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216 The Voice and Voice Therapy
TABLE 71. Twenty-Five Facilitating Approaches in
Voice Therapy
Parameter of Voice Affected
Facilitating Approach Pitch Loudness Quality
1. Auditory feedback x x
2. Change of loudness x x x
3. Chant–talk x x
4. Chewing x x x
5. Confidential voice x x
6. Counseling (explanation of
x x
problem)
7. Digital manipulation x x
8. Elimination of abuses x x
9. Establishing a new pitch x x
10. Focus x x x
11. Glottal fry x x x
12. Head positioning x x
13. Hierarchy analysis x x x
14. Inhalation phonation x x
15. Laryngeal massage x x
16. Masking x x
17. Nasal/glide stimulation x
18. Open-mouth approach x x
19. Pitch inflections x
20. Redirected phonation x x x
21. Relaxation x x x
22. Respiration training x x
23. Tongue protrusion /i/ x x
24. Visual feedback x x x
25. Yawn–sigh x x x
CHAPTER 7 Voice Facilitating Approaches 217
Some patients with movement disorders might profit from the use of an auditory metronome
that can pace either an increased or decreased rate of speaking for the patient. For example, a
metronome set at about 60 words per minute can result in a marked slowing of the Parkinson’s
patient’s speech rate, which may improve voice quality, loudness, and speech intelligibility. Others
have been reported to benefit from delayed or frequency altered feedback, which serves to feed
the voice back into the auditory system (McNeil, 2009; Snyder et al., 2018). Some of those
instruments are manufactured by PENTAX Medical Corp. (Montvale, New Jersey), Casa Futura
Technologies (Boulder, Colorado), and Griffin Laboratories (Temecula, California).
Most voice patients profit from auditory modeling: Hearing either their own voice on auditory
playback or an external model (perhaps a speaking pitch note or the clinician’s voice). Auditory
modeling, to be effective, must be immediate. The clinician must stop recording and play back
for the patient the recording of the model and the patient response. The auditory playback is easy
to achieve on most digital recorders or smartphones. It is important that the recording device
has at least two ports for a speaker, or headphones, so that the client and clinician can hear the
production immediately after generating it.
Procedural Aspects of the Approach
Let us separate the application approaches for three forms of auditory feedback: real-time amplification, metronome pacing, and loop playback.
1. Real-time amplification of speech and voice enables one to hear oneself more clearly
than would be possible without such self-amplification and auditory focus. Real-time
amplification requires the clinician to use a device that features good quality amplification
and playback.
a. The patient listens closely on the headphones to what they will be saying. Usually
another voice is used, such as chanting or focus, that the patient will use while speaking.
The patient then listens closely to the sound of the voice or speech while they are using
the approach.
b. The patient evaluates the appropriateness of their response. If adjustments are needed,
the patient listens with real-time amplification again.
2. The clicks or beats of a metronome may provide good auditory pacing for patients who
need to decrease or increase their rate of speech.
a. The rate of clicks per minute is set on the instrument. All windup or electronic
metronomes have a setting switch. The Auditory Feedback module by PENTAX
Medical Corp. (Montvale, New Jersey) offers variable rates, as do many smartphone
apps.
b. The best pacing practice is achieved by the patient matching the clicks by shortening
or prolonging the vowel duration of the practice material. Changing vowel duration
is a preferred way to change rate rather than altering pause duration between words or
phrases. Reducing the temporal length of the vowel is often suggested for individuals
presenting with spastic or ataxic dysarthria (see Chapter 5).
3. Auditory feedback allows the patient to hear immediately what was just said. Current
technology features digitized recorders that are stand-alone or in smartphone apps.
218 The Voice and Voice Therapy
Typical Case History Showing Utilization of the Approach
Josie, a 49-year-old social worker, had a 2-year history of functional dysphonia. At the time of the
initial interview, it was found that elevating her pitch slightly at the end of a phrase or sentence
seemed to eliminate all hoarseness. Immediate digitized auditory playback was very effective in
helping her realize that raising pitch slightly in an upward inflection cleared the hoarseness from
her voice. Working with her SLP using auditory playback, she practiced repeating sentences in
two different ways: one, with the usual downward inflection (which caused hoarseness), and two,
with an upward inflection. Using immediate auditory feedback in a few practice sessions appeared
to be a primary approach in developing better functional voice outside the clinic, especially in her
work as a social worker.
