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256 The Voice and Voice Therapy
in part because production of nasals produce quite low intraoral and supraglottal pressures
(Maxfield et al., 2015). Titze (2006) suggested that the SOVT configuration of nasals and glides
results in lower vibrational amplitudes at the glottis. This may be beneficial at reducing tension
at the level of the glottis (Titze, 2006). Boominathan and colleagues (2023) found significant
reductions in vocal fatigue and perceptions of dysphonia by including nasal-glides into an eclectic
approach targeting hyperfunctional voice disorders. Patients with hyperfunction commonly
report that these stimuli allow them to produce voice with less effort. Word stimuli containing
many nasal-glide consonants appear to facilitate in voice therapy a voice that sounds better and is
produced (according to patient self-evaluation) with less effort.
18. Open-Mouth Approach
Kinds of Problems for Which the Approach Is Useful
Some individuals may underestimate to what degree the mouth needs to be open for speech.
Encouraging the patient to develop more oral openness often reduces generalized vocal hyperfunction. Increasing mouth opening can also reduce oral resistance and increase oral resonance
(Kummer, 2011b). The open-mouth approach promotes more natural size–mass adjustments and
more optimum approximation of the vocal folds, and this helps correct problems of loudness,
pitch, and quality. In a study describing voice directivity, that is, how sound is radiated into space
from the mouth and nasal orifices, Brandner and colleagues (2020) wrote that vocal directivity
increases with greater mouth opening. Opening the mouth more is also recommended to increase
oral resonance and improve overall voice quality. The voice also sounds louder. Developing greater
openness should be part of any voice therapy program wherein the patient is attempting to use
the vocal mechanisms with less effort and strain. This approach is often combined in treatment
with other VFAs.
Procedural Aspects of the Approach
1. Have the patient view themself in a mirror (or on a video playback, if possible) to observe
the presence and absence of open-mouth behavior. Identify any lip tightness, mandibular
restriction, or excessive neck muscle movement for the patient.
2. Children seem to understand quickly the benefits of opening the mouth more to produce
better-sounding voices. In our voice program for children (Boone, 1993), we use a brief
story that illustrates two boys, one who talks with his mouth closed and one who speaks
with his mouth open. We then introduce a hand puppet and ask the child if the child has
ever been a ventriloquist. The ventriloquist is described as someone who does not open the
mouth, in contrast to the puppet, who makes exaggerated, wide-mouth openings.
3. The ventriloquist–puppet analogy also works well with adults. Let the patient observe the
marked contrast between talking with a closed mouth and talking with an open one. Ask
the patient to watch themself speak the two different ways in a mirror. Instruct the patient
that what they are attempting will at first feel foreign and inappropriate. The initial stages
of letting the jaw relax are frequently anything but relaxed.
CHAPTER 7 Voice Facilitating Approaches 257
4. To establish further this oral openness, ask the patient to drop the head toward the chest
and let the lips part and the jaw drop open. Once the patient can do this, have the patient
practice some relaxed /a/ sounds. When the head is tilted down, and the jaw is slightly
open, a more relaxed phonation can often be achieved (Boone & Wiley, 2000).
5. For patients to develop a feeling of openness when listening, and as a preset to speaking,
they must first develop a conscious awareness of how often they find themselves with
tight, closed mouths. One way to develop this awareness is to have patients mark down,
on cards they carry with them, each time they become aware that their mouths are closed
unnecessarily. The marking task itself is often enough to increase a patient’s awareness.
Over a period of a week, the number of mouth closings should decrease notably. Another
way of developing an awareness of greater orality is to have patients place in their living
environments (on a dressing table, desk, or car dashboard) a little sign that says “OPEN” or
perhaps has a double arrow or any other code that might serve as a reminder.
6. Greater oral openness requires a lot of self-practice to overcome the habit of talking
through a restricted mandible. Steps 3 and 4 facilitate greater mouth opening and are good
practice tasks. After some practice in using greater mouth opening, the patient should
confirm what it looks like by viewing video playback in practice sessions. Practice materials
for improving greater mouth opening may be found in practice kits for children (Blonigen,
1994; Boone, 1993) and in voice books such as Andrews (2006), Brown (1996), Case
(2002), and Stemple and colleagues (2018).
