G. Paul Moore Lecture: Unifying the Disciplines of Our Voice Smorgasbord

Daniel R. Boone

Tucson, Arizona

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.

INTRODUCTION Hotel in Chicago. This friendly, accessible human In 1961, I met the President of the American being invited me to sit with him for breakfast. That Speech and Hearing Association (ASHA) by a man was Paul Moore. That was 40 years ago, and chance seating in the coffee shop of the Sherman 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 Accepted for publication September 26, 2003. our friend Doug Hicks, at either an ASHA meeting or Presented at The Voice Foundation’s 30th Annual Sympo- sium: Care of the Professional Voice, Philadelphia, PA, June at the annual Voice Foundation Symposium. Many 16, 2001. of us in the room have had our career heroes. G. From the Department of Speech & Hearing Sciences, Univer- Paul Moore is mine. He is brilliant, yet humble, and sity of Arizona. always comfortable with himself. This has al- Address correspondence and reprint requests to Daniel R. lowed him to reach out to students and to voice Boone, 5715 N. Genematas Drive, Tucson, AZ 85704-5935. newcomers, as well as to the more established and E-mail: [email protected] sometimes opinionated members of our lot. When Journal of Voice, Vol. 18, No. 3, pp. 375–386 0892-1997/$30.00 he is with other people, he has the knack of making ą 2004 The Voice Foundation them feel important, feeling good about themselves. doi:10.1016/j.jvoice.2003.09.006 For me to be asked to present this lecture, named

375 DANIEL BOONE376 for a person so dear to all of us, is indeed a personal deservedly low in the hierarchy of other profession- and professional challenge at this late stage of my als at this renowned aphasia center. Like many of career. us early in our careers, I was unaware of what I My topic today concerns fostering communica- did not know. However, this unawareness that we tion and understanding between various voice disci- experience early in our careers, which hopefully plines, a topic that was needed more one half a diminishes with experience and time, probably en- century ago than it is today. A meeting like this one, ables us to function in our particular discipline. the Voice Foundation’s 30th Annual Symposium: For example, as one develops more awareness of Care of the Professional Voice, could not have been other treatment alternatives, it may become more held 50 years ago. There was no unity among our difficult to be comfortable with a particular treatment diverse professions. We were further apart than we regimen one may be using. After 5 years of doctoral are today. We had performers, actors, and singers. training and increased clinical experience, I found We had professional users of voice like teachers and that education was in part becoming aware of what preachers. There were singing teachers and vocal one does not know. It has been wisely said that, “the coaches. There were voice scientists and speech pa- more one knows, the greater awareness of what one thologists. There were dentists and physicians, such doesn’t know.” In this context of being unaware, it as plastic surgeons and laryngologists. I have is my belief that many of us today do not fully searched for an all-inclusive word for such a collec- appreciate the knowledge base, competency, and ex- tion of specialists. Tentatively, I am using the word perience of voice professionals in other disciplines. “smorgasbord” for this presentation. The origins of Or the specialist within a particular profession may the Swedish word “smorgasbord” were for naming not appreciate the competence and clinical worthi- a collection of appetizers and other tasty foods in ness of a colleague who practices in an entirely one setting; the word has emerged in the English different area within that profession, ie, the present- language as a noun for naming a “widely varied as- day speech-language pathologist (SLP) who is a sortment or collection.”1 The professional use and specialist in swallowing disorders may not appreci- care of the voice has been practiced by a diverse ate the clinical genius of the SLP who successfully group of individuals with very little training beyond reduces vocal hyperfunction in children with vocal their own specialty. Indeed we were a smorgas- nodules. bord with sparse communication between individu- Among the 1859 members of ASHA2 in 1951, als. When people crossed over the threshold beyond the clinical membership, members who provided their particular specialty, they were viewed as an speech and voice therapy, was outnumbered slightly amateur or invaders of a turf for which they had no by the speech-voice scientists and teachers of speech training. The remnants of this kind of thinking still pathology in the universities. From these universi- interfere with our attempts at professional cross- ties, a clinical voice literature emerged in the 1950s fertilization and our acceptance of the views of with more focus given to cleft palate and velopha- people trained differently than we were. In the 30 ryngeal inadequacy (VPI) than to the remediation of years of the VoiceFoundation’s annual symposiums: symptoms related to vocal abuse and voice misuse. Care of the Professional Voice, there has been re- Velopharyngeal problems were one of the first clini- markable growth in acceptance of our professional cal treatment areas that blended the skills of the diversity. Although we may unnecessarily guard our voice scientist, the speech pathologist (designated turf, we listen more and are more accepting to those name before 1978), and the dentist or medical sur- among us with different backgrounds. geon. Perhaps one reason for the early prominence My look at our vocal smorgasbord begins in 1951 in correcting velopharyngeal incompetence was that when I first began as a professional speech patholo- particular dimensions of the problem, such as air gist, working at that time with a Bachelor’s degree volumes and pressures, were measurable. Physical in an aphasia center at the Veteran’s Hospital in defects like cleft palate or velar insufficiency were Long Beach, California. Obviously, at that time with clearly observable with the measuring equipment of a scant education and limited clinical training, I was the day. Furthermore, the problem could often be

