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