Section 4 - Facilitating Approaches
(from The Voice and Voice Therapy, 5th Edition, D.R. Boone and S.C. McFarlane, 1994)

While many of the voice therapy facilitating approaches in The Voice and Voice Therapy. 5th Edition by Boone and McFarlane (1994) use various forms of auditory feedback, three approaches are presented here, quoted directly from the text: Approach 9, Establishing a New Pitch; Approach 10, Feedback; and Approach 17, Masking. Used with permission granted by the publishers, Allyn & Bacon.

Approach 9 - Establishing a New Pitch

A. Kinds of problems for which the approach is useful. Although it is fairly well established (Bless, 1984; Minifie, 1984) that there is no absolute optimum pitch on which a particular person should speak, some people with voice problems may profit from speaking at a different pitch level. A change of pitch will often have positive effects on voice, such as improving vocal quality and loudness. Speaking at the very bottom of one’s pitch range requires too much force and effort. Similarly, speaking habitually toward the top of one’s range can be vocally fatiguing. Because a number of instruments available today can portray fundamental frequency in real time (while one is phonating), awareness and feedback of one’s ongoing pitch level play prominent roles in establishing new pitches through therapy.

B. Procedural aspects of the approach

1. If pitch needs to be raised or lowered, describe where the patient is and where the target pitch is. The methods for determining habitual and optimum pitches described in Chapter 4 can be applied here. Make a tape recording of the patient producing various pitches, including feedback about the old pitch and the projected target pitch. The playback should always be followed by some discussion comparing the sound and the feeling of the two pitches.

2. Most voice patients can imitate their own pitch models, once they have been produced by the appropriate facilitating technique. Occasionally patients cannot initiate a pitch to match a model, as Filter and Urioste (1981) found in testing college women with normal voices. A useful model can be produced by having the patient extend an /i/ at the target pitch level for about 5 seconds and recording the phonation on a loop tape recorder. If the loop is set for a 5- to 10-second playback, the patient will immediately hear the target production. The loop tape playback will provide the patient with a continuous playback of his or her own voice model of the target pitch. There are many advantages to using the patients’ own voices as their voice models, in that they already have voicing experience producing the sounds they are now trying to match. Remain with the loop model /i/ for considerable practice before introducing a new stimulus.

3. Several excellent instruments available today can provide real-time display of fundamental frequency, both with a digital write out and on a display screen on a monitor: PM 100 Pitch Analyzer, Phonatory Function Analyzer, Visi-Pitch™, and
B & K Real-Time Frequency Analyzer (see reference section at end of book). Usually, these instruments permit the clinician to display patient voice values specific to frequency and intensity. The PM 100 and Visi-Pitch each offer split-screen capabilities, whereby a voice model can be put on an upper screen and the patient’s production displayed on a lower screen, permitting comparisons between model and trial productions. Any instrument that can display fundamental frequency information can provide valuable feedback to a patient attempting to establish a new voice pitch.

4. The Tunemaster III (see reference section at end of book) provides feedback information relative to correctness of patient production. The desired pitch level is set on the Tunemaster HI. The display dial can then provide feedback to the patient whether voice production is within 30 cycles (sharp or flat) of the target frequency. Using any of the four instruments previously described in step 3, the patient can receive exact digital feedback about the frequency he or she is producing. Any deviation below or above the target pitch level can be given immediate feedback. Of great therapeutic benefit is that the patient will know immediately when he or she is producing the target frequency.

5. Establishing a new pitch is facilitated by working first on single words, preferably words that begin with vowels. Each word is repeated in a pitch monotone (using the target pitch). Occasionally a patient has more difficulty using the new pitch with certain words. Any such "trouble" words should be avoided as practice material, because what is needed at this stage of therapy is practice in rapidly phonating a series of individual words at the new pitch level.

6. Once the patient does well at the single-word level, introduce phrases and short sentences. It is usually more productive at this stage to avoid practice in actual conversation because the patient is better able to use the new phonation in such neutral situations as reading single words, phrases, and sentences. When success is achieved at the sentence level, assign the patient reading passages from various voice and diction books. Success in using the new pitch level can be verified by using the instruments described earlier, in step 3.

7. After reading well in a monotone, the patient may try using the new pitch in some real-life conversational situations. In the beginning he or she may have more success talking to strangers, such as store clerks; patients often find it difficult to use the new pitch level with friends and family, because their previous "sets" may prevent them from utilizing their new vocal behavior. Whatever conversational situation works best for the individual should be the one initially used.

8. It is helpful in therapy to tape-record the patient’s voice as he or she searches to establish a new and different pitch level. When the patient is able to produce a good voice at the proper pitch level, his or her own "best" voice can then become the therapy model.