Journal of Voice, Vol. 18, No. 3, 2004 G. PAUL MOORE LECTURE 377 corrected through prosthodontic or surgical treat- TABLE 1. The Typical Clinical Areas ment followed by speech/voice therapy. Finally, Evaluated in a Voice Evaluation Prior to 1960 treatment success could be measured by pretreat- Evaluation ment and posttreatment comparisons. Audiometric testing Another area of developing cooperation in the Respiration testing (V, p/f, kinematics) early 1950s between speech pathology and otolaryn- Acoustic testing gology was in the postsurgical rehabilitation of the Recordings (wire, disc, reel to reel audiotape) Spectrogram Piano/pitch pipe matching laryngectomy patient. In Detroit, 1952, the Interna- Exams of structure and physiology tional Association of Larynectomees (IAL) was Peripheral oral exam founded, primarily through the efforts of Julius Mirror exam of larynx McCall, otolaryngologist, and Warren Gardner, Stroboscopy speech pathologist. The early focus of the IAL was Perceptual scaling on incorporating lay patient visits for the new laryn- Stimulability geal cancer patient who was usually facing a total laryngectomy. These preoperative visits, arranged jointly by the surgeon and a speech pathologist, 1950s in doctoral training in speech pathology with coupled the new patient with a previously operated an interest in voice disorders chose doctoral minors patient who could demonstrate good esophageal in clinical psychology. We coordinated our voice voice. In the early years of the IAL, less favorable therapy closely with the services of practitioners in reaction was given for using the artificial larynx psychiatry and clinical psychology. (pneumatic or electronic) rather than using func- From the perspective of a speech-language pathol- tional esophageal speech. The IAL went on to ogist in the year 2001, I see occasional reference become a program of the American Cancer Society3 that voice and resonance are two separate entities. with a continuing focus on providing local support Resonance is part of voice. In this particular presen- group and rehabilitative services for the patient sur- tation, I view voice (as most of us assembled here do) viving laryngeal cancer after successful partial or as a product of phonation and resonance combined. total laryngectomy. Phonation coming from vocal fold vibration is con- Both the literature and my personal recollection tinually influenced by changes in the force and of speech pathology in the early to mid-1950s is that voice therapy was more focused on voice problems volume of the airstream with continual resonance secondary to organic pathologies related to cancer, variation related to changes in laryngeal, pharyngeal, dysarthria, and organic resonance deviation than it nasal, and oral postures. was on functional voice problems. In addition to Looking at phonation and resonance historically, working with organic voice pathologies, the speech we can briefly summarize what we were doing in pathologist was active in the evaluation and treat- our voice evaluations prior to 1960, as shown in Table ment of articulation disorders, stuttering, aphasia 1. All voice evaluations included audiometric and and children’s language disorders, and motor speech respiratory data as a prelude to acoustic testing problems. There was in the 1950s a growing concern and the examination of the vocal mechanisms. The that many voice problems were but symptoms of better diagnostic-evaluation clinics at that time an underlying personality disorder. The book, The were in the universities and not in physician’s offices Voice of Neurosis,4 by Paul Moses was widely ac- or medical centers. Visualization of the larynx cepted by both the medical and speech pathology was accomplished by mirror examination, some- communities, presenting the view that it was the times supplemented by stroboscopic viewing. The voice patient’s anxieties and unresolved personal evaluation typically ended with stimulability testing conflicts that were not only the cause of the dyspho- to determine if application of a particular therapy nia, but also often the reason voice symptoms contin- technique, such as imitating an acoustic model, ued. Voice therapy was only treating symptoms. It would help the patient produce better voicing. We was, therefore, no accident that those of us in the call this today a “diagnostic probe.”