Evidence-Based Evaluation of the Approach
Voice change is often enhanced by listening closely to one’s voice (de Boer & Bressmann, 2017;
Kim et al., 2020; Lee et al., 2015). The use of auditory feedback is often an important step in
therapy for articulation, language, fluency, and voice disorders. Real-time amplification, external
metronomic pacing, and immediate auditory feedback can be effective auditory aids in voice
therapy. A holistic approach to correcting a voice disorder, such as listening to one’s voice, is
often preferred over fractionating various voice components (breathing, pitch, loudness, etc.) with
separate practice for each component.
2. Change of Loudness
Kinds of Problems for Which the Approach Is Useful
Some patients have voices that have inappropriate loudness: a voice that is too loud or too soft.
Many of the vocal pathologies experienced by children are related to excesses of loudness such
as screaming and yelling. Weak, soft voices may develop because of neurological disease, such as
Parkinson’s hypophonia (see Neurogenic Voice Disorders). Other presentations involve prolonged
hyperfunctional use of the vocal mechanism that results in the eventual breakdown of glottal
approximation surfaces, for example, a patient with vocal nodules who loses much airflow around
the nodules and is unable to produce an intense enough vocal fold vibration to achieve a sufficiently loud voice. Some speaking environments require a loud voice, and untrained speakers
or singers may push for loudness at the level of the larynx rather than adjust their respiration.
Inappropriate loudness of voice is most often not the primary causative factor of a voice problem
but rather a secondary, if annoying, symptom. Reducing or increasing the loudness of the voice
lends itself well to direct symptom modification through exercise and practice and, if other VFAs
are being used, often does not even require the use of loudness techniques.
Procedural Aspects of the Approach
1. For a decrease in loudness, follow these actions:
a. See that the patient has a thorough audiometric examination to determine adequacy of
hearing before any attempt is made to reduce voice loudness. Once it has been established that the patient has normal hearing, the following steps may be taken.
CHAPTER 7 Voice Facilitating Approaches 219
b. For young children, ages 3 through 10, the following hierarchy is introduced. Ask the
child to develop awareness of five different voices:
●
Voice 1 is presented as a whisper.
●
Voice 2 is presented as the voice to use when not wanting to awaken a sleeping
person, a quiet voice.
●
Voice 3 is the normal voice to use to talk to family and friends.
●
Voice 4 is the voice to use to talk to someone across the room.
●
Voice 5 is the yelling voice to call someone outside.
c. With patients over 10 years old, discuss with the patient the observation that the patient
has an inappropriately loud voice. The patient may be unaware of the loud voice and
should listen to digitized audio feedback samples of their speech (See auditory feedback
earlier). The best demonstration for loudness variations includes both the patient’s voice
and the clinician’s, to provide contrasting levels of loudness. Then ask the patient, “Do
you think your voice is louder than mine?”
d. Focus on making the patient aware of the problem. Once the patient becomes aware
that their voice is too loud, ask, “What does a loud voice in another person tell you
about that person?” Loud voices are typically interpreted to mean that the speaker feels
“overly confident” or “sure of himself”; or that the speaker is putting on a confident
front when they are really scared; or that they are mad at the world, impressed with
their own voice, trying to intimidate listeners, and so on. Some discussion of these
negative interpretations is usually sufficient to motivate the average patient to learn to
speak at normal loudness levels.
e. Practice using a quiet voice (voice 2 in section b). The practice for the quiet voice can be
facilitated by using audio feedback with a sound-level meter (SLM). Keeping the SLM
at a fixed distance, the patient can quickly learn to generate a lower intensity level to
maintain the SLM numeric target.
