pathologist (SLP). I have never liked the name and have protested it silently for the past 15 years by handing out my professional business card that reads "Daniel R. Boone, Ph.D., Speech-Voice Pathologist." Although many people comment on my name, no one has ever commented on how I designate my profession. In any case, in the United States in 2003, there are now over 110,000 speech-language pathologist members of ASHA.

Rather than go through the agony of citing the history of voice research and clinical practice over the ensuing years since the middle 1960s, I would like to comment on some major developments that have had great impact on all of us interested in voice. First of all, speech-language pathology was rocked by operant psychology in every dimension of clinical work throughout the 1960s and the 1970s. We are just emerging clinically from its influence. Rather than taking detailed histories and as much pretherapy measurement as possible, we took a baseline measurement of a particular behavioral component. Let us say we took a measure of voice loudness, measuring intensity at exact decibel levels. That would be our primary baseline measurement. We would then develop a program for changing loudness, either less or louder, breaking the program into sequential steps. If the voice patient succeeded in producing the target loudness value, he or she was given a positive reinforcement and we moved to the next step in the loudness program. Having taught for 3 years at the University of Kansas Medical Center, which at the time was the "operant capitol" of speech-language pathology, I became well versed in operant principles and their application to symptomatic voice therapy. About that time, 1968, I read the work of Wyatt (12) who had treated 300 cases of various forms of conversion hysteria by symptomatic therapy, reporting that not 1 patient revealed "symptom migration or psychotic reaction" after losing a particular symptom from therapy. It appeared that symptomatic voice therapy could return as a rehabilitation regimen administered by the speech-language pathologist. Hence, my book, The Voice and Voice Therapy, (13) was one of the first texts consistent with the view that hyperfunctional voice symptoms could be modified directly. Fortunately, over the years, there have been many ensuing books and published studies supporting the view of direct modification of symptoms related to laryngeal abuse and voice misuse.

The computer came along in the late 1970s and revolutionized what we were able to do in voice diagnostics and evaluation. Stand-alone instrumentation could now have a computer assist to its analyses. Instead of counting striations on a phonellograph as a measure of fundamental frequency, we could now display real-time analysis of frequency as the patient was actually speaking. Scant acoustic data, such as identification of formant frequencies, could now be expanded to include perturbation measures, signal-to-noise ratios, and other measures that could not only be recorded on the computer screen, but also printed out in fine detail on the patient's data sheets. Detailed respiratory and resonance data could now be visually portrayed and used clinically or as group data in research. In the middle 1980s, physicians and speech-language pathologists began replacing fluoroscopic and rigid endoscopic usage with rigid and flexible endoscopy with or without stroboscopy coupled with video playback. We could for the first-time capture what was happening on a video playback tape. It was now possible to blend the efforts of the physician, the voice scientist, and the voice clinician into detailed study of specific vocal parameters, such as looking at vocal fold structure and vibratory characteristics in unbelievable graphic detail, such as developed by Hirano et al. (14) A review of the Journal of Voice since its inception in 1987 reveals that most of the articles reported were only possible since the advent of the computer and various forms of computer-based instrumentation. Our knowledge of vocal tract structure and function and our detailed analyses of the patients' vocal performance have never been greater than they are today in 2001. Unfortunately, the application of detailed physiologic, acoustic, and respiratory data in the voice therapy lags far behind the precision of our laboratory data. Our fixation on the values displayed on the computer screen do not translate easily for the patient, let alone for the clinician. Our patients do not have the stability and the consistency of our computer-driven instrumentation. The chemistries and motivations of people are constantly changing, lacking the consistent reliability of the equipment in our clinical laboratories. Some of our voice patients need their symptoms. As clinicians, we sometimes provide the patient our computer values as biofeedback measures with some success. Or we look with the patient at the physiology of his or her larynx, often forgetting that the patient's knowledge of the "voice box" is perhaps as limited as ours was before we began our studies of anatomy and physiology.

