230 CHAPTER SEVEN: VOICE DIFFERENCES Voice As A Reflection Of Self The voice is perhaps the most personal and internalized of all the characteristics of an individual's communication system. It is more intimately tied to the personality of the individual than any other communication feature. The voice also is a reflection of the internal state of the speaker. The voice is often a signal to others of how we feel. It can indicate that we are happy, sad, tired, upset, or any other of the wide range of emotions humans possess. Regardless of the words we use, the voice may betray the real message. You have heard the saying "it's not what she said, it's the way she said it." We can easily choose words that conceal how we feel, but it can be difficult to mask emotions contained in the voice. My wife usually asks me what I think of a new hairstyle she is trying. I'll admit that I am not much of a connoisseur of coiffure, so I usually try to make some comment that isn't open to a lot of speculation as to meaning, such as "it looks fine." This usually elicits a scowl and a response "you don't like it, do you?" Is it my voice that gives it away? Voice is strongly identified with a sense of self. People are recognized by their voices. You recognize persons talking on the telephone or in a crowd where you can hear, but not see them, by their voices. As such, voice becomes a part of your appearance. That is probably the most significant aspect of voice. Like other aspects of communication, voice is a part of the appearance by which you will be judged. Just as the clothes you wear, your hygiene, and hairstyle. Many first impressions are changed dramatically when the person speaks. You've probably heard something like "He was really a cute guy, 'til he opened his mouth." It is estimated that 40% of the initial impression a person makes on first meeting another is in response to the spoken language. People may have a difficult time realizing their voice is different. Voice is not something we can stand back and look at in the same manner we can look at our appearance in a mirror. Our feedback comes through hearing ourselves speak. However, what we hear when we listen to ourselves speak is very different from what others hear. Think of the last time you listened to yourself on a tape recording. Did the voice sound the same as it sounds to you when you speak? The reason our voice sounds different to ourselves is that when we talk, we not only cause vibrations in the air, we cause the bones and other tissues in our head to vibrate. Put your thumb on your Adam's apple and spread your fingers across different points on your face. Count to ten and feel the vibration of the tissue in the face and throat. The ear senses these vibrations, just as it does the vibration of air particles. So when we listen to ourselves, we hear not only what others hear (vibration of air particles), but vibrations of our own speech mechanism transmitted through the body's tissue. The only way we can hear ourselves as others do is on a tape recorder. A Lesson In Humility The fact that voice is a truly integral part of an individual's self-perception was driven home to me while I was working with voice clients who were participating in an experimental approach to changing pitch. I was a graduate student working in an instrumentation laboratory. We were using a behavior approach to changing pitch based on bioacoustic feedback. Basically, the set up involved electronic instrumentation configured to analyze the voice signal spoken into a microphone. The subjects sat in a sound treated room and read general reading material. We adjusted the machine to turn on a light that signaled the clients that they were speaking at the desired pitch. It was strictly an operant approach in that we gave the subjects no instructions other than to keep the light on as much as possible. The subjects knew they were there to work on pitch, but no advice was given on how to change. The study by itself was fascinating in that we found people could quickly learn to manipulate the light by changing pitch. Most of the subjects for this study were adult males who had retained a pre-puberty pitch. The ultimate result was that they had the pitch of a female. Most had referred themselves to the clinic not because they felt there was anything wrong with their voices, but because they were tired of being mistaken for females on the telephone. One subject, who was a student living in the men's dormitory on campus, reported "if I hear one more person say to me on the phone 'sorry, I was calling the boy's dorm' I'm going to scream." The first lesson I learned about voice from this study was that no matter how inappropriate the voice sounded, speakers did not recognize the degree of difference that was evident to others. All knew they were mistaken for females on the telephone, which you might expect would have been enough to make them want to change. However, all were college students or older who had been speaking in the high pitch since puberty. It took several years of being mistaken for a female to bring them to take any action. The operant approach worked extremely well. Within a short period of time most could speak at the target pitch, which was, in fact, a pitch range within the limits for males. All of the subjects had been checked by a physician and found to have normal larynges (voice mechanisms). They had been talking in what is known as falsetto voice to maintain the higher pitch, so the new pitch actually reduced strain on their vocal folds. As clinicians trying to effect change, those of us working in the study would almost cheer when they hit the normal range. Here were guys coming in sounding like females, who with a little training were sounding like normal male speakers. When a subject came from the training room after a session in which they had achieved the desired pitch level, we greeted them with congratulations and told them how good their new voices sounded. The subjects we found, however, weren't as impressed. The typical comment after the first few days of using the new, normal sounding pitch during the training sessions was "It sounds funny" or "it doesn't sound right." Most