2. For an increase in loudness, follow these steps:
a. Determine first that the inappropriate softness of the voice is not related to hearing
loss, general physical weakness (deconditioning), neurogenic disease, or a psychosocial complication. These etiologies require medical intervention, which then may be
followed by symptomatic approaches. The steps that follow are for voice patients who
are physically and emotionally capable of speaking in a louder voice.
b. Discuss the soft voice with the patient. Listening to audio feedback of the patient’s and
clinician’s voices in conversation usually illustrates for the patient the inadequacy of
the loudness. After the patient indicates some awareness of their soft voice, ask, “What
does a soft, weak voice tell us about a person?” Inadequately loud voices are typically
interpreted to mean that the speaker is afraid to speak louder, is timid and shy, is unduly
considerate of others, is scared of people, has no self-confidence, and so on. Some
discussion of these negative interpretations is usually helpful.
c. By exploring pitch level and fundamental frequency, try to achieve a pitch level at
which the patient can, with some ease, produce a louder voice. If the patient habitually
speaks near the bottom of their pitch range, a slight elevation of pitch level will usually
be accompanied by a slight increase in loudness. The Visi-Pitch and Computerized
Speech Lab (CSL), Sona-Speech II, and even a musical keyboard or pitch-matching app
have been useful in helping patients associate changes in pitch with relative changes in
220 The Voice and Voice Therapy
intensity. Certain frequencies produce greater intensities. When the patient finds the
“best” pitch level, they should practice sustaining an /a/ at that level for 5 s, concentrating on good voice quality. The patient should then take a deep breath and repeat the
same pitch at a maximum loudness level. After some practice at this “home base” pitch
level, ask the patient to sing /a/, up the scale for one octave, at one vocal production per
breath; then have the patient go back down the scale, one note per breath, until they
reach the starting pitch.
d. Explore with the patient their best pitch, that is, the one that produces the best
loudness and quality. Auditory feedback should be employed so that the patient can
hear their voice and speech. Some counseling may be needed about the practice pitch
used because the patient may resist using a new voice amplitude and pitch level. Note
that the practice amplitude level may well be only a temporary one and not necessarily
the amplitude level the patient will use permanently. It is important that the work be
pursued both in and outside therapy. A change in loudness cannot be achieved simply
by talking about it. It requires practice.
e. Sometimes respiration training (which we discuss later in the chapter) is necessary for
a patient with a loudness problem. Remember, however, that even though loudness
is directly related to the rate of airflow through the approximated vocal folds, little
evidence indicates that any particular way of breathing is the best for optimum phonation. Any respiration exercise that produces increased subglottal air pressure may be
helpful in increasing voice loudness.
f. For patients who seem unable to increase voice loudness, we might employ the
Lombard effect (Lau, 2008; Whittico et al., 2020). The Lombard effect is observed
when patients reflexively voice at louder levels when reading or speaking against
increasing competing noise. For example, as the patient reads aloud, the clinician
introduces about 75 dB of speech-range masking (see the VFA called Masking for
application procedures).
3. Patients or people wanting to improve their voices sometimes demonstrate little or no
loudness variation. Fluctuation in loudness can be helped by the following:
a. Make an audio recording of the patient’s voice. Ask the patient how they like the voice
on playback. People who become aware of the monotony of their voices and who are
concerned about it can usually develop loudness variation (and pitch inflection) with
practice.
b. Use an auditory playback system. Record speech or oral reading and then listen back
immediately. Ask the patient about the relative appropriateness of loudness or loudness
variation.
c. Most voice and diction books include practice materials for developing loudness varia-
tion in the voice.
Typical Case History Showing Utilization of the Approach
Curtis, a 31-year-old teacher, complained for more than a year of symptoms of vocal fatigue,
that is, pain in the throat, loss of voice after teaching, and so on. Laryngoscopy revealed a normal
CHAPTER 7 Voice Facilitating Approaches 221
larynx, and the voice evaluation found that the man spoke at “a monotonous pitch and low
loudness level, with pronounced mandibular restriction, at times barely opening his mouth.” Early
efforts at therapy included the chewing approach, with special emphasis given to varying pitch
level and increasing voice loudness using a SLM. The patient was highly motivated to improve the
efficiency of his phonation; he requested voice therapy three times a week and supplemented the
therapy with long practice periods at home. After 9 weeks of therapy, pre-therapy and post-therapy
digitized recordings were compared, and the patient agreed with the clinician that he sounded
“like a new man.” Speaking in a louder voice for this patient seemed to have an immediate effect
on his overall self-image, resulting in an almost immediate increase in his total communicative
effectiveness. Not only did the patient achieve a better-sounding speaking voice, but he reported
no further symptoms of vocal fatigue.