The multiple diagnostic data are difficult to translate to therapy with the patient. It becomes increasingly frustrating for the laryngologist or voice clinician to be part of an exact diagnostic evaluation, thanks to computer-based instrumentation, and not be able to translate detailed findings to positive clinical change. Frustration is experienced, also, by the vocal coach or singing teacher who must translate laboratory data presented at a conference or in a journal into imagery that can be used to improve vocal performance. Clinicians in their frustration often shop for new therapy approaches, wanting to match their evaluation data with greater precision for what they do in therapy. Or they find greater comfort in working with voice problems that have more exact medical or surgical solutions, such as working with patients with sulcus vocalis or working closely with the laryngologist with paralytic patients after thyroplasty. It is often more difficult to work with that large body of patients with muscle tension dysphonia as part of vocal hyperfunction or with those clients who have artistry performance problems.

We now have many meetings and activities that bring the disciplines of our vocal smorgasbord together. For 30 years, we have had the meetings of The Voice Foundation's annual symposium, Care of the Professional Voice. Although much of the program is devoted to medical care of the voice patient, to voice science, and to speech-language pathology, the annual programs always include workshops with their emphasis on techniques of singing, vocal performance, and voice therapy. The Journal of Voice, published quarterly by The Voice Foundation and the International Association of Phonosurgeons, publishes diverse articles, with the typical issue presenting papers by all of our voice disciplines. For example, in the March 2001 issue of Journal of Voice, 51 physicians and 53 nonphysicians coauthored the total number of articles within that particular issue. The Pacific Voice Conference, starting in 1987, brought together annually the disciplines of laryngology, voice science, speech-language pathology, professional voice coaches and teachers, and workshops with performers. The annual meetings and publications of ASHA, NATS, and VASTA have done much to expose their members to other disciplines dealing with voice. Although the national and international meetings of various otolaryngological organizations present cutting-edge medical research and clinical practice in voice, more and more nonmedical scientists and clinicians are participating in these meetings. Through the efforts of these various organizations of voice professionals, we have done much to breakdown the barriers between our separate disciplines. My experience is that we are talking to each other now as we have never done before.

Over 25 years ago, ASHA introduced the concept of special interest groups. Members with a particular interest could develop their own suborganization, developing their own competency standards that could be recommended for use both in training programs and in clinical practice. It was hoped that out of the special interest groups, specialty certification would develop, recognizing an individual's clinical competence in a particular specialty. ASHA's Special Interest Division (SID) 3: Voice and Voice Disorders today has over 1000 members with its own quarterly publication, an e-mail list server, and an "in-person" meeting at the ASHA annual convention. Although SID3 has done much to minimize diversity among its members, its dialogue on the e-mail list-server reveals marked membership differences in background and clinical work setting. I believe that the diverse backgrounds of the SID3 members may be a primary reason why getting together to develop specialty recognition has been and continues to be a difficult task. However, I also believe that one day in the future, ASHA specialty recognition in voice will be a reality.

Voice therapy approaches in 2001 are primarily practiced by speech-language pathologists, and voice training with or without corrective emphasis is often the work of the teachers of singing or the speech-voice trainer. Particular approaches in use today might be classified as cognitive, gestalt-holistic, resonant therapy, muscle training, imagery, and symptomatic therapy. In order to minimize differences between clinicians and particular turf boundaries as we briefly discuss therapy approaches, I will omit names and identifying literature associated with particular approaches. In the real world of clinical practice, the typical voice clinician frequently crosses the boundaries of separate therapy approaches to meet the needs of the patient (or client).

The cognitive approach puts its emphasis on prevention of a voice disorder, or it presents alternative behaviors the voice patient can use to minimize the voice problem. For example, the clinician presents stories with illustrations to the 8-year-old boy with bilateral vocal nodules about the need to curb excessive yelling as a way to reduce his nodules. With the cognitive approach, the clinician hopes to promote a change in vocal behavior by helping clients understand the cause of their voice problems. Twenty years ago, I viewed books and presentations espousing the cognitive approach as too random, too personal, and too anecdotal to be generalized to a particular patient or clinical situation. Then I realized that an illustrative anecdote could often change vocal behavior better than using other therapy approaches. Fortunately, we have today excellent books and clinical materials for all ages that promote the cognitive message.