telling was a comment from one young man who summed it all up with "it sounds sorta good, but it's not me." It was a bit of a blow to my ego as a clinician that this marvelous change had been made, but not appreciated by the person whose voice had been changed. The new pitch always sounded "different" to them. When we tried to get them to use the new pitch outside of the clinic, they were highly resistant. First, they weren't convinced internally that the new voice was really better, and second, they knew they would get a reaction from their friends if they suddenly started talking with the new voice. One of the most difficult parts of the process, which we did not anticipate when we started, was how difficult it would be motivating the subjects to use the new voice in everyday situations. The study was to change the pitch in the training setting using an operant methodology. That part was a success. However, change is only meaningful if it becomes a standard feature of the user's speaking voice. We used different counseling (maybe I should say 'selling') approaches to get them to use the new voice. We found that first we had to have them become accustomed to listening to the new voice so they could identify with it. We achieved this by having them talk to themselves in the new voice anytime they were in an automobile by themselves. This is a good strategy, because most people spend a significant amount of time in an automobile getting from one place to another, and there are no others around to hear the voice. After they had spoken in the new voice long enough to feel comfortable with it, we found we had to contrive situations which would explain to others why they were speaking in a new voice. The ploy that worked best was to have the subjects come back from a school break using their new voice. When someone commented, they could say they had gotten a bad cold and sore throat over break and the voice changed. One of the persons who did not have breaks from those around him (his family lived in the town in which the University was located) presented a special challenge. He had a car accident one day, which really did very little damage other than some nasty looking facial bruises. He used that to explain his voice change. Once the subjects were using their new voice with friends and family consistently, treatment was complete. They would get such positive comments that reinforced using the voice that it would have been counter to human nature for them to return to using the old voice. But our egos as clinicians, merchants of change, were further bruised when we had the subjects come back for six months check ups. All had retained the new, lower pitch, with no other negative developments. However, they were not convinced that the new voice was that much different from the old. We played them tapes of the pre-treatment voice to demonstrate the difference. To our surprise, some denied that the pre-treatment tape was their voice. They had so internalized the new voice that the previous one was completely erased. Those who did not outright deny the pre-treatment tape was theirs, simply looked at us skeptically. They were too polite to challenge us, but I believe that they, too, did not think the pre-treatment tape was of their voice. Later I learned that while it is disappointing for a clinician to make a positive change in an client and not get recognition for it, it may be one of the best compliments of a treatment process. If the person making the change so adopts the new behavior as to believe it has always been there, then the treatment has to be considered a success. It is nice to be appreciated by the person in treatment, but sometimes the reinforcement from doing a good job has to come from self-satisfaction of being a part of the change. Or, perhaps, all of the above are rationalizations to accommodate a clinician who needs reward. Characteristics Of The Voice There are three basic characteristics of a voice that can shape listeners' opinion of the speaker. There are pitch, intensity, and quality. Pitch Pitch is the frequency of the voice, judged on a continuum of from low to high. Pitch often is equated with size. We normally expect a larger person to have a lower voice. A five foot four inch tall male with a slightly high pitch would most likely be judged to have a normal voice. The same pitch used by a six feet four inch tall male would probably be perceived as unacceptably high. Physiologically, pitch can be measured as the rate of vibration of the vocal folds. This measurement is called fundamental vocal frequency (FVF). Normal male speakers have a median FVF of around 120 Hz, while females have a median of about 220 Hz (Fitch & Holbrook, 1970; Zemlin, 1988, p.150). Range, or variability, is an aspect of pitch that also draws attention to itself. Most of us use a pitch range of about an octave. This in simple terms means the highest pitch we use is twice as high in frequency as the lowest pitch we use. People who speak with a narrow pitch range, or lack of variability in pitch, are often described as speaking in a 'monotone.' Monotone speech may appear to be lacking in emotion and may suggest that the speaker has a low energy level. Persons who use a wide pitch range can be described as using 'highly inflected' speech. This type of voice suggests an enthusiastic speaker, or one with a high energy level. However, highly inflected speech may be a part of the cultural pattern, such as in Southern speech. Intensity Intensity refers to the loudness of voice, judged on a continuum from soft to loud. We all know persons who are loud and others who are soft spoken. We often equate shyness or timidity with soft voices and brashness or arrogance with loud voices. However, loudness may be a reflection of culture or family traits. Some cultures/families tend to speak at the upper range of loudness tolerance, whereas others are known for understatement, or soft speech. Loudness, as pitch, can be measured in physical units known as decibels (dB). Range, or variability of loudness, is often correlated with pitch range and variability. Whether a speaker is judged as being monotone or highly inflected is related to the changes in