Evidence-Based Evaluation of the Approach
Inappropriate loudness of voice, whether too loud or too soft, penalizes the patient. Many of
the VFAs described in this chapter influence voice loudness, and inadequate loudness is also
highly modifiable (Rose et al., 2017). This was demonstrated in a study by Schneider-Stickler and
colleagues (2012). These researchers found that voice pitch ranges and amplitudes of call center
agents were easily modified using biofeedback software. Results suggest that controlling amplitude
can result in the treatment and prevention of abused and misused voices. Having immediate
access to biofeedback allowed subjects to adjust for voicing made with appropriate amplitude as
well as pitch and speaking rate. The authors concluded that the use of a comfortable speaking
voice, notably with respect to amplitude, is one of the most important factors in preventing vocal
disorders. Van Stan, Mehta, and Hillman (2015) found similar phonation modifications using
ambulatory biofeedback approaches; however, the authors reported that the improved behaviors
may not be retained after biofeedback removal. They suggested testing more innovative biofeedback approaches based on motor control and learning theories to increase retention of improved
vocal motor behaviors.
3. Chant-Talk
Kinds of Problems for Which the Approach Is Useful
Voice problems related to hyperfunction are often helped by the chant approach. The chant in
music is characterized by reciting many syllables on one continuous tone, creating, in effect, a
singing monotone. We hear chanting in some churches, mosques, and synagogues, performed
by clergy and select groups. The words run continuously together without stress or a change in
prosody for the individual word segments. In singing, the legato is similar to the chant we use
in voice therapy. A common dictionary definition of legato is “smooth and connected with no
break between tones.” The chant in therapy is characterized by prolongation of vowels, lack of
syllable stress, and an obvious softening of glottal attack. Once a patient can produce the chant
in its extreme form (such as in a Gregorian chant), it can usually be modified to resemble conversational phonation. We have used chanting with other VFAs, such as chewing, open-mouth, and
yawn-sigh.
222 The Voice and Voice Therapy
Procedural Aspects of the Approach
1. The chant-talk approach is explained to the patient as a method that reduces the effort
in talking. It is important to point out to the patient that the method will be used
temporarily only, as practice, and will not become a permanent and different way
of talking. Demonstrate chant-talk by playing a recording of a religious chant. Then
imitate the recording by producing the same voicing style while reading any material
aloud.
2. Urge the patient to imitate the same chant voicing pattern. Most patients can do this with
some degree of initial success. For those who cannot chant in initial trials, present a chant
recording again and then follow it with choral chanting with the clinician and then the
patient’s own chant production. Some lighthearted kidding is useful to tell the patient
that the chant is a different way of talking and will be used only briefly as a voice training
device. If the patient cannot chant after several attempts, use another VFA. For those
patients who can chant, go on to Step 3.
3. The patient should now read aloud, alternating the regular voice and the chant voice.
Twenty seconds has been found to be a good time for each reading condition. Ask the
patient to read aloud first in the normal voice, then in a chant, then back to normal voice,
then in a chant, and so on.
4. Record the patient’s oral reading. On playback, contrast the different sound of the normal
voice with the chanted voice. Discuss the pitch differences, the phonatory prolongations,
and the soft glottal onset.
5. Once patients can produce chant-talk with relative ease, they should try to reduce the
chant quality, approximating normal voice production. Slight prolongation and soft glottal
onset should be retained as the patient reads aloud in a voice with only slight chant quality
remaining.
Typical Case History Showing Utilization of the Approach
Clara was a 28-year-old woman who worked at a call center selling telephone directory advertising. She began to experience increased dysphonia and “dryness of throat,” particularly toward
the end of a busy day of calling on customers. On endoscopic examination, she was found to
have bilateral vocal nodules with unnecessary supraglottal participation during phonation. She
spoke at an inappropriately low pitch, with mandibular restriction and noticeable hard glottal
attack. Twice a week she received voice therapy designed to “take the work out of phonation.”
The chewing approach, coupled with the chant-talk approach, dramatically changed her overall
voicing style. She was able early in therapy to incorporate the soft glottal attack of the chant
into her everyday speaking voice. Other approaches, such as open mouth and yawn-sigh, were
added with various self-practice materials she could use. The patient reported that she practiced
throughout the day in her car, driving between appointments. In about 12 weeks, videoendoscopy revealed that the nodules had disappeared and that her supraglottal structures stayed
open during normal voicing. There was no evidence of hard glottal attack at the time of her
clinic discharge.