C. Typical case history showing utilization of the approach John, a 10-year-old boy, was referred by his public-school speech clinician for a laryngeal examination because of a 6-month history of hoarseness. The findings included a normal larynx and a "low-pitched dysphonic voice." John could readily demonstrate a higher phonation, which was characterized by an immediate clearing of quality. In the discussion that followed the tape-recorded playback of his "good" and "bad" voice, John stated that he thought he had been trying to speak like his older brother. The clinician pointed out to him that his better voice was more like that of other boys his age, and that the low-pitched voice he had been using was difficult for others to listen to. In subsequent voice therapy with his public-school clinician, John focused on elevating his voice pitch to a more natural level. His success was rapid, and therapy was terminated after 6 weeks.

D. Evaluation of the approach. The pitch of the voice changes constantly, according to the speaker’s situation. In some patients, however, the pitch level appears to be too high or too low for the overall capability of the laryngeal mechanism. In other people, an aberrant pitch level is just one manifestation of the total personality. Patients with additive masses to the folds (nodules, papilloma, polyps, and so on) may have lower pitch levels than normal because the thicker vocal folds vibrate more slowly, emitting a lower fundamental frequency. As the lesion is reduced or eliminated, the frequency of the voice becomes higher, perhaps approaching normal limits. For patients with additive laryngeal lesions due to vocal hyperfunction, it is often best to work slowly toward increasing pitch level to approximate levels of the patient’s age and sex peers. Some patients use aberrant pitch levels because of personality factors. Counseling such patients and helping them want to change pitch levels might well have to precede actual symptomatic therapy to alter pitch. Typically, however, voice patients who may need to change pitch levels can do so rather quickly, after experiencing marked improvement in overall voice quality because of pitch change.

Approach 10 - Feedback

A. Kinds of problems for which the approach is useful. Once the patient can produce a model voice—his or her own or one that matches some external model—it is important that he or she attempt to study what the voice feels like and how it sounds. Tactual and proprioceptive feedback are common modalities through which we get some information about our voices as we speak, but we primarily use the auditory feedback system to monitor our own phonation. We have little awareness of what our muscles are doing in the larynx, throat, palate, or tongue, which is why voice therapy relies heavily on the auditory feedback mechanism.

With modern instrumentation, we can provide needed feedback specific to the physiology of respiration, phonation, and resonance. Much of the evaluation instrumentation described in Chapter 4 can be used as effective feedback devices because they permit the patient to view various ongoing, speaking-voicing events as they are occurring. It is sometimes helpful to provide the voice patient with information specific to what he or she may be doing in respiration while producing voice. The physiology of respiration can be studied by placing a pair of magnetometers on the chest wall and another pair on the abdomen; Hixon and his associates have studied relative chest wall-abdominal movements during singing (Watson & Hixon, 1985) and in dramatic performances (Hixon, Watson, & Maher, 1987). This use of magnetometers can provide valuable feedback to the patient attempting to develop more optimal breathing patterns.

Nasoendoscopy, as described in Chapter 4, permits direct observation of the actual physiology of various oral, pharyngeal, and laryngeal events while phonating. Supraglottal participation in vocal quality and resonance can be directly observed; the patient can watch himself or herself using various therapy techniques that produce changes in voice. Patients who have marginal velopharyngeal (VP) closure can watch the closure of the VP mechanism on a television monitor and use the experience as direct feedback in therapy (Shelton, Paesani, McClelland, & Bradfield, 1975). For patients with problems of nasal resonance, the Kay Nasometer is a useful feedback device that provides an ongoing ratio of the relative oral-nasal resonance in the patient’s voice. By applying a particular therapeutic technique or attempting to match a particular resonance model, the patient and the clinician can get immediate feedback on the patient’s production.

Feedback specific to voice frequency and quality can be provided by many electronic instruments, some of which we present later, when we describe some of the procedures using feedback. As the patient is presented various target vocal behaviors to produce or match, instrumentation can provide real-time or delayed feedback specific to the correctness of the response. If the patient is off target in production, he or she can alter the vocalization to more closely match the target model.

Biofeedback specific to the patient’s relaxation state can be helpful in voice therapy. The patient is introduced to some kind of biofeedback instrumentation that quantifies physiological changes, such as galvanic response or blood pressure, which are believed to be correlates of anxiety or systemic tension. As the patient becomes more relaxed, the physiological tension data go down; increased tension is characterized by increased data values. The patient in effect learns what it feels like to be more relaxed, and the relaxed state is confirmed by lower tension scores as portrayed on biofeedback instrumentation. Once relaxation behaviors are learned (Stroebel, 1983), the biofeedback confirmation of the relaxed state is often no longer needed.