loudness as was pitch. Quality Quality is the third characteristic by which voice is described. While there are some physical measurements that purport to relate to quality, quality is a subjective appraisal of the voice on a continuum of good-to-poor. A 'good' voice is one that sounds the way we expect it to sound. It doesn't have characteristics that draw attention to it. Most of us have problems of voice quality at some times in our lives. Hoarseness is a common problem of voice quality that occurs after loud vocalization, such as cheering at a sporting event. It can also be caused by a sore throat, or inflammation of the vocal folds. The perceptual characteristic of hoarseness is created by an increase in the stiffness of the vocal folds. The stiffness is the result of swelling of the vocal folds (as would be caused by cheering or inflammation). The swelling makes the folds more stiff than they usually are and makes it more difficult to close the vocal folds. The result is a difference in the vibratory pattern. Breathiness is another term often used to describe a difference in voice quality. Breathiness is excessive airflow that is the result of the vocal folds not being brought together at the midline. This can be functional, meaning there is no physical basis, or it can be the result of nerve damage that affects the muscles that close the vocal folds. It can also be brought about by the same causes as hoarseness. Breathy voices in men can project femininity. Breathiness in females can project sensuality. Both, however, are stereotypes that exist only in the eyes, or perhaps we should say “ears,” of the beholder. The last commonly used term for describing types of voice problems is harshness. Harshness is the result of irregular vocal fold vibration. This can be the result of irregularities caused by physical damage to them. Harshness is described as a 'rough' or 'gravel' type voice. It can be due to hyperfunction, or the speaker pulling the vocal folds together too tightly, even to the point of them overlapping. It can also be due to physical damage. Harsh voices are usually more acceptable in males than females. The Mechanics of Voice Production Let's review the material from an earlier chapter on what the voice is and how it is produced before discussing the myriad of ailments from which it can suffer. The voice is produced by vibration of the vocal folds. The vocal folds are, as the name suggests, folds of tissue in the larynx. They are heavily invested with muscle tissue, which means they are capable of very fine motor control. You can think of the vocal folds as shelves that are fastened to the sides of the larynx. The muscles in the shelves allow the speaker to bring the vocal folds together and adjust the tension with precise control. The biological function of the vocal folds is to control airflow from the lungs, and, along with other structures of the larynx, prevent food and drink from getting into the trachea, or windpipe. The larynx is located just in front of the esophagus, which is the pathway for food and drink. See figure 7. The pharynx, or throat, is a pathway for both air and food. However, it can be used only for one or the other purpose at any given time. If we try to talk or laugh, which involves airflow, while we are eating or drinking, the result can be choking. When this occurs, we usually cough to clear the windpipe. Coughing involves pulling the vocal folds together tightly and releasing them with a sharp exhalation. With luck, whatever is in the windpipe is carried out with the airflow. The biological function of the vocal folds provided a perfect mechanism for the evolution of speech. Air passing through partially closed vocal folds sets the folds into vibration. This creates the 'voice' that is used for speech. The fine motor control permits us to make discrete changes in length and tension of the folds, resulting in variations in the pitch of the voice. Most people can easily raise the vocal vibration rate to twice what they normally use. In musical terms, that would be an octave. Changes in pitch add meaning and color to communication, as we discussed previously. People who talk in monotone (not varying pitch) are generally labeled “boring”. Consider that the word 'monotonous' derives its meaning from the word 'monotone' and you can understand the importance of inflected speech. - - - - - - - - - - - - - - - - - - - - - - - - - - - - Figure 7 Schematic of the normal larynx and pharynx about here - - - - - - - - - - - - - - - - - - - - - - - - - - - - - As indicated earlier in the book, not all sounds are voiced. However, all vowels and over half of the consonants are voiced, so voice does play a substantial role in the production of speech. Changing from voiced to unvoiced sounds in connected speech is a terribly finite act. I am still amazed of the voice control it requires to produce phrases such as "cookie cutter." The voice is turned off and on eight times during the second required to say that phrase. However, the normal speaker never realizes the sophistication of the act of adjusting voice during running speech. Although maintaining voicing throughout an utterance is neurologically more simple, most of us have difficulty if we try to use all voicing during speech. To get an idea of what it is like to talk with all voiced sounds, try saying "Mazzajuzetts" for "Massacusetts" or "Mizzizzibbi" for "Mississippi. It is easier to talk with all unvoiced sounds than with all voiced sounds. (Talking with all unvoiced sounds is called “whispering.”) Problems Of The Voice Given the finitude of the act of voicing, it is not surprising that a number of things can occur to disrupt its functioning. Voice problems can be divided into the two larger categories of the "functional" and "organic" problems as we have discussed previously. Such things as vocal nodules, polyps, and cancer of the larynx are organic problems. Hysterical aphonia (loss of voice) is an example of a functional voice problem. Voice Disorders With Vocal Abuse Origin The major problem with the classification system of functional and organic in regard to voice is that it describes the present state of the voice, but does not