The gestalt approach to voice training or voice therapy takes the holistic view that whenever possible, we avoid fractionating voice into its various components. Rather, we search for ways that can change vocal behavior without focusing on particular muscle groups by using a single, isolated vocal behavior. For example, asking the patient to make a big yawn, followed by a prolonged sigh, produces these vocal tract changes: the larynx lowers, the vocal folds separate slightly when phonating, the tongue is retracted, and the pharynx dilates, as seen in this CT scan, Figure 1. These massive changes in vocal tract size and physiology are all achieved instantly by initiating the yawn-sigh behavior. The opposite holistic effect can be seen in the same subject when he is asked to imitate and produce the tight barker voice: The larynx elevates, the tongue goes forward, the vocal folds approximate more firmly, and the pharynx dramatically narrows, as seen in Figure 2. Other examples of a holistic approach to voice improvement can be found in changing posture or head position, which can produce noticeable phonation or resonance effects. Asking the voice patient to speak louder or more softly can result in an immediate change in breathing patterns and phonation style without fractionating the task into isolating elements of breathing. We could mention once again the immediate and detailed changes of the vocal tract when an impersonator merely thinks of a celebrity voice and begins to imitate it. As one impersonator told me, "Think who you want to sound like and the components will all line up for you automatically and out comes this famous voice."

The present practice of resonant therapy had its origins with voice trainers and vocal coaches in the early 1960s. Designed to soften glottal attack and the force of vocal fold approximation, the client is presented four models of voices produced with different modes of voice effort: listening to the pressed voice, the normal voice, the breathy voice, and the resonant voice. Through auditory feedback, the client becomes aware of the differences between pressed and breathy phonation. The resonant voice was modeled as a phonation with very little effort, approaching the normal voice in quality. The client developed an awareness of phonation produced by barely abducted or barely adducted vocal folds. This easy vocal fold approximation produced the easy phonation, which was then directed toward the supraglottal resonators, in which the "ring" or focused vocal quality was produced. Once easy vocal fold approximation was established, clients practiced using easy phonations, often by matching auditory models, to develop voices with clear supraglottal "facial mask" resonance.

Over the years there have been various exercises designed for improving the muscle functions at various sites of the vocal tract. An early voice improvement writer wrote, "exercising the muscles of your vocal instrument is like going to a gymnasium for exercises for other muscles of your body." (15) Confusions abound in the literature when skeletal muscle models, which operate using elaborate kinesthetic-proprioceptive feedback, are compared with muscles of the velopharynx, pharynx, and intrinsic or extrinsic muscles of the larynx, which may not only lack this movement feedback, but also lack the cortical controls required for isolated movements. Today, we are more likely to see the use of vocal function exercises requiring voicing tasks that have a particular value in improving muscle physiology for particular functions in speaking or in singing. Most vocal tract muscles play several roles, getting a real workout with every meal we consume, as well as the continual physiologic adjustments required for inspiratory and expiratory breathing. Although these physiologic requirements in normal living keep vocal tract muscles well toned, the vocal requirements for professional users of voice may profit from muscle exercises used in particular talking or singing tasks.


Imagery is often used successfully in developing performance voice, either in acting or singing. The vocal coach who tells his pupil, "Get your voice out of your throat and put it up on the bridge of your nose," is using a form of imagery. Or the singing teacher instructs her pupil, "Reach down and feel your voice support at the bottom of your rib cage." Although such imagery directions may be physiologically incorrect, they may produce an immediate and measurable change in the sound of the voice. Breathing and voicing instructions often require an imagery component that the client or patient is able to use in modifying a particular aspect of voice. I have heard it said that it is all right to use imagery in therapy or performance training, as long as the clinician can separate the imagery from fact. I am not sure today that the aesthetics of voice are any better served by a sequence of facts than they are by an imagery suggestion.