Typical Case History Showing Utilization of the Approach
Jennifer, a 17-year-old high school student, was examined by an ENT physician about 1 year after
an automobile accident in which she had suffered some injuries to the head and neck. Laryngoscopic examination found all visible laryngeal structures normal in appearance and function,
despite the fact that, since the accident, the girl’s voice had been only barely audible. The speech
pathologist was impressed with her relatively closed mouth while speaking, which seemed to result
in extremely poor voice resonance. Voice therapy combined both the chewing and the open-mouth
VFAs. It was discovered in therapy that, for 3 months after the automobile accident, the girl had
worn an orthopedic collar that seemed to inhibit her head and jaw movements. It appeared that
much of her closed-mouth, mandibularly restricted speech was related to the constraints imposed
on her by the orthopedic collar. When using the open-mouth approach with her head tilted down
toward her chest, she was immediately able to produce a louder, more resonant voice. The openmouth approach was initiated before beginning chewing exercises, and both achieved excellent
results. Therapy was terminated after 6 weeks, with much voice improvement in both loudness
and quality.
Evidence-Based Evaluation of the Approach
The end point of the vocal resonator is the anterior oral cavity, which, when widened, contributes
acoustically to increased vocal amplitude (Brandner et al., 2020; Kummer, 2016). The voice, both
normal and dysphonic, improves in quality with greater mouth opening. Besides opening the
258 The Voice and Voice Therapy
mouth more while speaking, the approach also encourages slight mouth opening while listening.
A gentle opening of less than one finger wide between the central incisors keeps the teeth apart and
generally fosters a relaxed oral posture. The open-mouth approach has been particularly effective
with performers who often open their mouths well during performance (acting and singing) but
may forget the importance of opening their mouths during conversation.
19. Pitch Inflections
Kinds of Problems for Which the Approach Is Useful
The prosodic and stress patterns of the normal speaking voice are characterized by changes in
pitch, loudness, and duration. In some individuals, the lack of pitch variation is noticeable because
the resulting voice is monotonous and boring to listeners. Speaking on the same pitch level with
little variation, which for the average speaker is impossible to maintain, may be associated with
the inhibition of natural inflection. Fairbanks (1960) describes pitch variation as a vital part of
normal phonation and defines inflection and shift: “An inflection is a modulation of pitch during
phonation. A shift is a change of pitch from the end of one phonation to the beginning of the
next” (p. 132). Voice therapy for patients with monotonic pitch seeks not only to establish more
optimum pitch levels but also to increase the amount of pitch variability. Any voice patient with
a dull, monotonous pitch level will profit from attempting to increase pitch inflections. Many
patients with functional dysphonia related to vocal hyperfunction appear to speak with little pitch
fluctuation, often part of a pattern of oral and mandibular tightness, with the lips and mandible
in a fixed, nonmoving pattern. The voice clinician typically combines work on increasing loudness
(intensity) with efforts to increase pitch variability; working on pitch alone is difficult without
influencing loudness variations. Another population that may benefit from pitch inflection intervention is a transwoman seeking to increase the naturalness of her prosody (Adler et al., 2019).
Wolfe and colleagues (1990) suggested that female speakers had a higher percentage of upward
intonation and downward shifts in conversational speech.
Procedural Aspects of the Approach
1. The patient must first become aware of their vocal monotony via auditory playback. Play
samples that lack pitch variability and follow with samples of good pitch variability, as
provided by the clinician. Follow the listening with evaluative comments.
2. Begin working on downward and upward inflectional shifts of the same word, exaggerating
in the beginning the extent of pitch change. Helpful sources for increasing pitch variation
may be found in Boone (1997), Boone and Wiley (2000), Brown (1996), McKinney
(1994), Morrison and Rammage (1994), among many others.
3. Using the same practice materials, have the patient practice introducing inflectional shifts
within specific words, keeping loudness levels about the same.