necessarily relate to cause. For example, many voice problems we see in a clinical setting are ones that started as functional problems. Such problems are the result of speakers using the vocal folds in such a way as to put a strain on them. The continued strain eventually results in physical damage to the folds. Thus what started as a "functional" problem later becomes an "organic" one. A good example is vocal abuse. One of the more common voice problems is vocal nodules. These are changes on the vocal folds that can be roughly equated to callouses on the hands. They are caused by vocal hyperfunction, which is another way of saying the person is talking with too much effort. They commonly occur in children who talk loudly and yell a lot, singers who use their voice beyond its limits, and cheerleaders. Using the voice for prolonged periods of time or with excessive force are forms of vocal abuse. Vocal nodules are produced by bringing the vocal folds together with more force than necessary. The normal production of voice is initiated by bringing the vocal folds together at the midline so they just barely touch, or not quite touch, then forcing the air between them to make them vibrate. Hyperfunctional speakers bring the vocal folds together tightly at the midline. The continued forced contact causes irritation that leads to the formation of vocal nodules, much in the same way that extended forced contact of a rake with a hand first causes blisters, which then become callouses, if the person continues the contact. It is the body's way of protecting the tissue from continued assault. A second common form of vocal abuse is smoking. Tobacco smoke contains irritants that can result in physical changes to the vocal folds. Consider the number of puffs on a cigarette multiplied by the number of cigarettes a person smokes daily. Each puff contains irritants that attack the tissue of the mouth, throat, and larynx. The long-term damage that smoking can cause is well documented. The only effective long-term treatment for voice disorders caused by vocal abuse is to stop the abuse. Short-term medical treatment can alleviate the symptoms, but until the abuse is eliminated, the symptoms will re-occur. Voice Differences With Psychosocial Origins At one time I worked with a clinic that had an intensive summer program for children with severe communication disorders. The children from families who lived long distances from the clinic stayed on campus for the whole four-week period. Ones who lived closer either commuted or went home on weekends. Most of the children had communication differences resulting from cleft palate or hearing loss. One was a child with a repaired cleft palate who also had a very harsh voice. We found after some demonstration and simple exercises he was able to produce a much less harsh voice. However, he went home on weekends and when he came back the gains were gone and the harshness in his voice had returned. At the end of the four-week period we knew that there must be something in his environment at home that was maintained the disordered voice. His mother, who picked him up and brought him back, could think of nothing that would cause a change. She seemed pleasant and concerned, and it seemed that the home was stable. She indicated that the child was very much attached to his father and they spent most of the weekends he was home working on the farm or fishing. At the end of the program, families came to pick up their children and talk with clinic personnel about follow up. A gentleman we had never seen before came in to the clinic and said he was there to pick up his child. The familiarity of the harshness of his voice carried down the hall and several of us stopped and looked at each other. There was no doubt whose father he was. The voice pattern of the son and father were so familiar to the mother that she did not recognize it as a problem. Some voice disorders, such as the one just described, are the result of the interaction between the person with the disorder and the people in his/her environment. Imitation is a good example of voice problems with psychosocial origin. In the case above, the boy strongly identified with his father and that was expressed in his assuming the father's voice characteristics. We imitate people who we emulate as role models. It is only natural that voice would be a target for imitation. This origin was also evident in the individuals who came to the pitch control program discussed earlier. They were males with high-pitched voices. Most were from homes in which they had been raised primarily by a female: the mother or grandmother. Perhaps they maintained the higher pitch after the vocal fold size changed in puberty, even though it was a strain to do so, because of identifying with female role models. Other psychosocial voice problems are not uncommon. Stress can result in various degrees of voice change. Many of us find our pitch goes up a bit when we are tense or anxious. Tension in the voice can also create the hoarseness, breathiness, or harshness discussed above. Most of the time it is short term; we are preparing for a test, having to deal with someone we don't care to deal with, working too many hours, etc. In such instances the voice may be a barometer of the degree of stress. Long-term, or severe, stress can result in a complete loss of voice. The term 'hysterical aphonia' is used to describe an individual who has the ability to use the vocal folds normally, but who does not use voice. The client reports not being able to use voice. All speech is produced in a whisper. However, it can be easily demonstrated that the person has normal vocal fold function. Coughing and laughing require bringing the vocal folds together, so if a person can do either of these, we know they have adequate vocal fold control for voice. I'll talk more about a case of hysterical aphonia later in this chapter. Treatment for voice problems of psycho-social origin is determined by the type of problem. For example, voice problems that are caused by imitation are tough ones with which to work. If there is a role model in the individual's life who has exerted a strong positive influence, teaching that