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TABLE 2. Management and Therapy TABLE 3. The Typical Evaluation for Voice Problems Prior to 1960 and Management Procedures Used for Resonance Disorders Prior to 1960 Management Therapy Disease identification/treatment Emotional/psychological Evaluation Management/Therapy Modify physiological performance Vocal performance Pressure/Flow Structural Adequacy Elocution Cinefluorography Surgery Projection Rigid Endoscopy Appliance Speaking/singing

Graduate courses in speech pathology in the 1950s Most of the university and college voice clinics and early 1960s put more emphasis on speech and had consulting neurologists and otolaryngologists. In voice science than on voice remediation: The first the 1950s, if it had been determined that an organic emphasis was on voice science followed by psycho- or physical problem was the origin of the voice logical aspects, then resonance defects, and with disorder, the primary management of the patient minor emphasis given to voice therapy. The voice belonged to the physician. If all organic factors science curriculum included anatomy and physiol- could be eliminated as causal factors, the diagnosis of ogy, acoustics, respiratory physiology, instrumenta- functional dsyphonia was usually made. Patients tion, and the ASHA required course of phonetics. Landmark research in the 1950s by Moore and von with diagnoses of functional dysphonia were often 5 sent for psychological testing followed by possible Leden employed high-speed cinematography to psychotherapy. The voice therapy literature was look at laryngeal function and vibratory characteris- tics of the vocal folds under different conditions. sparse for what to do with functional voice prob- Thus, viewers were able using high-speed film to lems (see Table 2). see vocal fold adductory patterns like we had never The evaluation and management of resonance dis- been able to see before. This was 20 years before orders, particularly related to velopharyngeal inade- the common use of both flexible and rigid fiberoptic quacy (VPI), moved out of the university speech endoscopy, which has so revolutionized our under- clinics and into the hospitals. The University of standing and treatment of voice disorders. In the Iowa, for example, became prominent in the litera- 1950s, through the use of the phonellogram and ture for nasal resonance research and in provision spectrogram, we were able to isolate fundamental of management and therapy for VPI resonance prob- frequency and the relative positioning of formants. lems. The message that emerged in the 1950s was Some of our brethren ask today, “why was there so that successful management of nasal resonance much focus on pitch and optimum pitch thirty years problems first required establishment of structural ago?” One simple answer could be that it was one adequacy. Voice therapy would not be effective of the few parameters of voice that we were able until velopharyngeal closure adequacy had been es- to measure. tablished. This message still needs to be repeated Clinical voice courses put emphasis on such or- today. Also, the speech-voice scientist reminded ganic problems as laryngectomy, cleft palate and us that we were dealing with two functions, air other nasalance problems, and motor speech disor- emission and sound-wave resonance, both related ders. As mentioned earlier, both undergraduate and but traveling separately through the nasopharynx graduate students in audiology and speech pathology and nasal cavities, contributing to coexisting prob- were exposed to a number of psychology courses. lems of speech articulation and voice. After struc- We learned to appreciate the coloring of the voice tural adequacy of the velopharyngeal mechanism as an expression of emotions, developing an appreci- had been established through prosthodontia or plas- ation of the voice as an instrument of beauty, sad- tic surgery, beginning therapy efforts often focused ness, fear, or agony. We studied the effects of the on articulation rather than on problems of nasalance cry and the laugh and their contribution to the human (see Table 3). condition. Our background in psychology coupled

Journal of Voice, Vol. 18, No. 3, 2004 G. PAUL MOORE LECTURE 379 with a growing exposure to semantics helped us equipment became smaller and more portable, play- realize that the speaking voice was capable of shad- back equipment was available for real-time or de- ings that could lead to different meanings for the layed feedback in any setting. With the advent of same single word. How the word was said might VHS recording systems, all of the voice disciplines carry more meaning than what was actually said. In were able to show endoscopic or stroboscopic play- our voice improvement efforts, we not only looked back recordings. In time, the laryngologist was at vocal technique, but we looked at the person working with the speech pathologist and the voice behind the voice. In the 1950s and 1960s, graduate scientist in developing endoscopic skills, enabling training in speech pathology included more student these disciplines to perform endoscopy as may be exposure to the normalvoices of professional users of needed in the voice clinic. Video playback for the pa- voice, such as actors and singers. Such performers tient today is part of many therapy sessions, probably would demonstrate the control and unusual power providing some patients with more visual knowledge of their voices. They would discuss the need to keep than they are able to absorb. The playback capabili- their vocal techniques under control under varying ties of our instrumentation today focus on the visual conditions, such as singing without amplification image: We can see the vocal folds in action, or we before a large audience in a noisy outdoor tent the- can follow the real-time playback of some aspect ater. Theater amplification was just beginning. If of phonation on a monitor. Today, our extensive you wanted to be heard, you knew what to do in use of visual feedback in therapy may be coming at respiration and projection. the expense of not using kinesthetic-proprioceptive Over the years, the various voice disciplines have feedback and auditory feedback. For many patients used these feedback systems in voice therapy and in therapy, it can be a giant leap to change a produc- vocal training: visual feedback, tactile/kinesthetic/ tion of one’s voice from visual information provided proprioceptive feedback, and auditory feedback. In on a screen, particularly if that information is not the early days, the mirror was used heavily for visual accompanied by auditory feedback. feedback by vocal trainers and singing teachers; as The vocal coach and singing teacher may use kin- film and videotaping became more available, cli- esthetic and proprioceptive feedback in their training ents were able to study body and head posturing sessions more than the SLP does. Although sensory on visual playback. Most measuring devices that feedback receptors are plentiful in the more anterior produced visualization of a function, either by nu- portions of the vocal tract, they become less available merical data or some kind of pictorial display could as we move back within the oral cavity. Our facial serve as visual biofeedback, providing the client muscles and mandible joint moving muscles have ongoing feedback about a particular voice compo- fine sensory receptors as does the anterior-middle nent. Auditory feedback equipment like the Phonic tongue. However, the velopharyngeal mechanisms Mirror6 and the Language Master7 provided auditory have sparse kinesthetic receptors and propriocep- feedback for the voice patient who could compare tors, and in the oropharynx, they are almost lacking. his or her production with target voice models. In The tactual sensitivities in the VP area permitting the the 1960s, much more emphasis was given to audi- gag-reflex are the exception. The intrinsic muscles tory feedback in voice therapy than is provided in of the larynx lack kinesthetic receptors. Even the therapy today. laryngeal extrinsics that play a role in elevating Perhaps the greatest achievement in any kind of orloweringthelarynxgiveoffverysparseinformation feedback was the emergence of videoendoscopy. In relative to laryngeal positioning. The plus side of the 1960s, the early videoendoscopic voice tapes this lack of posterior sensory information is that it recorded by the laryngologist using the rigid endo- permits the human to eat and speak simultaneously, scope revolutionized the understanding of the larynx requiring no cortical monitoring; the negative aspects and its multiple functions. Lack of portability of are that in training the voice, our patients have little early videotaping equipment with its 2-inch tapes sensory information to guide them specific to vari- required the services of a video technician to permit ous muscle movement requests. In voicing, how- video playback in the clinic or the classroom. As ever, the auditory system plays a very active role in