B. Procedural aspects of the approach

1. Discuss with the patient the general concept of feedback. Tactual feedback might be illustrated by moving the fingertips lightly over the surface of a coin. Proprioception can be demonstrated by having the patient close the eyes, extend an arm, and slowly raise the arm, bending it at the elbow joint. Muscle and joint proprioceptors tell us where our arm is in space and that it is moving. In the larynx, however, such proprioceptive feedback is essentially lacking; we must rely on hearing our voices as we phonate to monitor what we are doing laryngeally.

2. The conventional tape recorder has never been particularly useful as a training device for auditory feedback. All it can do, essentially, is serve as an amplifying system. By the time you rewind the tape and find the precise recording segment, the patient has already lost his or her focus on that particular stimulus. Many auditory tape devices are available: Language Master, Echorder, Artik (see reference section). You can make your own loop tapes for either reel-to-reel recorders or cassettes by following simple procedures (Boone, 1982). The loop playback provides valuable auditory feedback. A loop recording device, for example, set on a 3-second delay, will give the patient an immediate playback of what he or she has just said. By using such a device, patients can immediately match what they thought they sounded like with the actual playback of what they sounded like externally. Vowel prolongations, single words, and phrases are used as the stimuli in this delayed-feedback practice. Remember that such practice in self-listening is much more effective if coupled with commentary and questions about what was heard, and what was different between the old voice and the new.

3. Introduce the patient to the feedback instruments that will provide the needed feedback. In respiration, any of the measuring devices for air volume and pressures described in Chapter 4 may be useful. Duration measurements, such as how long one can prolong an /s/, can be used for feedback. The magnetometers can provide ongoing information about respiratory physiology. Videoendoscopy can provide excellent feedback for the physiology of VP closure, pharyngeal and supraglottal laryngeal participation in voicing, and vocal fold movements. Information about pitch and quality—for example, digital and graphic data about the patient’s ongoing phonation—can be provided by the PM 100 Pitch Analyzer, the Kay Visi-Pitch, and
B & K Frequency Analyzers (see reference section at end of book).

4. Once the patient develops an awareness of what he or she is doing with the help of feedback devices, remove the feedback and see if the patient can then maintain the target production. For example, when the patient no longer can see on a scope the normal coordination of abdomen and thorax in breathing for speech, can the optimum pattern be maintained? Both biofeedback of some physiological system and ongoing auditory feedback eventually need to be phased out of the therapy session to facilitate generalization of improved production outside the therapy.

C. Typical case history showing utilization of the approach. Cheryl was a 22-year-old college student with vocal nodules and a severe dysphonia. Her voice evaluation showed that she spoke at the very bottom of her limited pitch range. When she spoke one or two full musical notes higher than the bottom of her pitch range, her voice sounded near normal. We spent time in therapy giving her auditory feedback of her new voice at a higher pitch level, utilizing a 4-second tape loop cartridge. This provided Cheryl with immediate feedback about how she sounded. We then coupled the auditory feedback with the visual feedback of a Visi-Pitch scope, where she could witness the increased periodicity of her voice indicated by a sharper tracing line on the scope. Not only did she sound better to herself, but she could also see that voicing one or two notes higher than she had been produced a smoother, better-sounding voice. The voice therapy used the auditory and visual feedback, coupled with some practice reducing excessive glottal attack, opening her mouth more, and so forth. At the end of 15 weeks of twice-weekly voice therapy, Cheryl’s nodules were gone and we (including the patient) judged her voice as normal.

D. Evaluation of the approach. As instrumentation is developed that can portray various aspects (respiration-phonation-resonance) of voice, it can play an important role in providing feedback to patients. Once a target behavior has been isolated for a patient, such instrumentation can provide ongoing feedback on the appropriateness of patient production. Feedback presents various visual portrayals (values of frequency, jitter, shimmer, and so forth) of what the patient is hearing. Various facilitating efforts in therapy often produce changes in the sound of voice that are confirmed by different feedback devices. Once an optimal voicing pattern has been established, the use of feedback devices is no longer necessary.

Approach 17 - Masking

A. Kinds of problems for which the approach is useful. Patients with functional aphonia are often able to produce normal phonation under conditions of auditory masking. Some patients with functional dysphonia produce faulty voices because of poor auditory monitoring of what they are doing. The masking facilitating approach uses a voicing reflex test, used by audiologists as the Lombard test (Newby, 1972). In fact, the Lombard test was first introduced as a method of finding voice in patients with functional aphonia. When asked to phonate in a loud noise background, patients with functional aphonia sometimes used light voice. In the voice-reflex situation, the patient wears earphones and is asked to read a passage aloud. As the patient is reading, a masking noise is fed into the earphones. The louder the masking, the louder the patient’s voice. At loud masking levels the patient cannot monitor well either the loudness or the clearness of his or her voice. Some patients with functional dysphonias actually experience clearer voices when they cannot monitor their productions because of loud masking. The clinician may make a tape recording of all the patient’s oral reading, with and without masking, and then play back the results to the patient. The patient may well experience the "proper" set for more optimal phonation during the masking conditions and be able to maintain this improved production without continued masking.