4. Pitch inflections can be graphically displayed on many instruments, such as the Visi-Pitch
IV or Sona-Speech (PENTAX Medical Corp., Montvale, New Jersey). Set target inflections
for the patient to see if the patient can make their pitch level reach the same excursions or
movement as the target model on the monitor.
CHAPTER 7 Voice Facilitating Approaches 259
5. Record and play back for the patient various oral reading and conversational samples,
critically analyzing the productions for degree of pitch variability.
Typical Case History Showing Utilization of the Approach
Tyrone, a 51-year-old economics professor, received severe course evaluations from his students,
who complained of his monotonous voice. On a subsequent voice evaluation, during both conversation and oral reading, he used “the same fundamental frequency with only minimal excursion
of frequency.” His voice was indeed monotonous, not only in pitch but in loudness too. He also
used the same duration characteristics for most vowels. Tyrone was highly motivated to improve
his speaking voice and manner of speaking. Subsequent therapy focus was on increasing pitch
inflections and improving loudness variations. He was provided with digital recordings, which
he practiced daily, matching the target model productions with his own voicing attempts. After
6weeks of voice therapy and intensive self-practice, Tyrone demonstrated improvement in both his
conversational and lecture voices. Unfortunately, his lack of overall animation continued to result
in poor course evaluations; however, his conversational voice with increasing pitch inflections
appeared to make a much more favorable impression on those around him.
Evidence-Based Evaluation of the Approach
Voice quality in functional dysphonias is often improved when overall effort in speaking is
reduced. Speaking for an extended period of time in a monotone is tiring (to both the speaker
and the listener). People who wish to improve the quality of their speaking voices can often profit
from increasing pitch variability as they speak (Boominathan et al., 2023). This technique is also
instrumental in reducing noise-to-harmonic ratio (Meerschman, 2018). Using auditory feedback,
listening to one’s voice on playback, and having naïve listeners judge the quality of inflection in
a speaker’s voice appears to be a good way of improving pitch variability in one’s voice. At our
clinics, we often record the patient’s voice during speaking tasks, then randomize the recordings
and present them to listeners who are not familiar with the patient. The listeners’ judgments are
powerful biofeedback to the patient. To judge the recordings, clinicians can use the GRBAS or
the CAPE-V auditory perceptual scales (see Chapter 6).
20. Redirected Phonation
Kinds of Problems for Which the Approach Is Useful
Some children and adults with voice problems have trouble finding their voices. This is particularly
more common among patients with functional aphonia or functional dysphonia in their attempts
to find interactive phonation. In redirected phonation, the SLP searches with the patient to find
some kind of noncommunicative phonation (coughing and gargling [Boone, 1983], laughing,
throat clearing) or some kind of intentional voicing (“playing” the comb or kazoo, humming,
singing, lip or tongue trilling [Colton & Casper, 1996], or saying “um-hmm” [Cooper, 1990]).
If the patient has the capability of voicing one or more of these noncommunicative (other than
“um-hmm”) sounds, the sound(s) might be redirected into production of the speaking voice
260 The Voice and Voice Therapy
(Tezcaner et al., 2019). After hearing the unintended phonation for speaking, the clinician
counsels the patient, “Now your vocal folds sound like they are coming together well when you
make that sound on the kazoo (or other voiced production).” This is usually followed by recording
the phonation, such as the gargle or the “um-hmm,” and then using it as the patient’s beginning
intentional voicing model.
Procedural Aspects of the Approach
The search for key phonations that can be redirected to the speaking voice for patients with functional aphonia or functional dysphonia is obviously highly individualized. While some patients
will “uncover” phonation on nontalking tasks, many patients are never able to reveal any phonation, no matter what the task may be. Because there appears to be no preference for introduction
of particular behaviors that may reveal phonation, we list alphabetically nine phonatory behaviors
that have been reported as useful for redirecting phonation to the speaking voice:
1. Coughing. Asking the functional aphonic patient to cough has long been used to uncover
a vegetative phonation that might be redirected to the “lost” speaking voice (Van Riper &
Irwin, 1958). The patient produces a cough on command and is then instructed to prolong
the cough with an extended vowel. See Chapter 3 for further description of ways to use the
cough in searching for the voice in functional aphonia.