Journal of Voice, Vol. 18, No. 3, 2004 DANIEL BOONE380 guiding posterior oropharyngeal and laryngeal voice patients wearing headphones, receiving real- muscle movements. time amplification. The speech/voice trainer and singing teacher have In the United States, the specialists in our voice always appreciated the importance of self-hearing. smorgasbord in the 1950s and early 1960s first of The ability of a mimic or voice impersonator to match all included the otolaryngologist whose prominent a celebrity voice tells us there is some kind of “silent” role continues today. Voice scientists 40 years ago prephonation set that unifies vocal components to played a more pervasive role in the management of produce a holistic vocal response. In discussing how voice patients than they do today. The role of emo- singers can sing on request an exact note, being nei- tions and life-adjustment on the human voice as ther sharp nor flat, Wycke8 wrote that the auditory voiced by psychiatrists and psychologists, unfortu- system provides a “prephonatory tuning” with an nately, is all but silenced in today’s voice clinics. “acoustic monitoring.” Recent auditory research by The work of the vocal coach and speech trainer of Kawahara and Williams9 document the auditory sys- the 1960s lives on today through the establishment tem’s ability to make instantaneous corrections of the Voice and Speech Trainers Association (within 120 to 180 ms) for subjects correcting pitch (VASTA). Over the years, singing teachers and per- shift changes of their produced fundamental frequen- formers often asked the speech-language pathologist cies. Singers make these instantaneous corrections of and the laryngologist to demonstrate some facet of frequency to stay on pitch. More amazing, after the their work at the National Association of Teachers presentation of a target pitch, the human larynx is of Singing (NATS) meetings; however, I have wit- able to provide the right amount of vocal fold tension nessed far less invitations to members of NATS required to produce the precise tone of that target to demonstrate their work at meetings of speech pathologists or laryngologists. pitch. It has been postulated10 that the temporal lobe Of all the professions in our collection of voice functions for the speaking and singing voice similar disciplines, speech pathology has grown the fastest to how the premotor strip of the frontal lobe functions over the years with dramatic changes in role, aca- for skeletal muscle motor innervation. demic, and practicum requirements. In 1979, the There are two forms of auditory feedback that name of ASHA was changed to accommodate a appear to be positive factors in voice production. growing segment of the profession who worked pri- One is real-time self-amplification: Hearing oneself marily in language development and language disor- through headphones when speaking or singing is ders to the American Speech-Language-Hearing commonly used in broadcasting and in recording Association. By using hyphens instead of commas, studios. Voice quality is often improved with such the Association was able to preserve its established real-time feedback. A second form of auditory feed- logo, ASHA. As an immediate Past President of backuseful clinicallyin phonology trainingand voice ASHA in 1977, I argued the position of voice clini- therapy is immediate feedback of what was just cians that if we were going to change the name said, such as can be heard with the solid-state loop of our professional association, let us represent the 11 feedback on the Facilitator. The patients may profit membership best by calling it the American Speech- from comparing their voice with a model. Clinically, LanguageVoice-Hearing Association. The debate there are two alterations of auditory feedback that over the name change lasted heatedly over 2 years. can change performance. Delayed auditory feedback Once the name of the Association was changed, (DAF) has been demonstrated for over 40 years as an there was an immediate cry to change the name of the effective way of improving fluency among stutterers practitioner to speech-language pathologist (SLP). and inducing dysfluent speech in normal speakers. Or I have never liked the name and have protested it masking noise can be useful diagnostically: Beyond silently for the past 15 years by handing out my the reflex of speaking louder, what does the voice professional business card that reads “Daniel R. sound like when the speakers are unable to hear Boone, Ph.D., Speech-Voice Pathologist.” Although themselves speak? I have always used auditory feed- many people comment on my name, no one has ever back extensively in voice therapy with most of my commented on how I designate my profession. In