B. Procedural aspects of the approach

1. The masking approach is best used without any prior explanation. Because increased voice loudness comes about with increased intensities of masking on a reflexive, nonvolitional basis, there is no need to discuss the method in advance. In fact, there is evidence that some patients can override the voice reflex and maintain constancy of voice loudness despite fluctuations in masking intensity.

2. The patient is seated next to an audiometer. He or she then puts on headphones and listens to a bilateral presentation of masking at a low level, roughly 40 dB SPL. Once the patient acknowledges hearing the masking, the masking stimulus is discontinued. The patient is then instructed to read aloud and to keep reading, no matter what kind of interruption he or she may hear in the headphones. Typically, the patient is asked to read aloud for a total period of about 2 minutes, with the masking fluctuating off and on throughout the reading. On playback, variations in loudness of the patient’s voice usually signal when the masking noise was introduced and when it ceased.

3. An audiocassette recording should be made as the patient reads aloud. An aphonic patient’s whisper may change to voice under conditions of masking. It is important to have recorded the emergence of voice, which the patient can use in step 5. The dysphonic patient (functional, ventricular, or puberphonic) should also be recorded while using the masking approach. Marked differences in voice quality between the absence or presence of masking conditions will probably be evident.

4. Five or ten-second exposures to masking are introduced to the patient bilaterally. The intensity levels should be in excess of 90 dB SPL, which is sufficiently loud to mask out the patient’s own voicing attempts. Whenever an aphonic patient hears the loud masking, he or she may attempt some feeble vocalization. Under masking, a dysphonic patient will produce a louder voice and often a voice with more normal vocal quality, as well.

5. Do not use the masking method beyond the trial stage with those few voice patients who do not demonstrate the voice-reflex effect. If it works well, and produces voice improvement, the method may be used as part of every therapy period. You might then experiment by having the patient listen to tapes of himself or herself, to see whether the patient can match volitionally his or her voice under masking- conditions. Recordings can then be made contrasting the voice without masking (attempting to recreate the same voice as heard under masking) and the voice with masking. Try to have the voices sound alike.

6. A patient may profit from reading aloud under masking conditions, and then having the masking abruptly ended to see if he or she can maintain the better voice. Many other variations using the masking noise can be initiated by inventive clinicians.

C. Typical case history showing utilization of the approach. Lillian was a 9-year-old girl who had a history of vocal nodules that had been previously treated successfully with voice therapy. Several months after therapy had been terminated as successful (no nodules, normal voice), Lillian developed a severe influenza that left her with no voice. She was completely aphonic, and could communicate only by whispering and using good facial expressions and gestures. The aphonia continued for 1 month (over the December holiday break) before she returned to the voice clinic. The masking approach was used with Lillian after attempts at modeling and request for voice failed. Lillian was asked to read aloud under conditions of 90 dB masking. Her reading attempts were recorded on a 20-second loop tape. As soon as masking was introduced, light phonation was heard and recorded on the loop cassette. The masking and oral reading were stopped, and Lillian was asked to hear her good voice on the tape. The child clapped her hands in joy that she now had a returned voice. Further masking followed by ear training was used as her voice became stronger. After two follow-up therapy sessions, Lillian was discharged with a normal voice. The pushing approach—producing the word patch with sudden extension of arms—was then demonstrated for Lillian to use "if you ever lose your voice again." Hopefully, her "believing" in pushing as a protection against future voice loss will function as a placebo effect and prevent any recurrence of aphonia. Lillian has had no voice problem in the 2 years since the 1 month of aphonia.

D. Evaluation of the approach. The masking approach is most helpful with aphonic patients. It is also helpful for patients with some form of functional dysphonia or young men with puberphonia. If the masking noise is loud enough, in excess of 90 dB SPL, patients cannot hear their voices to monitor phonation. If required to continue speaking by reading aloud under conditions of masking, patients will often produce relatively normal voices under the masking condition. Clinicians should use some care in confronting the patients on audiotape playback with their "good" voices. Improved voices under conditions of masking should be used as the patients’ models for their own imitation phonations. Clinicians should use the masking approach with some degree of eclecticism—that is, if the approach works, use it; if it does not, quickly abandon it.