2. Gargling. The voice used in gargling can often be extended after the gargling ceases. Only
introduce this approach if the patient is comfortable with gargling. This is usually not
recommended for children. During the gargle, the patient places water in the mouth, tilts
the head back, and agitates the solution in the back of the throat by making a prolonged
expiratory phonation. The patient is asked to hold the gargle expiration for 5 s. Back
vowels /k/ and /g/ are then introduced “on top” of the gargle. Keeping the same tilted
upward head position, the patient is then asked to produce a “dry” prolonged gargle
sound, using these back phonemes. The gargle voice is then redirected to communicative
phonation practice materials.
3. Humming. An occasional dysphonic patient may develop a voice with less perturbation
by humming a song. The clinician explains to the patient that “We are going to listen to
a certain song you may know, and as we hear it, we’ll hum together the tune we hear.” If
the patient can hum along, the humming should be recorded and used as a possible target
voice. In searching for the patient’s best voice, we have occasionally found the voice during
humming (and immediately afterward) as the best voice to build on in therapy.
4. Laughing. Humor and laughing can play an important part in voice therapy, particularly
with the patient who displays excessive muscular tension while voicing. The typical patient
does not realize that their laughter is a form of voicing. The laugh is recorded; presented
on playback; and discussed from the points of view of pitch, loudness, and quality.
Spontaneous laughter is usually relaxed and can provide for the patient a sharp contrast to a
hyperfunctional voice, both in sound and overall body tension.
5. Playing the comb or kazoo. Occasionally, a patient with functional aphonia can produce
voice while playing on a comb or humming a tune through a kazoo. The aphonic patient
may be unaware that their musical attempts when playing the comb or kazoo are producing
CHAPTER 7 Voice Facilitating Approaches 261
vocal fold vibration, or voicing. The voice clinician does not confront the patient with
the discrepancy of a musical sound (voice) with no speaking voice. Instead, the patient is
instructed to articulate a word (using nasal-glide words) “on top of” the tune being played.
If this can be done, attempts are made to produce the same sounds without the tune of the
comb or the kazoo.
6. Singing. Singing can sometimes be redirected as speaking voice phonation. Some patients
with functional dysphonia present clearer voices with less perturbation while singing. If
this can be demonstrated, an early therapy task is to combine singing and speaking by
singing practice sentences. Like procedures used during chant-talk, the goal is to phase out
the singing as a prelude to using the speaking voice. Efforts should be made, however, to
continue using the improved breath control, ease of production, and better vocal quality
that was used while singing.
7. Throat clearing. Many voice patients clear their throats continually in their search for
clearer phonation. In fact, typical vocal hygiene programs eliminate habitual throat clearing
as part of the program. For the functional aphonic patient, however, we may use throat
clearing in our search for a speaking voice. If the aphonic patients can clear their throats,
we ask them to do it with intention. Toward the end of the throat clearing, the patient is
asked to continue the effort by prolonging a low back vowel or a hum. This vocalization is
then used as a “starter sound” for production of monosyllabic words beginning with low
back vowels. We have redirected a vegetative phonation into a speaking voice.
8. Trilling. For the typical person, producing a trill is a difficult task. If a voice patient can
produce a lip or tongue trill, it can be a most helpful technique for developing a better
voice. The lip trill is produced by blowing air through the lips while voicing. The tongue
trill is produced by the tongue tip on the alveolar ridge with the anterior tongue oscillating
in the outgoing airstream. Colton and Casper (1996) wrote, “The trill appears to ‘jump
start’ the vibratory behavior of the vocal folds” (p. 289). For most voice patients, the trill
seems to produce the best voice they can make and is therefore useful in voice therapy for
functional dysphonia.
9. Um-hmm. We call um-hmm the voice of agreement. When Person A is listening to
Person B in conversation, Person A may agree with Speaker B by saying “um- hmm” in an
automatic, natural way. Much of Cooper’s (1990) direct voice rehabilitation and training
focuses on redirecting the patient’s utterance of um-hmm into an easy and improved
speaking voice. The voice produced by the um-hmm voice is reported by Cooper to be
spoken at an appropriate pitch level with good facial mask resonance. We redirect this
automatic phonation with dysphonic patients, using the um-hmm as a starter phonation,
followed by other nasalized words, such as um-hmm one, um-hmm man, um-hmm
many, on the same breath. Provide immediate auditory feedback of the patient’s um-hum
productions. Introduce phrases and sentences, monitoring the patient’s productions to have
the same pitch and quality heard on the single words.