Journal of Voice, Vol. 18, No. 3, 2004 G. PAUL MOORE LECTURE 381 any case, in the United States in 2003, there are as a measure of fundamental frequency, we could now over 110,000 speech-language pathologist now display real-time analysis of frequency as the members of ASHA. patient was actually speaking. Scant acoustic data, Rather than go through the agony of citing the such as identification of formant frequencies, could history of voice research and clinical practice over now be expanded to include perturbation measures, the ensuing years since the middle 1960s, I would signal-to-noise ratios, and other measures that could like to comment on some major developments that not only be recorded on the computer screen, but have had great impact on all of us interested in also printed out in fine detail on the patient’s data voice. First of all, speech-language pathology was sheets. Detailed respiratory and resonance data could rocked by operant psychology in every dimension now be visually portrayed and used clinically or of clinical work throughout the 1960s and the 1970s. as group data in research. In the middle 1980s, We are just emerging clinically from its influence. physicians and speech-language pathologists began Rather than taking detailed histories and as much replacing fluoroscopic and rigid endoscopic usage pretherapy measurement as possible, we took a base- with rigid and flexible endoscopy with or without line measurement of a particular behavioral compo- stroboscopy coupled with video playback. We could nent. Let us say we took a measure of voice loudness, for the first-time capture what was happening on a measuring intensity at exact decibel levels. That video playback tape. It was now possible to blend would be our primary baseline measurement. We the efforts of the physician, thevoice scientist, and the would then develop a program for changing loud- voice clinician into detailed study of specific vocal ness, either less or louder, breaking the program into parameters, such as looking at vocal fold structure sequential steps. If the voice patient succeeded in and vibratory characteristics in unbelievable graphic producing the target loudness value, he or she was detail, such as developed by Hirano et al.14 A review given a positive reinforcement and we moved to the of the Journal of Voice since its inception in 1987 next step in the loudness program. Having taught reveals that most of the articles reported were only for 3 years at the University of Kansas Medical possible since the advent of the computer and vari- Center, which at the time was the “operant capitol” ous forms of computer-based instrumentation. Our of speech-language pathology, I became well versed knowledge of vocal tract structure and function and in operant principles and their application to symp- our detailed analyses of the patients’ vocal perfor- tomatic voice therapy. About that time, 1968, I mance have never been greater than they are today read the work of Wyatt12 who had treated 300 cases of various forms of conversion hysteria by symptom- in 2001. Unfortunately, the application of detailed atic therapy, reporting that not 1 patient revealed physiologic, acoustic, and respiratory data in the “symptom migration or psychotic reaction” after voice therapy lags far behind the precision of our losing a particular symptom from therapy. It ap- laboratory data. Our fixation on the values displayed peared that symptomatic voice therapy could return on the computer screen do not translate easily for as a rehabilitation regimen administered by the the patient, let alone for the clinician. Our patients speech-language pathologist. Hence, my book, do not have the stability and the consistency of our The Voice and Voice Therapy,13 was one of the first computer-driven instrumentation. The chemistries texts consistent with the view that hyperfunctional and motivations of people are constantly changing, voice symptoms could be modified directly. Fortu- lacking the consistent reliability of the equipment in nately, over the years, there have been many ensuing our clinical laboratories. Some of our voice patients books and published studies supporting the view of need their symptoms. As clinicians, we some- direct modification of symptoms related to laryngeal times provide the patient our computer values as abuse and voice misuse. biofeedback measures with some success. Or we The computer came along in the late 1970s and look with the patient at the physiology of his or her revolutionized what we were able to do in voice larynx, often forgetting that the patient’s knowledge diagnostics and evaluation. Stand-alone instrumen- of the “voice box” is perhaps as limited as ours was tation could now have a computer assist to its analy- before we began our studies of anatomy and ses. Instead of counting striations on a phonellograph physiology.

