What Actually Happens in the Therapy Sessions?
Voice therapy programs generally include education about voice and training in technical skills. Within the educational component, two basic topics are covered. The first is an overview of normal and healthy voice production. People are better able to take care of themselves and to prevent injury when they understand the basic mechanisms of how the body works. You will learn the structures (anatomy) and function (physiology) of the voice production system - how we make sound, the difference between voice and speech, how loudness and pitch are controlled. This knowledge allows you to take an active role in recovery from voice problems, and to establish a program of preventative healthcare to maintain a healthy voice.
The second topic of education focuses upon vocal hygiene (PDF). Vocal hygiene consists of habits that help keep the voice production system healthy. These include drinking enough water, reducing or removing exposure to irritants such as cigarette smoke or acid reflux, and avoidance of throat-clearing, habitual yelling, talking in noisy environments, or extensive talking when ill. For more information about what you can do to keep your voice healthy, see our tips on vocal hygiene (PDF).
The majority of the time spent in therapy sessions focuses upon the technical skills training component. This consists of exercises to encourage optimal balance of the voice production physiology, to help coordinate breathing, producing sound and achieving the pitch, loudness and quality of the sound you desire in a way that is healthy for the vocal folds and most importantly, that meets your daily communicative requirements. The specific type of technical skills training will depend upon your specific voice disorder - the symptoms you are experiencing and the underlying cause. In part, you can liken the technical skills training to physical therapy for the voice. However, unlike neck, shoulder and knee movements, many voice problems are not caused by muscle injury or joint damage, but rather by damage to the delicate mucosal tissues covering the vocal folds. For more information about these exercises, take a look at the different types of technical skills training.
How Long is the Voice Therapy?
The length of each individual voice therapy session is usually 1/2 hour. Most often, the sessions are weekly. However, for some types of voice disorders, two or more sessions per week are best for the first few weeks, tapering down as the therapy progresses. The duration of the entire voice therapy program is highly individual. The program can be as short as just a few sessions, or as long as 12 weeks or more. It depends, in part, upon your personal therapy goals and the progress being made in the session. To a great extent, you determine how long you want to participate in therapy.
Can't I Just do this myself if you give me a list of exercises?
Voice therapy is not just a list of words, sounds or exercises used for rote practice. Practice, of course, is an important part of the therapeutic process. But within the therapy session, careful attention to vocal productions and feedback are essential for shaping the exercises into a useful tool for the voice. Similar to learning any new skill, an individual can achieve much greater success with a teacher or coach than within a self-study program, especially within the early stages of the learning process.
How successful is voice therapy?
The success of the program relies heavily upon your active participation with the therapy session and the adherence to vocal hygiene and the practice of the technical skills training exercises outside of the therapy session. In many ways, it is no different from learning to play a musical instrument, speak a foreign language, or learn a sport. No one can learn a set of new skills well just by focusing upon them "in class". Beyond the issue of practice and patient participation, however, the success of the therapy depends very much upon the nature of the underlying laryngeal disorder or disease. At The Voice and Swallowing Institute, we will discuss with you the potential outcome of your voice therapy program.
Within the therapy sessions, both the voice therapist and the patient have certain responsibilities to help make the therapy program a success.
It is the responsibility of the voice therapist to:
- Establish goals that are realistic and that address the needs and concerns of the patient
- Help the patient understand the purpose of each goal and provide a means to attain each goal
- Stay up-to-date with current theories and techniques
- Be flexible - try different approaches to achieve the best results possible
- Provide a supportive environment within which the patient is encouraged to try new vocal techniques.
It is the responsibility of the patient to:
- Take personal responsibility for relieving the vocal symptoms and improving the voice
- Participate fully in each voice therapy session
- Be flexible - be willing to try new voice techniques and behaviors
Who provides the voice therapy and what is the difference between a voice therapist, a speech pathologist, a voice coach, and a singing teacher?