Typical Case History Showing Utilization of the Approach
Sister Catherine was a 42-year-old nun who lost her voice while on a month-long renewal tour,
during which she had to give daily lectures at several parochial schools. Subsequent laryngoscopy
262 The Voice and Voice Therapy
found her to have a normal larynx, and the physician and voice clinician diagnosed “functional
aphonia.” Attempts at coughing and inhalation phonation were unsuccessful in early therapy
attempts to help her find her voice. The humming approach was introduced with immediate
results. She was able to produce a good voice while humming. The clinician rewarded her early
humming phonations with comments like “Now your cords are coming together.” Catherine was
reassured that her vocal folds could come together well and produce voice on expiration. After
several repetitions with the hum gliding into singing, speaking voice was sustained without the
need of the hum. At the first therapy session, when the hum was successfully introduced, counseling, vocal hygiene, and voice education were provided. Toward the end of the session, Catherine
was able to produce a good voice consistently by coupling her phonation attempts with chanting
and the open-mouth approach. Within four therapy sessions, she reported having her normal
voice back on a consistent basis.
Evidence-Based Evaluation of the Approach
In redirected phonation, the clinician searches with the patient to find some kind of voicing, such
as coughing or playing a kazoo, then takes that phonation and redirects it into the speaking voice
(Christmann & Cielo, 2017). For the patient with functional aphonia, the search for any kind of
vocal fold vibration is often the first step in voice therapy (Tezcaner et al., 2019). This phonation
is then extended to the speaking voice. The dysphonic patient has often adapted several poor
voicing behaviors that might be better replaced by “um-hmm” or one of the other eight nonverbal
phonations described here. Each behavior is made automatically by the patient, and once it has
been redirected to the speaking voice, it is no longer needed. The search for nonverbal phonations
is often part of the voice evaluation and is frequently used in the early phases of voice therapy.
Once the patient resumes normal phonation, we find it very important to provide an audiovisual
sample of the therapeutic intervention to the patient as soon as possible. We encourage the patient
to use their smartphone to film the therapeutic session with the clinician. The patient performing
the maneuvers him- or herself is even more powerful (Bandura & Hall, 2018). If the patient
does not have a smartphone, we record the session with a digital camera and provide an audio or
audio–video file of the session at the subsequent visit.
21. Relaxation
Kinds of Problems for Which the Approach Is Useful
It is not possible for most students, working adults, and retirees to have a world that is free of
tension. As Eliot (1994) has written in describing the need for relaxation and a reduction in life’s
stresses, “When you can’t change the world, you can learn to change your response to it” (p. 87).
Because encountering stress is part of the human condition, what becomes important is how we
react to stress. Patients with hyperfunctional voices often develop vocal symptoms as part of their
stress reaction. Among the voice symptoms related to stress are diplophonia, dry throat and mouth,
harshness, elevated pitch, functional dysphonia, and shortness of breath (Boone, 1997). Others
have reported irregular respiration, increased subglottal pressures, and cricothyroid tension (Van
Puyvelde et al., 2018). Accordingly, a frequent goal in voice therapy is to take the work out of
CHAPTER 7 Voice Facilitating Approaches 263
phonation by using voice therapy techniques such as the open-mouth and yawn-sigh approaches
along with symptomatic relaxation.
Symptomatic relaxation methods might well relax components of the vocal tract, but they may
not lead to overall relaxation from stress reduction (Feldman, 1992). It is usually useless to imply to
voice patients that if they would “just relax,” their voice symptoms would lessen, and their voices
would improve. If our patients could relax, they would! The clinician must recognize that a certain
amount of tension and muscle tonus is normal and healthy; however, some individuals overreact to
their environmental stresses and live with “a fast idle,” expending far more energy and effort than
a situation requires. When such psychosocial effort is causative or coupled with voice symptoms,
some encouragement for increasing the patient’s relaxation abilities is in order. By relaxation, we
mean a realistic responsiveness to the environment with a minimum of needless energy expended.