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The multiple diagnostic data are difficult to trans- organizations present cutting-edge medical research late to therapy with the patient. It becomes in- and clinical practice in voice, more and more non- creasingly frustrating for the laryngologist or voice medical scientists and clinicians are participating clinician to be part of an exact diagnostic evaluation, in these meetings. Through the efforts of these vari- thanks to computer-based instrumentation, and not ous organizations of voice professionals, we have be able to translate detailed findings to positive clini- done much to breakdown the barriers between our cal change. Frustration is experienced, also, by the separate disciplines. My experience is that we are vocal coach or singing teacher who must translate talking to each other now as we have never done laboratory data presented at a conference or in a before. journal into imagery that can be used to improve Over 25 years ago, ASHA introduced the concept vocal performance. Clinicians in their frustration of special interest groups. Members with a particular often shop for new therapy approaches, wanting to interest could develop their own suborganization, match their evaluation data with greater precision developing their own competency standards that for what they do in therapy. Or they find greater could be recommended for use both in training pro- comfort in working with voice problems that have grams and in clinical practice. It was hoped that out more exact medical or surgical solutions, such as of the special interest groups, specialty certification working with patients with sulcus vocalis or working would develop, recognizing an individual’s clinical closely with the laryngologist with paralytic patients competence in a particular specialty. ASHA’s Spe- after thyroplasty. It is often more difficult to work cial Interest Division (SID) 3: Voice and Voice Dis- with that large body of patients with muscle tension orders today has over 1000 members with its own dysphonia as part of vocal hyperfunction or with those quarterlypublication, an e-mail listserver, andan “in- clients who have artistry performance problems. person” meeting at the ASHA annual convention. We now have many meetings and activities that Although SID3 has done much to minimize diversity bring the disciplines of our vocal smorgasbord to- among its members, its dialogue on the e-mail list- gether. For 30 years, we have had the meetings of server reveals marked membership differences in The Voice Foundation’s annual symposium, Care background and clinical work setting. I believe that of the Professional Voice. Although much of the pro- the diverse backgrounds of the SID3 members may gram is devoted to medical care of the voice patient, be a primary reason why getting together to develop to voice science, and to speech-language pathology, specialty recognition has been and continues to be the annual programs always include workshops a difficult task. However, I also believe that one day with their emphasis on techniques of singing, vocal in the future, ASHA specialty recognition in voice performance, and voice therapy. The Journal of will be a reality. Voice, published quarterly by The Voice Foundation Voice therapy approaches in 2001 are primarily and the International Association of Phonosurgeons, practiced by speech-language pathologists, and publishes diverse articles, with the typical issue voice training with or without corrective emphasis presenting papers by all of our voice disciplines. is often the work of the teachers of singing or For example, in the March 2001 issue of Journal the speech-voice trainer. Particular approaches in of Voice, 51 physicians and 53 nonphysicians coau- use today might be classified as cognitive, gestalt- thored the total number of articles within that partic- holistic, resonant therapy, muscle training, imagery, ular issue. The Pacific Voice Conference, starting in and symptomatic therapy. In order to minimize dif- 1987, brought together annually the disciplines of ferences between clinicians and particular turf laryngology, voice science, speech-language pathol- boundaries as we briefly discuss therapy approaches, ogy, professional voice coaches and teachers, and I will omit names and identifying literature associ- workshops with performers. The annual meetings ated with particular approaches. In the real world and publications of ASHA, NATS, and VASTA have of clinical practice, the typical voice clinician fre- done much to expose their members to other disci- quently crosses the boundaries of separate therapy plines dealing with voice. Although the national and approaches to meet the needs of the patient (or international meetings of various otolaryngological client).