A speech pathologist (the full title is speech-language pathologist) is required by law to have completed postgraduate university training, certification from the American Speech-Language-Hearing Association (the initials CCC-SLP), and licensing from the state in which she or he practices. Although all speech pathologists receive some training in voice problems, considerable additional clinical experience is required to conduct effective voice therapy. A voice therapist is a speech-language pathologist with extensive experience and interest in voice disorders. A voice coach generally refers to an individual who works with performers (actors and singers) to improve diction, accents, pronunciation of foreign words in songs and the acting voice. Singing teachers work specifically on vocal artistry and technique of the singing voice. Neither voice coaches nor singing teachers are required by law to be licensed.
I have been told that I breathe wrong - that I have poor "breath support. What does that mean?
Sound is produced by the vibration of air molecules, which in turn is caused by the vibration of the vocal folds. The air that is exhaled from the lungs is both the power source that causes the vocal folds to vibrate open and closed, and it is the medium that is set into vibration which we perceive as sound. The air pressures and air flows we generate during speech are critical to voice production. Therefore, our breathing is important for producing voice.
In general, breathing problems of voice patients may be divided into three types. One type of breathing problem is due to lung disease, such as emphysema (caused by smoking) or asthma. Lung disease makes it very difficult to generate enough air pressure and air flow to produce voice consistently enough to have an easy conversation. Treatment includes certain medications to help make breathing easier, and voice therapy to develop speech and voice strategies to help compensate for the lung disease.
The second type of breathing problem is due to inadequate laryngeal valving. This means that the vocal folds do not come together completely during the closed phase of vibration when voicing. Complete closure of the vocal folds during each cycle of vibration is important for adequate loudness level and other aspects of vocal quality. Common reasons for inadequate laryngeal valving include atrophied (thinned) vocal folds from aging (presbyphonia), nodules, polyps and cysts, or vocal fold paralysis. These medical problems cause incomplete glottal closure, resulting in air wastage during speaking and poor breath support for speech. Treatment depends upon the exact cause of the glottal gap, but may include surgery or voice therapy.
The third type of breathing problem relates to the coordination of breathing with speech, specifically the regulation and modification of air flows and air pressures for a variety of speaking tasks. In these cases, most often there is nothing wrong with the way people breathe when not speaking, or when speaking within normal conversation. We carefully regulate the amount of air in the lungs when speaking. (Think about what you would do if you were told to yell - you'd start by taking a deep breath.
A specific level of air pressure from the lungs is required to initiate and to maintain vocal fold vibration (depending upon the pitch and loudness level, among other factors) When we start out speaking on a lung volume that is above the resting lung volume level, then the natural tendency of the external intercostals muscles and diaphragm is to relax. This makes it rather easy to maintain adequate air pressure for speech. Once we begin to speak below resting lung volume, we must use active muscle contraction to force more air out and hence to maintain adequate air pressure. Therefore, speaking becomes more effortful. And speaking moderately loudly, such as during a presentation to a group, is even more effortful and difficult.
This type of breathing problem occurs most often in individuals who must speak for extended periods of time or who must use a loud voice on a regular basis. This includes teachers, customer service or technical support representatives, salespeople, law enforcement agents, union negotiators, individuals who give presentations or training sessions to groups of people, and people who must talk within very noisy environments such as aerobics instructors, waiters, and trades people who work around noisy machinery.
For these types of vocal demands and speech environments, there are ways to breathe during speaking ("speech breathing") that will help the voice come out clearly and loudly and easily. We call this a well-supported voice. Some people do this naturally. Most do not. Some people can "get away with" a poorly supported voice, even with significant vocal demands (just the way some people can stay slim with bad eating habits and little exercise, while the rest of us get fat with that type of lifestyle!) We don't know why some individuals are susceptible to voice problems and others are not.
We suspect that there are a variety of factors that may contribute to an individual's susceptibility to voice problems, including overall health and genetic factors. Until we learn more specifically what predisposes people to voice problems, we will focus upon healthy voice habits. And a well-supported voice (good speech breathing habits) is a great place to begin!
Good speech breathing habits (a well-supported voice) can be learned easily with a voice therapist, a voice coach or a singing teacher. The professional is best suited to help you depends upon your specific vocal needs.