The success of symptomatic voice therapy relates strongly to the findings of the initial voice evaluation. The organic and structural components of the problem, if present, must be identified and treated. The evaluation data will reveal what the patient can do and what he or she cannot do. Whenever possible, the clinician identifies "can do" behavior and uses that as a baseline function, shaping and modifying that behavior by application of various therapy approaches. I used the term "facilitative approaches" to name the things we do in therapy that perhaps uncover and use vocal behaviors the patient is already able to perform. The symptomatic approach to voice therapy borrows heavily from the literature and from past and present practitioners. For the clinician in therapy, therapy materials abound in workbooks and texts, along with workshops that represent a particular trainer's experience. A few such programs actually have predata and postdata to increase their respectability. With the advent of the computer and advanced instrumentation, there are many commercially available software programs that offer ready response success for both children and adults.


There may be more unity between the disciplines of voice than there is between the diverse ranks of speech-language pathologists. Where one received her (95% of SLPs in 2001 are female) undergraduate and graduate education has much to do with her eventual work setting. About half of currently certified SLPs work in the schools, with a limited caseload in voice. The school clinician often works only in group therapy and rarely has instrumentation available for therapy. The other half works in clinics, hospitals, or in private practice. In these settings, the voice patient load can be heavy with attention diverted to swallowing problems and to such severe problems as vocal fold paralyses or degenerative disease dysarthrias. Our academic preparation and clinical practicum is often too limited for developing the voice competence needed for the settings in which we work. No wonder that many SLPs are drawn to one new treatment approach or particular patient group, only to abandon that interest and find a new one. With the added impetus of continuing education requirements coupled with state licensing, hundreds of workshops are offered annually, giving the SLP a wide menu of new approaches to therapy with old and new populations.

One might speculate a moment and comment on what could improve voice competency among SLPs. Undergraduate education might increase the science requirements: Our students ought to have exposure to neurology 101, acoustics 101, and physics 101. If students show any interest in clinical voice, a beginning course in music 101 might save them the future embarrassment when working with singers of not knowing a treble cleft from a bass cleft. The graduate curriculum would include several courses in voice and voice disorders and their treatment, as well as a course or 2 in clinical psychology. The course sequences being developed for a vocology degree by Titze (16) at the University of Iowa might be considered by other training programs. Finally, the elimination of a minimum number of hours in voice practicum for clinical certification by ASHA should be strongly challenged by the 1000 members of SID3. If at all possible and as soon as possible, a larger number of voice practicum hours should be reinstated and required.


We have looked today at the many disciplines of voice over the past 50 years from the perspective of a speech-language pathologist. More of what I have said today has more application to the SLP than to the other disciplines assembled here. We can safely say today that the many disciplines of our voice smorgasbord know more about voice and its disorders than we ever did before. We have interdisciplinary sharing in our journals and conferences that has great impact on our ability to meet the needs of the client or patient with a voice disorder. Unfortunately, we are often unable to meet voice patient needs today not out of lack of knowledge as to what to do, but because our clinical practices are closely thwarted by the external funding limitations of government and the insurance industry. I do believe we need to hang on, keep listening to one another, knowing that in time things will get better.

TABLE 1. The Typical Clinical Areas Evaluated in a Voice Evaluation 
Prior to 1960


Audiometric testing
Respiration testing (V, p/f, kinematics)
Acoustic testing
Recordings (wire, disc, reel to reel audiotape) Spectrogram
Piano/pitch pipe matching
Exams of structure and physiology
Peripheral oral exam
Mirror exam of larynx
Perceptual scaling

TABLE 2. Management and Therapy for Voice Problems Prior to 1960

Management Therapy

Disease identification/treatment Emotional/psychological
Modify physiological performance Vocal performance

TABLE 3. The Typical Evaluation and Management Procedures Used for
Resonance Disorders Prior to 1960

Evaluation Management/Therapy

Pressure/Flow Structural Adequacy
Cinefluorography Surgery
Rigid Endoscopy Appliance

Accepted for publication September 26, 2003.

Presented at The Voice Foundation's 30th Annual Symposium: Care of the Professional Voice, Philadelphia, PA, June 16, 2001.


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Daniel R. Boone

Tucson, Arizona

From the Department of Speech & Hearing Sciences, University of Arizona.

Address correspondence and reprint requests to Daniel R. Boone, 5715 N. Genematas Drive, Tucson, AZ 85704-5935. E-mail:

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