CHAPTER 7 Voice Facilitating Approaches 223
Evidence-Based Evaluation of the Approach
The chant-talk approach is useful for alleviating the effects of vocal fatigue and vocal hyperfunction (Theis & Carlson, 2022). The technique is easy for most patients to use and has been
demonstrated to reduce the acoustic measure noise-to-harmonics ratio in normal speakers (Meerschman, 2018). In addition to our experiences, McCabe and Titze (2002) also recommend the
approach. These researchers introduced chant therapy and a placebo to public high school teachers
who complained of vocal fatigue. Based on the changes of the subjects’ responses to a fatigue task
after the delivery of chant therapy, the researchers concluded that the principles learned by the
subjects using chant-talk helped to reduce vocal fatigue. It is important to let the patient know
that chanting is only a temporary behavior, designed to take the work out of phonation. We have
found that the method works well with children, who seem to enjoy the “different” way of talking.
For those patients who need to reduce hard glottal attack, the chanting approach seems to produce
dramatic results for softening voicing onsets.
4. Chewing
Kinds of Problems for Which the Approach Is Useful
We see many people with vocal hyperfunction who appear to speak through clenched teeth with
very little mandibular or labial movement. Such patients profit from using the chewing approach.
We often kiddingly ask such patients, “Have you ever been a ventriloquist?” We then reply to
their usual answer in the negative with “You certainly could be because you barely move your
mouth when you speak.” Many hyperfunctional voice patients, after being asked the ventriloquist
question, develop immediate insight into their relative lack of mouth opening. Chewing is helpful
for the patient who speaks with great tension and hard glottal attack. During simultaneous voicing
and chewing, we often hear less strain in the voice, easier glottal attack, and an improvement in
voice quality.
Procedural Aspects of the Approach
1. We first do what is necessary to help the patient become aware of the need for greater
mouth opening while speaking. Following the ventriloquist question, we may ask the client
to speak while in front of a mirror. Mirror intervention is a good method for instructing
the patient specific to the relative amount of mouth opening the patient is using.
2. The clinician and patient look in a mirror as the clinician demonstrates exaggerated
chewing. Care is given to have both good vertical and horizontal movements of the mouth.
We pretend that we are chewing a stack of three crackers or a wad of French bread at one
time with an open mouth. Ask the patient to imitate exaggerated chewing as has been
demonstrated. Point out to the patient the amount of mouth opening by saying something
like, “You see that we let our jaw drop down with our lips open wide. If we were actually
chewing crackers, the crumbs would all drop out of our open mouth.” Spend as much time
as needed to develop good open-mouth chewing.
224 The Voice and Voice Therapy
3. We now add light voice to the chewing. Here we have to be careful to avoid the same
kind of monotonous sound, like “yam-yam-yam,” that can come from chewing in the
same pattern while voicing. To mix the sounds (and the mouth movements) a bit, we
may have the patient say in a chantlike way nonsense words such as “ah-la-met-erah” or
“wan-da-pan-da.” Stay with such nonsense word until the patient masters the simultaneous
chewing and speaking. It should be noted here that most children like to do chewing and
take easily to the approach. Some adults may resist doing it or be unable to do it; if so,
the approach should be abandoned and other approaches used, such as the open-mouth
approach.
4. Once simultaneous chewing and speaking are established, ask the patient to count and
chew. It will take several practice attempts before the patient can do it. Listen and watch
the first attempts on video playback. Tell the patient at this point that the chewing is “a
means to the end of producing a more relaxed voice.” The patient should be counseled
that the exaggerated chewing is used only temporarily and that we will soon cut down the
movements to resemble more “the mouth movements of normal speakers.”
5. Now use words and phrases for practice chewing. When the patient can do this, we then
practice sentences. Avoid going too fast. Go back to earlier levels if the amount of chewing
seems to be fading.
6. After the patient has mastered Step 5, the patient should be taught how to diminish the
exaggerated chewing to resemble more normal mouth movements. Practicing oral reading
with chewing is a good final step. Video recording the practice session allows the patient to
study their success on video playback.