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The cognitive approach puts its emphasis on pre- impersonator merely thinks of a celebrity voice and vention of a voice disorder, or it presents alterna- begins to imitate it. As one impersonator told me, tive behaviors the voice patient can use to minimize “Think who you want to sound like and the compo- the voice problem. For example, the clinician pres- nents will all line up for you automatically and out ents stories with illustrations to the 8-year-old boy comes this famous voice.” with bilateral vocal nodules about the need to curb The present practice of resonant therapy had its excessive yelling as a way to reduce his nodules. origins with voice trainers and vocal coaches in the With the cognitive approach, the clinician hopes to early 1960s. Designed to soften glottal attack and promote a change in vocal behavior by helping cli- the force of vocal fold approximation, the client is ents understand the cause of their voice problems. presented four models of voices produced with dif- Twenty years ago, I viewed books and presenta- ferent modes of voice effort: listening to the pressed tions espousing the cognitive approach as too voice, the normal voice, the breathy voice, and the random, too personal, and too anecdotal to be gener- resonant voice. Through auditory feedback, the alized to a particular patient or clinical situation. client becomes aware of the differences between Then I realized that an illustrative anecdote could pressed and breathy phonation. The resonant voice often change vocal behavior better than using other was modeled as a phonation with very little effort, therapy approaches. Fortunately, we have today ex- approaching the normal voice in quality. The cellent books and clinical materials for all ages that client developed an awareness of phonation pro- promote the cognitive message. duced by barely abducted or barely adducted vocal The gestalt approach to voice training or voice folds. This easy vocal fold approximation produced therapy takes the holistic view that whenever possi- the easy phonation, which was then directed ble, we avoid fractionating voice into its various toward the supraglottal resonators, in which the components. Rather, we search for ways that can “ring” or focused vocal quality was produced. change vocal behavior without focusing on particu- Once easy vocal fold approximation was estab- lar muscle groups by using a single, isolated vocal lished, clients practiced using easy phonations, often behavior. For example, asking the patient to make by matching auditory models, to develop voices with a big yawn, followed by a prolonged sigh, produces clear supraglottal “facial mask” resonance. these vocal tract changes: the larynx lowers, the vocal Over the years there have been various exercises folds separate slightly when phonating, the tongue designed for improving the muscle functions at vari- is retracted, and the pharynx dilates, as seen in this ous sites of the vocal tract. An early voice improve- CT scan, Figure 1. These massive changes in vocal ment writer wrote, “exercising the muscles of your tract size and physiology are all achieved instantly vocal instrument is like going to a gymnasium by initiating the yawn-sigh behavior. The opposite for exercises for other muscles of your body.”15 holistic effect can be seen in the same subject when Confusions abound in the literature when skeletal he is asked to imitate and produce the tight barker muscle models, which operate using elaborate kines- voice: The larynx elevates, the tongue goes forward, thetic-proprioceptive feedback, are compared with the vocal folds approximate more firmly, and the muscles of the velopharynx, pharynx, and intrinsic pharynx dramatically narrows, as seen in Figure or extrinsicmuscles ofthelarynx, whichmay notonly 2. Other examples of a holistic approach to voice lack this movement feedback, but also lack the improvement can be found in changing posture or cortical controls required for isolated movements. head position, which can produce noticeable phona- Today, we are more likely to see the use of vocal tion or resonance effects. Asking the voice patient to function exercises requiring voicing tasks that have speaklouder ormore softly can resultin an immediate a particular value in improving muscle physiology change in breathing patterns and phonation style for particular functions in speaking or in singing. without fractionating the task into style without frac- Most vocal tract muscles play several roles, getting a tionating the task into isolating elements of breath- real workout with every meal we consume, as well ing. We could mention once again the immediate as the continual physiologic adjustments required and detailed changes of the vocal tract when an for inspiratory and expiratory breathing. Although

Journal of Voice, Vol. 18, No. 3, 2004 384 DANIEL BOONE

FIGURE 1. A CT scan depicts the dilated pharynx of a normal subject prolonging the /i/ vowel on an extended sigh after a yawn.

these physiologic requirements in normal living have heard it said that it is all right to use imagery keep vocal tract muscles well toned, the vocal re- in therapy or performance training, as long as the quirements for professional users of voice may profit clinician can separate the imagery from fact. I am from muscle exercises used in particular talking or not sure today that the aesthetics of voice are any singing tasks. better served by a sequence of facts than they are Imagery is often used successfully in developing by an imagery suggestion. performance voice, either in acting or singing. The The success of symptomatic voice therapy relates vocal coach who tells his pupil, “Get your voice out strongly to the findings of the initial voice evalua- of your throat and put it up on the bridge of your tion. The organic and structural components of the nose,” is using a form of imagery. Or the singing problem, if present, must be identified and treated. teacher instructs her pupil, “Reach down and feel The evaluation data will reveal what the patient can your voice support at the bottom of your rib cage.” do and what he or she cannot do. Whenever possible, Although such imagery directions may be physio- the clinician identifies “can do” behavior and uses logically incorrect, they may produce an immediate that as a baseline function, shaping and modifying and measurable change in the sound of the voice. that behavior by application of various therapy ap- Breathing and voicing instructions often require an proaches. I used the term “facilitative approaches” imagery component that the client or patient is able to name the things we do in therapy that perhaps to use in modifying a particular aspect of voice. I uncover and use vocal behaviors the patient is