individual to sound different may be seen as a betrayal of the role model. In the case of children imitating a role model, we often work with the voice of the role model, with the expectation that the child will change if the role model changes. That is easier said than done, because changing the communication behavior of an adult is a much more difficult task than changing a child's. If the role model can't change for one reason or another, we teach the role model what changes the child needs to make so they can encourage those changes. Working with voice problems that are the result of stress or other factors in the individual's environment is as complex as the set of circumstances that cause the problem. Often there is a need for counseling along with making the changes in the communication process to help the individual understand what precipitated the problem and how to make changes to alleviate it. Voice Differences With Physical Origins Some voice problems are the result of disease or damage to the vocal folds. The vocal folds are susceptible to abnormal growths, just like any other part of the body. Polyps are soft, fluid filled sacks that result from a submucosal hemorrhage. The hemorrhage is normally the result of some form of vocal abuse. While the hemorrhaging is normally due to repeated episodes of abuse, polyps can be caused by a single occurrence (Brodnitz, 1971, p.75; Wilson, 1979, p.36). The vocal folds can also be damage by direct injury. Automobile accidents are not uncommon causes. Also, vocal folds may be damaged when a child ingests a caustic agent, such as a household cleaner, drain cleaner, or other strong chemical compound. The scars left by such injuries are often permanent. Parents of small children should keep household cleaning materials in locked cabinets. Voice problems are only one of many problems that can occur when a curious child encounters a bottle or can of something with caustic capabilities. Any voice problems that is of recent origin, or that has increased in degree over a period of time, should be referred to a medical specialist. Abnormal growths on the vocal folds are not uncommon, the most serious of which is cancer. In 1980, the American Cancer Society estimated 10,500 new cases per year. In 1993, that figure rose to over 13,000 (Doyle, 1994, p.5). This is likely to continue to increase as the general age of the population increases. Early identification is extremely important, as cancer treatment is much more effective in the early stages of cancer development. A rule of thumb is to see a physician if a change in voice lasts more than two weeks. Cancers of the larynx are often ones that can spread to other parts of the body. Early diagnosis and treatment can mean the difference between life and death. All speech-language pathologists are taught to refer individuals with voice changes promptly for medical examination. Cancer can occur for a number of reasons, but smoking is by far the major culprit. I believe the reason few people in my profession smoke is because early in our training we are exposed to the problems that can result because of it. Treatment for physical problems such as polyps, cancer, and other growths on the vocal folds is generally through surgery. In some cases the treatment is as simple as removing the growth from the vocal folds, which is only slightly more involved than removing a growth from the skin on the back of your hand. In the case of cancer, the earlier the detection, the less the probability the vocal folds will need to be removed. Sadly, many cancer surgeries involve complete removal of the larynx. Voice Difference with Neurological Basis We have discussed the need for finite control of the vocal folds for normal speech. Starting and stopping vocal folds vibration at the rate of several times per second requires fine motor control. So does adjusting tension in the voice to obtain normal pitch and loudness intonation patterns. The integrity of the nervous system is greatly challenged by this task. Any neurological disorder that results in decreased motor control may affect the voice early in onset. Parkinson's disease and Alzheimer's are prime examples. Also, persons with cerebral palsy and other chronic neurological disorders often have voice differences. Case Histories Eddie Eddie was referred by a teacher who noted that his voice sounded “funny.” Most persons not trained in communication disorders find it hard to describe exactly what is wrong, but they do recognize when a voice doesn't sound right. I was working in the public schools and was appreciative of the fact that she recognized a problem. Many teachers did not refer. When I asked them about a child from their class who had finally been identified as having some sort of communication disorder by someone other than the teacher, but who they had not referred, I often found that this was a child who didn't talk much. In a room of 30 first graders, most of whom are more than talkative, it can be hard to get enough of a sample of speech from a quiet one to tell if there is a problem. Also, most teachers are by nature very accepting. After they get to know their children, they accept the way they are, including their speech, without judgment. Public school speech- language pathologists ask teachers to listen for problems at the first of the year while the children are still new to them. This is because after the first few weeks teachers may accept the child's communication system (unless there it is a significant problem) and not notice the difference thereafter. Voice problems usually don't interfere with intelligibility, so the difference may be attributed to simply being a unique characteristic of that child. Often when I have asked a teacher if they noticed the way a certain child in their class talked (one with a voice problem), they would say, "yes, but that's just the way he talks. Back to Eddie. Eddie was from a gregarious family with six children. He was next to the youngest child. From watching them come and go to and from school I knew all were talkers, full of energy, and happy, enthusiastic, well-adjusted kids. Mom and dad were just as verbal, so the speech activity level in the