Procedural Aspects of the Approach
1. For children, we develop an understanding of principles of relaxation, following some of
the recommendations and materials offered by Andrews and Summers (2002), Kelchner
and colleagues (2014), Hartnick and colleagues (2018), and Stemple and Hapner (2019).
For adults, the voice clinician may provide an overview of how the body engages in motor
adaptation to physiological disturbances or perceived threats. We explain that aversive
stimuli can trigger a series of negative motor adaptations, ultimately disturbing muscle
activation patterns and their biomechanical outcomes, such as respiration and voice
(Desjardins et al., 2022).
2. Introduce to the patient the concept of differential relaxation as outlined by Feldman
(1992) and Gao and colleagues (2018), who called the approach progressive muscle
relaxation (PMR). Under differential relaxation, the patient concentrates on a particular
site of the body, deliberately relaxing and tensing certain muscles, discriminating between
muscle contraction and relaxation. The typical procedure is to have the patient begin
distally, away from the body, with the fingers or the toes. Once the patient feels the
tightness of contraction and the heaviness of relaxation at the beginning site, the patient
moves up the limb (on to the feet or hands, and then to the legs or arms), repeating at
each site the tightness–heaviness discrimination. Once the torso is reached, the voice
patient should include the chest, neck, “voice box,” throat, and the mouth and parts of
the face. With some patients, we start the distal analysis with the head, beginning with the
scalp and then going to the forehead, eyes, facial muscles, lips, jaw, tongue, palate, throat,
larynx, neck, and so on. Some practice in this progressive relaxation technique can produce
remarkably relaxed states in very tense patients.
3. Various biofeedback devices can help the patient develop a feeling of relaxation. Feedback
such as galvanic skin response, pulse rate, blood pressure, and muscle responsiveness
through electromyographic tracings all seem to correlate well with patients’ feelings of
anxiety and tension. By performing a particular relaxed behavior, such as yawning, a patient
can confirm their particular arousal state by the biofeedback data. Using such biofeedback
devices, the patient can soon learn what it feels like to be relaxed or free of tension.
4. Next, we combine relaxation with hierarchy analysis. The patient responds to particular
tension-producing cues with a relaxed response, such as feeling a heaviness or warmth at a
264 The Voice and Voice Therapy
particular body site and maintains a relaxed response in the tension situation. The patient
may instead develop a situational hierarchy specific to tension and voice by attempting to
use a relaxed voice at increasingly tense levels of the hierarchy.
5. Head rotation might be introduced as a technique for relaxing components of the vocal
tract. This should only be done with patients free of neck or back pathology or pain. The
patient sits in a backless chair, dropping the head forward to the chest. The patient then
“flops” their head across to the right shoulder, then lifts it, then again flops it (the neck
is here extended) along the back and across to the left shoulder. The patient then returns
to the anterior head-down-on-chest position and repeats the cycle, rolling the head in a
circular fashion. A few patients will not find head rotation relaxing, but most will feel the
heaviness of the movement and experience definite relaxation in the neck. Once a patient
in this latter group reports neck relaxation, the patient should be asked to phonate an “ah”
as the head is rolled. The relaxed phonation might be recorded and then analyzed in terms
of how it sounds in comparison to the patient’s other phonations.
6. Open-throat relaxation can also be used. Have the patient lower the head slightly toward
the chest and make an easy, open, prolonged yawn, concentrating on what the yawn feels
like in the throat. The yawn should yield conscious sensations of an open throat during the
prolonged inhalation. If the patient reports that they can feel this open-throat sensation,
ask them to prolong an “ah,” capturing and maintaining the same feeling experienced
during the yawn. Any relaxed phonations produced under these conditions should
be recorded and used as target voice models for the patient. Encourage the patient to
comment on and think about the relaxed throat sensations experienced during the yawn.
7. Wilson (1987) includes a presentation on various relaxation procedures for use with
children, which seem to have equal applicability to adults. Most of the procedures
described can immediately increase relaxation and reduce tension associated with speaking.