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FIGURE 2. A CT scan depicts the constricted pharynx of a normal subject prolonging the /i/ vowel using a barker-type voice. already able to perform. The symptomatic approach in group therapy and rarely has instrumentation to voice therapy borrows heavily from the literature available for therapy. The other half works in clinics, and from past and present practitioners. For the clini- hospitals, or in private practice. In these settings, the cian in therapy, therapy materials abound in work- voice patient load can be heavy with attention di- books and texts, along with workshops that represent verted to swallowing problems and to such severe a particular trainer’s experience. A few such pro- problems as vocal fold paralyses or degenerative grams actually have predata and postdata to increase disease dysarthrias. Our academic preparation and their respectability. With the advent of the computer clinical practicum is often too limited for developing and advanced instrumentation, there are many com- the voice competence needed for the settings in mercially available software programs that offer which we work. No wonder that many SLPs are ready response success for both children and drawn to one new treatment approach or particular adults. patient group, only to abandon that interest and find There may be more unity between the disciplines a new one. With the added impetus of continuing of voice than there is between the diverse ranks of education requirements coupled with state licens- speech-language pathologists. Where one received ing, hundreds of workshops are offered annually, her (95% of SLPs in 2001 are female) undergraduate giving the SLP a wide menu of new approaches to and graduate education has much to do with her therapy with old and new populations. eventual work setting. About half of currently certi- One might speculate a moment and comment on fied SLPs work in the schools, with a limited case- what could improve voice competency among SLPs. load in voice. The school clinician often works only Undergraduate education might increase the science

Journal of Voice, Vol. 18, No. 3, 2004 DANIEL BOONE386 requirements: Our students ought to have exposure to of government and the insurance industry. I do be- neurology 101, acoustics 101, and physics 101. If lieve we need to hang on, keep listening to one an- students show any interest in clinical voice, a begin- other, knowing that in time things will get better. ning course in music 101 might save them the future embarrassment when working with singers of not REFERENCES knowing a treble cleft from a bass cleft. The graduate Webster’s New World Dictionary curriculum would include several courses in voice 1. . 3rd ed. NewYork: Simon and Schuster; 1988. and voice disorders and their treatment, as well as 2. 1975 ASHA Directory. Washington, D.C.: American Speech a course or 2 in clinical psychology. The course and Hearing Association; 1975. sequences being developed for a vocology degree by 3. Cleveland Lost Chord Club. Cleveland, OH: Cleveland Titze16 at the University of Iowa might be considered Hearing and Speech Center; 1962. by other training programs. Finally, the elimination 4. Moses PJ. The Voice of Neurosis. New York: Grune and Stratton; 1954. of a minimum number of hours in voice practicum 5. Moore GP, Von Leden H. Dynamic variations of the vibra- for clinical certification by ASHA should be strongly tory pattern in the normal larynx. Folia Phoniat. 1958;10: challenged by the 1000 members of SID3. If at all 205–223. possible and as soon as possible, a larger number 6. Phonic Mirror. Belvedere-Tiburon, CA: H.C. Electronics, of voice practicum hours should be reinstated and Inc. (No longer manufactured). Language Master required. 7. . Chicago, IL: Bell and Howell Co. 8. Wycke BD. Laryngeal neuromuscular control system in singing. Folia Phoniat. 1974;26:295–306. 9. Kawahara H, Williams JC. Effects of auditory feedback on voice pitch trajectories: characteristic responses to pitch CONCLUSIONS perturbations. In: Davis PJ, Fletcher NH, eds. Vocal Fold We have looked today at the many disciplines of Physiology, Controlling Complexity and Chaos. San Diego, CA: Singular Publishing Group; 1996:263–278. voice over the past 50 years from the perspective 10. Boone DR. Clinical relevance of controlling chaos and of a speech-language pathologist. More of what I complexity: implications for the speech pathologist. In: have said today has more application to the SLP Davis PJ, Fletcher NH, eds. Vocal Fold Physiology, Con- than to the other disciplines assembled here. We can trolling Complexity and Chaos. San Diego, CA: Singular safely say today that the many disciplines of our Publishing Group; 1996:347–357. Facilitator. voice smorgasbord know more about voice and its 11. Lincoln Park, NJ: Kay Elemetrics Corporation. 12. Wyatt GL. Voicedisorders and personality conflicts. Mental disorders than we ever did before. We have inter- Hygiene. 1941;25:237–250. disciplinary sharing in our journals and conferences 13. Boone DR, McFarlane SC. The Voice and Voice Therapy. that has great impact on our ability to meet the 6th ed. Boston, MA: Allyn and Bacon; 2000. needs of the client or patient with a voice disorder. 14. Hirano M. Morphological structure of the vocal cord as a Unfortunately, we are often unable to meet voice vibrator and its variations. Folia Phoniat. 1974;26:89–94. 15. Schumacher W. Voice Therapy and Voice Improvement. patient needs today not out of lack of knowledge as Springfield, IL: Charles C. Thomas; 1974. to what to do, but because our clinical practices are 16. Titze IR. Rationale and structure of a curriculum in vocol- closely thwarted by the external funding limitations ogy. J Voice. 1992;6:1–9.

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