family was always high. Being acknowledged at the dinner table must have been a competition. The energy level was as high as the speech level. Eddie was the first to the playground during recess and yelled the whole time he was there. The parents reported he was the same at home. The overuse of the voice, which we describe as voice hyperfunction, was programmed into him from an early age. Eddie was a lovable child whose voice reflected his whole outlook on life. It was full speed ahead and enjoy every minute of it. It worried me that by changing Eddie's vocal habits, we might change other aspects of his behavior. He was eight years old, an age at which children are susceptible to suggestion. I did not want him to think of himself as different, or think that there was something wrong with either him or his family. There is a tendency for practitioners of any profession to want to jump at the problem without studying the consequences of a particular treatment. We like to cure things we see wrong and sometimes we don't always consider the consequences of the cure. The first step in doing something for Eddie's voice was to make sure that there was no medical reason for the problem. While I was 99% sure that the nodules existed and had been caused by vocal abuse resulting from hyperfunction, there was always the outside possibility that something else was causing the voice problem. Working with the parents to get Eddie in for a medical evaluation accomplished another treatment objective, which was getting the family involved in the treatment program. I was lucky in that Eddie's family was very agreeable to schedule an appointment with the medical specialist. They also promised help in any kind of treatment. Such is not always the case. First of all, parents, even more than teachers, are accustomed to the child's voice and often don't see anything wrong with it. Some are offended at the suggestion that their child has any problem. Some have trouble affording the time and money to obtain the medical evaluation. Getting the family to accept the fact that action needs to be taken is often the most difficult part. The nodules were diagnosed by an otolaryngologist (ENT-ears, nose, throat physician) and treatment to reduce the hyperfunction was recommended. My job was to figure out a way to reduce the amount of loud talking and yelling to a level that would not only keep the problem from getting worse, and allow the vocal folds to heal themselves. I decided against a popular treatment of the time, which was vocal rest. Vocal rest dictates that the individual not use the voice for a period of time, usually weeks. After that the individual begins to use voice on a limited basis, after being taught a healthy vocal attack. Eddie's voice was so much a part of his daily life, it would have been a dramatic change to suddenly stop using it completely. I decided on a less drastic course of action, which was to teach the healthy voice attack while helping him learn to monitor his speaking intensity. First, I had Eddie's parents come in to be a part of the initial discussion. I explained to Eddie how the voice worked (this was also done for the parent's sake) and that his talking loud was hurting his vocal folds. I compared the damage to the vocal folds to something he had experienced; a blister caused by rubbing of the heel of a shoe that was slightly too large. I told him that his loud talking was rubbing his vocal folds together and causing them to develop callouses. His parents acknowledged this to him and discussed the ENT's report. While only eight, he needed to be convinced that action was needed so he would have the motivation to make changes. We planned a two-pronged attack. First, I would teach him how to talk using a voice that would reduce the strain on his vocal folds. Second, he was to learn to watch his loudness level to keep from further damaging the folds. When we finished that first session, we had a plan that he and his parents understood and to which all expressed commitment. Teaching him to monitor his times of speaking too loudly was accomplished by having him carry a small counter and click it every time he became aware that he was talking too loudly. Initially those around him reminded him. They told him to put one on the counter when they heard him talking loudly. Teachers, siblings, and parents were all a part of the group that monitored him. His physical education teacher became one of the prime motivators, as this was a school activity he loved and the physical education teacher was his hero. He seemed to listen best when she reminded him. Each day, at the end of school, he would bring me the counter. I would log in the number of times he had spoken loudly and reset it to zero. We made a large graph to put on the wall so we could see his progress in reducing the number of instances of vocal abuse. By the end of two weeks he was down to 1-2 times per day, which was probably as good as we could expect. We stopped counting after three weeks. He had learned to monitor himself and the people around him had become sensitized to the fact that he needed to talk with less effort. I never observed the family at home during this period, but I suspect everyone in the family became more conscious of the intensity level of their speaking voice. I saw Eddie twice a week to teach him how to produce a 'healthy' voice. This continued for what was left of the school year, which was over five months. Teaching a healthy voice is accomplished by having the client learn an easy attack to producing voice. To get an idea of a hard versus an easy attack, say the word 'at' with a lot of force. Listen carefully when you do and you will hear a slight explosion at the beginning of the word. That is a hard glottal attack. Now say “at” softly, without the explosion. You may have to put a slight 'h' sound in front of it to get the right effect. This is an easy attack. The vocal folds are drawn tightly together in the hard attack, causing the rubbing that leads to vocal nodules. The vocal folds do not touch in the easy attack, thereby relieving the vocal folds of strain. Eddie's voice improved gradually and he was released from treatment at the end