8. Ask the patient to think of a setting the patient has experienced, or perhaps imagined,
as the ultimate in relaxation. Different patients use different kinds of imagery here. For
example, one patient thought of lying in a hammock, but another person reacted to lying
in a hammock with a set of anxious responses. Settings typically considered relaxing are
lying on a rug at night in front of a blazing fire, floating on a lake, fishing while lying in a
rowboat, lying down in bed, and so on. The setting the patient thinks of should be studied
and analyzed; eventually, the patient should try to capture the relaxed feelings they imagine
might result from, or may actually have been experienced in, such a setting. With some
practice — and some tolerance for initial failure in recapturing the relaxed mood — the
average patient can find a setting or two that they can re-create in their imagination to use
in future tense situations.
Typical Case History Showing Utilization of the Approach
Mike, a 34-year-old mechanical engineer, developed transient periods of severe dysphonia when
talking to certain people. At other times, particularly in his professional work, he experienced
normal voice. Mirror laryngoscopy revealed a normal larynx. During the voice interview, the clinician noted Mike’s general nervousness and apparently poor self-concept. In exploring the area of
interpersonal relationships, the patient confided that, in the past year, he had seen two psychiatrists
CHAPTER 7 Voice Facilitating Approaches 265
periodically but had experienced no relief from his tension. Further exploration of the settings in
which his voice was most dysphonic revealed that his biggest problem was talking to unfamiliar
people, such as store clerks and garage mechanics. Some of his more relaxed experiences included
giving speeches and collaborating with his colleagues. Subsequent voice therapy included PMR.
Once relaxed behavior was achieved, the patient developed a hierarchy of situations, beginning
with those in which he felt most relaxed (collaborating with colleagues) and proceeding to those
in which he experienced the most tension (talking with unfamiliar people). After some practice,
Mike was able to recognize various cues that signaled increasing tension. Once such a cue occurred,
he employed a relaxation response, which enabled him to maintain normal phonation in situations that had previously induced dysphonia. As this consciously induced response continued to
be successful, Mike reported greater confidence in approaching the previously tense situations,
knowing he would experience little or no voice difficulty. Voice therapy was terminated after
11weeks, when the patient reported only occasional difficulty phonating in isolated situations
and increased self-confidence in all situations.
Evidence-Based Evaluation of the Approach
The popularity of many relaxation and stress-reduction programs today is probably due in part
to their offering people with excessive tensions some relief from their stress. Researchers Lloyd
and colleagues (2017), Sharma and colleagues (2021), and Duffy (2018) suggest that yoga techniques direct attention toward whole-body relaxation, body alignment, and breath coordination
for various singing and speaking tasks. On the other hand, symptomatic relaxation therapy
focuses on faulty voices and sometimes the tensions associated with (if not the cause of) the
vocal problems. Glaze (1996), Roy (2008), Caputo Rosen and colleagues (2021), and van Leer
(2021) have suggested that direct symptom modification, such as identifying and teaching relaxed
responses to replace previously tense responses, breaks up the circular kind of response that often
perpetuates maladaptive vocal behaviors. In effect, we talk the same way today that we talked
yesterday until we learn a better way to talk. Using the voice in a more relaxed manner with less
competitive tension is a “better way to talk.”
22. Respiration Training
Kinds of Problems for Which the Approach Is Useful
Singing teachers and vocal coaches often put more emphasis on respiration training for singers
and actors than SLP-voice clinicians do for patients with voice disorders. While training in breath
support is vital for the extremes of vocal performance produced by singers and actors, the typical
patient with a functional voice disorder may need only some instruction for developing expiratory
control (such as avoiding squeezing out final words of an utterance because of lack of adequate
breath). At the initial evaluation, we observe the patient’s breathing patterns at rest and during
conversational speech. We pay attention to how the patient coordinates breathing with vocalization and speech tasks. We have observed that some patients have minimal awareness of breathing
patterns. The SLP-voice clinician should note and document breath-holding tendencies or speaking
on residual air due to decreased frequency of replenishing breaths (Toles & Harris, 2023).