An Un-Supported Voice (Poor Speech-Breathing Habits)
- Poor posture
- Shallow breathing patterns, with failure to make full use of abdominal, back and chest muscles for breathing (using "clavicular" breathing).
- Failure to use catch-breaths and replenishing-breaths during prolonged or loud speaking
- Use of laryngeal squeezing and "pushing" to achieve loud voice instead of regulating air pressure and mouth opening to increase intensity.
A Well-Supported Voice (good speech-breathing habits)
- Good posture - upright, balanced, low and relaxed shoulders.
- Allowing full expansion of the lungs during inspiration, recruiting muscles of the abdomen and lower back to help the chest muscles and diaphragm expand the rib cage and lungs.
- Use of catch-breaths (short inspirations to help finish a phrase) and replenishing breaths (full inspirations) to avoid speaking on too low of a lung volume
- Use of certain vocal tract postures, sufficient air pressure, and gentle vocal fold vibration to achieve increased loudness.
I'm a performer (singer, actor). Shouldn't I just work with a singing teacher or voice coach instead of getting voice therapy?
It depends on the nature of your voice problem. (See our discussion in Professions at Risk: Vocal Performer and Vocal Performers' FAQs). If, after a thorough vocal function evaluation, the cause of your voice symptoms appears to be associated with a technical singing or stage voice problem, a singing teacher or voice coach may indeed be the best person with whom to work. However, it is often the case that the cause of a performer's voice problem lies in the use of the non-performance voice, in which case a voice therapist trained in the singing voice would generally be the best professional to help you. In addition, it may be that the technical errors that caused the voice problem have also caused inflammation or nodules, polyps and cysts on the vocal folds. In that case, it is best to work with a voice professional who is trained to work with a performer with an injured larynx. This is either a voice therapist who specializes in vocal artists, or a singing teacher who has additional training and experience with medical voice problems.
I've heard that whispering is bad for the voice. True or false?
First, let's clarify the different meanings of whispering. There are two types of whispering - one is produced with voice, and the other without. In a voiced whisper, the vocal folds are vibrating but the voice is produced very softly and with much breathiness. It is low-effort (gently produced), low airflow, low pressure and very gentle on the vocal folds. We call this confidential voice and it is very healthy for injured vocal folds. It is, however, not useful for any type of communication except one-on-one in a very quiet environment. When the voiced whisper is produced with the intention of others hearing it easily, it is called a "stage" whisper. It is effortful and produced with considerable airflows and pressures and a high degree of muscle tension. That's never a good idea and we suggest you avoid that type of whispering.
The other type of whisper - the voiceless whisper, is produced by holding the vocal folds open and forming the sounds of speech with our mouth but without the sound produced by vibrating vocal folds. Because there is no vocal fold vibration (no vocal fold contact), the sound is extremely weak. When the voiceless whisper is produced very gently, it is not harmful to the vocal folds, but the listener must be very close to the speaker in a quiet environment. In most cases when patients use a voiceless whisper, they are trying to make themselves understood within normal speaking environments, and so substantial air pressure and airflow are used. The vocal folds must be held quite stiffly in order to prevent them from vibrating under such aerodynamic conditions. This can constrict the tiny blood vessels in the vocal folds which is not healthy for the tissues. In addition, the use of excessive air pressures and muscle tension are not a healthy way to produce voice and these habits work against establishing more optimal voice production patterns.
I've heard that piping hot or ice cold drinks are bad for the voice. True or false?
In our opinion, from a medical and physiological perspective, the temperature of the liquid does not affect the vibratory behavior of the vocal folds or shaping of the sound. (Of course, the exception would be liquid that is so hot it burns the mouth and throat!) Food and drink do not touch the vocal folds. (If they do, by mistake, the result is violent coughing.) However, temperature is a matter of individual preference. Some people may find that swallowing warm liquids (and enjoying the accompanying steam) is soothing to the throat and helps relieve some of the ache and discomfort that can accompany muscle tension/misuse dysphonia. Others find that very cold liquids tend to produce a sensation of tension in the throat. But in general, temperature of food and drink does not influence the voice of most people.
I've been told that I speak at the wrong pitch. What does that mean?