of the year. A follow up visit to the ENT revealed that the nodules, while not entirely gone, were significantly reduced. His voice quality was good and I felt that we had done the things we needed to do to insure a healthy future for his voice. Abe I received a call late one Friday afternoon from the otolaryngologist with whom I had been working, asking me to see a patient. Abe was a 68 year-old gentlemen who had been diagnosed as having laryngeal cancer. It had taken the patient several days from the time the otolaryngologist had made his recommendation to agree to the operation. There is normally little choice other than surgery for laryngeal cancer identified in the later stages. And because the larynx is a site from which the cancer can spread, it is important to identify it and remove it as soon as possible. The operation was to be the next day. I went to the hospital mid-evening to meet with the patient. When I arrived at his room, he was sitting on the edge of his bed. Seated next to him was his wife, Marne, an attractive lady at least 20 years younger. Marne looked more concerned than Abe. Abe had a smile on his face as he shook my hand. The purpose of a visit by the speech-language pathologist prior to the surgery is to answer any questions the patient may have concerning communication after the operation. Most patients are scared, as they realize they have cancer and this operation is necessary to stop the cancer from spreading. Most have experienced no pain or discomfort to this point, only persistent hoarseness that caused them to go to the physician. After they understand there will be an operation, the surgeon will normally tell them they will 'lose their voice,' but they may not fully realize the implications of that statement. I have worked with patients who were not told before surgery that they would lose their voice. This causes an extreme amount of distress when they awaken in recovery and find they cannot talk. The speech-language pathologist discusses the problems of loss of larynx while patients still have the capacity for normal speech and can ask questions easily. Patients can be told the alternative methods of restoring voice, of which the primary ones include esophageal speech, using an artificial larynx, and using a tracheal-esophageal device. Tracheal-esophageal devices were still experimental at that time so there were only two viable recommendations. The remaining alternatives (esophageal speech or artificial larynx) are dramatically different ways of producing voice. But, unfortunately, voice is not the only aspect of their lives that will be changed by the operation. To best understand the operation, let's look at a schematic that shows what happens to the patient. Figure 8 shows a schematic of the normal speech mechanism and the mechanism after the larynx is removed. Remember that the biological purpose of the larynx is to prevent food and drink from getting into the windpipe. Normal breathing is accomplished by drawing air in through the nose or mouth, through the throat, and into the windpipe. Eating is accomplished by taking food in the mouth, pushing it down the throat and into the esophagus. The throat is the common pathway for both air and food. When air is being taken in, the muscles of the esophagus close it and the larynx opens to allow the air to get to the windpipe (trachea). When food is ingested, the larynx closes the opening to the windpipe and the food is forced into the esophagus. Sometimes we don't get the actions sequenced just right. If the larynx is open when we are swallowing, food or drink will go into the windpipe and we will choke. This sometimes happens if someone makes us laugh when we are trying to swallow something. Usually a cough will force the foreign matter out of the windpipe, the larynx closes, and we can continue eating. Air that is meant for the windpipe can also get into the esophagus. This happens frequently when we are eating. Air gets mixed with the food and forced into the esophagus. This is easily corrected by a burp or belch to expel the air. That's what a belch is all about, air in the esophagus. Now look back at the figures of the operation. The pathway for food is still the mouth, throat, and esophagus. However, the top of the windpipe has been sealed in the laryngectomee and air is taken in through a hole in the front of the throat. - - - - - - - - - - - - - - - - - - - - - Tracing of selected structures that probably would be removed if the larynx was totally removed. - - - - - - - - - - - - - - - - - - - - - - - - - - - FIGURE 8. Normal larynx and associated structures. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Speech mechanism with larynx removed about here - - - - - - - - - - - - - - - - - - - - - - - - - - - This is necessary because when the larynx is no longer present, food and drink would go into the windpipe. The hole in the windpipe is referred to as a 'stoma,' which simply means an opening. Obviously this presents some major problems to the laryngectomee. He can no longer use air from the lungs as a basis for voice and speech. He has to adopt one of the three options noted above: esophageal speech, an artificial larynx, or a tracheal-esophageal device, to produce voice. Let's examine these possibilities. Esophageal speech uses air from the esophagus (as in belching) for the sound source. The speaker swallows air to get it into the esophagus, or forces air into the esophagus with the tongue, and then releases it. Esophageal speech is, in fact, controlled belching. Males tend to do this more efficiently than females (probably tied to early training through burping contests), but either sex can accomplish the task. The advantage of esophageal speech is it does not require any artificial device or further surgery. Many people can develop enough skill to make it sound almost like a normal voice with a low pitch. The disadvantages are that many people cannot develop the control needed, and the quality of the sound of it may leave something to be desired. An artificial larynx is a device that produces vibrations similar to those of the vocal folds. There are various kinds that have slightly different configurations. The most