7. Ultimately, the patient just thinks the chewing method. By this time, the patient has
developed an awareness of what oral openness and jaw movement feel like and has
experienced the vocal relaxation that accompanies the feeling.
Typical Case History Showing Utilization of the Approach
Sara, a 44-year-old realtor, began to experience extreme vocal fatigue toward the end of her
working day. At the voice evaluation, she reported, “Sometimes I lose my voice altogether at the
end of the day, or after I talk a lot, it hurts right here” (she pointed to the general hyoid area).
As she volunteered her history, little mouth opening was observed with her voice sounding at
an inappropriate high pitch and the ends of sentences characterized by “squeezed phonation.”
On endoscopy, her vocal folds showed “posterior redness, suggestive of reflux with no middle or
anterior pathology noted.” A diagnosis of MTD was made with a special notation made relative
to speaking through clenched teeth. Early in voice therapy, the patient worked on developing
better respiration skills for voicing and developing more natural oral movements (less mandibular
restriction). There was some initial resistance by the patient to using the chewing approach, but
after she began to experience increased oral relaxation as she practiced the chewing, she incorporated greater oral movements into her everyday speaking pattern. The patient experienced a
very good voice result from both reduction of her reflux by a medical regimen and eliminating
her dysphonia and vocal fatigue from voice therapy (with early emphasis given to using the
chewing approach).
CHAPTER 7 Voice Facilitating Approaches 225
Evidence-Based Evaluation of the Approach
Chewing was listed as one of the VFAs studied by McCory (2001) in a retrospective audit of voice
therapy outcomes in vocal nodules. Results revealed that this approach was consistent with best
practice and that voice therapy is effective in the reduction, and in some cases elimination, of vocal
nodules. In another study, 27 healthy females were randomly assigned to an experimental (chewing)
or control group. The experimental group revealed decreases in jitter and noise-to-harmonic ratio
and an expansion of the voice range profile (Meerschman et al., 2015). Meerschman (2018)
found that the chewing technique was associated with improvements in the Dysphonia Severity
Index, and Agheană and Mircea (2022) found that chewing, along with humming and yawn-sigh,
revealed reduced pain and improved quality of life for five patients presenting with voice disorders.
The chewing approach is not a panacea for all voice problems, but its positive effectiveness in
reducing MTD or vocal hyperfunction is observed soon after it is applied. It appears that when oral
structures are involved in the automatic function of chewing, according to Brodnitz and Froeschels
(1954) who first introduced the technique, these oral structures (facial muscles, mandible, tongue)
appear capable of “more synergic, relaxed movement.” It appears that relaxing the overall vocal
tract while chewing also relaxes the phonatory function of the larynx and pharynx. By employing
a commonly used action, such as chewing, the patient is able to achieve relaxation of the vocal
tract from a holistic or gestalt point of view, without attempting to relax particular muscles. For
the voice patient who appears to be talking between clenched teeth, the chewing approach is a
good way to develop more open, natural oral movements. This approach may be contraindicated
for the patient with temporomandibular joint syndrome.
5. Confidential Voice
Kinds of Problems for Which the Approach Is Useful
Using a soft, confidential voice as an alternative to using a voice produced by much effort and
hyperfunction was first described as the confidential voice by Colton and Casper (1996). Confidential voice has subsequently been studied by several researchers, who report that the approach
is effective in reducing loudness, excessive vocal use, and abusive vocal patterns (Behrman etal.,
2008). Confidential voice is similar to the soft voice recommended for children to use as the
quiet voice, the second voice level of loudness that allows voicing at a quiet level “not loud
enough to awaken someone sleeping nearby” (Boone, 1983). Both children and adults seem to
be able to speak in the easy, confidential voice, which makes the approach useful in reducing
overall vocal hyperfunction. The confidential voice, with its increased breathiness, not only reduces
voice loudness but also affects breath control, slows down speaking rate, and seems to create a
more open, relaxed airway. The technique employs light voice (not whispering) and is used in
a prescribed time period for reducing hyperfunction in functional dysphonia and in vocal hyperfunction resulting in vocal fold thickening and vocal nodules. The confidential voice is explained
to both children and adults as a temporary way of talking, a means to an end for developing a
better voice (see Video 7–1). In some populations, though, it is suggested as a long-term approach
to be used with other technologies, such as portable amplification devices. Roy and colleagues