The pitch of the voice is a perceptual judgment of the average musical note at which we speak. It corresponds in a complex way to the rate of vibration of the vocal folds. When an individual's pitch is identified as being incorrect, on a verage it may be too high, too low, or lacking in variation. (The opposite of lacking in variation would be "sing-song", but that is rarely a problem of patients with voice disorders.) Although there are ranges of normal pitch levels for adult men and women, these normal ranges are quite wide. Therefore, it is often the case that the voice team uses clinical judgment (based upon experience with many patients) to determine whether the pitch is incorrect for a specific patient. Habitual use of incorrect pitch may be a symptom of, or a contributing factor to a voice disorder. Or the problem may not involve incorrect pitch at all, but rather incorrect resonance of the voice. Let's look at examples of each of these.
The use of incorrect pitch may be a symptom -- an effect of the laryngeal problem, not the cause. For example, a patient with vocal fold paralysis may elongate the vocal folds and stiffen them in an attempt to increase vocal fold closure to obtain a louder voice. This will naturally cause the pitch to rise. Another example is the case of enlarged mass of the vocal folds, such as occurs in Reinke's edema. This will cause the vocal folds to vibrate more slowly, thereby lowering the pitch. In these examples, treatment does not focus upon changing the pitch. Once the underlying disease is treated, the pitch typically returns to normal.
There are situations in which the habitual use of an incorrect pitch appears to be a contributing factor to the voice disorder. We say that it "appears to be" the case because there are no research data to prove this one way or another. Rather, it is our opinion, based upon extensive combined clinical experience working with voice disordered patients. Use of an abnormal pitch may require increased contraction, or tension, of some of the laryngeal muscles. This reduces the flexibility or ease with which the larynx may adjust to the many contextual demands of speech, including varying the pitch and the loudness of the voice. This may cause the speaker to get "locked in" to a muscle pattern that facilitates excessive tension, which then may carry over to the other muscles of the neck, jaw and face. We commonly observe this type of pitch/tension problem in muscle tension dysphonia. It can occur especially in women who hold jobs where they must command authority, such as law enforcement officials, attorneys, teachers and sales representatives. Often, this will be combined with use of a loud voice, which may contribute to increased mucosal trauma by putting too much shear force or collision force on the mucosa, leading to formation of nodules, polyps and cysts.
In some situations, the habitual use of incorrect pitch is both a symptom and a cause of the voice disorder. This may be especially true in patients with laryngopharyngeal reflux. Patients may sometimes develop a habit of "guarding" the throat - trying to avoid further irritation to the laryngeal mucosa. This is similar to a person with a sore knee who walks carefully and tries to avoid having anything touch the knee, yet ends up with a sore back and ankle from putting incorrect tension on the muscles and joints that are involved in walking. Even in cases where an individual is not aware of the reflux, the mucosal irritation may still cause a patient to use a different pitch, loudness or style of producing voice that actually makes the voice worse. A common method that patients spontaneously use to guard the voice is to decrease the amount of air pressure arising from the lungs. Perhaps this is an effort to "drive" the vocal folds more gently. Often, however, the reduction in air pressure is too great, causing the vocal folds to vibrate very slowly in a mode called pulse phonation or glottal fry. The sound produced has a crackling quality and is irritating to the vocal fold mucosa.
Pitch is a qualitative perceptual judgment that is based not only upon rate of vibration of the vocal folds, but also upon the way the sound is resonated in the vocal tract. Use of limited breath support, and excessive tension of the muscles of the throat and mouth, can cause the tone focus, or bulk of the resonated sound, to get "caught" in the throat rather than radiated out towards the listener. In this case, the focus of the voice therapy is on improved breath support and changing tone focus, not changing the pitch.
In cases where the habitual use of incorrect pitch is partly or wholly a contributing factor to the voice problem, voice therapy is commonly an important part of the patient's treatment plan. It used to be that treatment focused directly upon finding the "optimal: or "natural" pitch. More current techniques seek to achieve a balance of appropriate muscle activation patterns and aerodynamic forces that allow the pitch to correct itself.