common one is the electro-larynx. It is a device that can be held in the hand, about the size of a small electric razor. It is, in fact, a simple vibrator that when pressed against the throat makes the tissues vibrate at about the same rate of vibration as the vocal folds do in a speaker with normal vocal folds. Laryngectomees use it by holding it against their throat and shaping the sounds with their mouth in the same manner as normal speech. It runs on batteries and may have controls that permit the user to change pitch. The primary advantage is that it doesn't require the physical skill and effort needed for esophageal speech. The primary disadvantage is that it sounds mechanical, often described as computer-like, or robot, speech. Now there is an attractive third alternative, the tracheal- esophageal device. It is called the Blom-Singer after the individuals who developed it. Figure 9 shows a schematic of this. An incision is made in the wall between the esophagus and trachea. A device is inserted through the puncture. Laryngectomees use it by covering the stoma and forcing air through the device. Some devices have valves that permit the user to close the valve with air pressure, eliminating the need for them to cover the stoma with finger or thumb. The device is constructed so that it vibrates at about the frequency of normal vocal folds. That sound is directed through the throat to the mouth, where it is shaped in the same manner as normal speech. The primary advantages are that it is easy to learn and uses the same power source as normal speech. Another advantage is the quality of the sound it produces, which is usually superior to other forms of alaryngeal voice production. The primary disadvantages are that it requires an additional surgical procedure and the device must be removed, cleaned, and reinserted daily. Also, the opening between the trachea and esophagus cannot be left open for over a few hours at a time or it will heal itself and close. This is because the body doesn't like openings imposed on its structures and heals them as quickly as possible. - - - - - - - - - - - - - - - - - FIGURE 9. Blom-Singer prosthesis for voice restoration - - - - - - - - - - - - - - - - - - Back to Abe. After introductions, I asked him how he felt and found that he was in less shock than patients' usually are. Often I spend the whole pre-surgical visit listening to the patient's concerns and never really talk about communication. Which is all right, because in such a case that is the patient's primary need. Abe was a complete optimist. He knew he would 'beat this thing.' He was further motivated by the fact that he needed communication to continue his life style. I learned that he owned a wholesale toy business that had done very well. He was still active in the business, but had a reduced schedule. He liked to travel so he went to trade shows several times a year to pick out the new toys for the season. He also went on two cruises a year for his vacations. Obviously communication was an essential part of his business. He was also very social, belonging to several organizations and spending many evenings with friends. He had no children. His life was his business, his wife, and his friends. He was financially advantaged and enjoying the life he had always wanted. Abe was a dynamic individual. It was easy to see how he had become successful. He looked for opportunities in everything. He saw the removal of his larynx as a temporary diversion from his lifestyle. He fully intended not to let it interfere with his life. We discussed the effects of the operation on speech and the alternatives speaking methods. It was easy to settle on a first choice. Abe could burp on command with the best of them. He informed me that he had been a belching champion in college. At that time, the tracheal-esophageal devices were not available. Abe's operation was a radical procedure, removing the complete larynx and some juxtaposed tissue to guard against spread of the cancer. It was a difficult recovery. I understand from patients that recovery from this type of surgery is extremely painful. Sometimes the surgery removes tissue as far away from the larynx as the shoulders to make sure all the cancer has been removed. Any movement of the upper body is painful for weeks after the operation. Abe healed well enough to come the clinic three weeks after he left the hospital. The smile was somewhat subdued, but it was still there. Marne had the same concerned look I had seen at the hospital. In the beginning, Marne sat in with us during the training sessions. I learned that they did everything together and were almost inseparable as a couple. They had been married for almost twenty years. The age difference did not seem to have had any effect on their relationship. It would probably have been better for Marne not to be present during the first few sessions. While Abe had been able to voluntarily inject and expel air before the operation, he was doing it now only with difficulty. It was obviously painful for her to watch him struggle and to witness his frustration. She waited for him in the waiting room of the clinic after the second week. There are some laryngectomees who are already starting to use esophageal speech when they come to the clinic after recovery from the surgery. Once it is demonstrated, and they have some practice, they develop the skill on their own. They are the lucky ones. Abe was not one of the lucky ones. And being a person who was accustomed to succeeding, he did not take well to the lack of progress. He was also not one to quit. We worked for four weeks with little progress. Occasionally he could produce esophageal speech, but it would be accompanied by stoma noise which masked the speech efforts. Stoma noise is air being forced out of the stoma because the laryngectomee is trying to use air from the lungs to produce speech as he did before the operation. The esophageal speaker must learn to talk while not breathing, which is unnatural after a lifetime of normal speaking. Abe kept his smile during the whole ordeal. The fifth week things started to turn around. His smile was wider when he came in and went through his homework, which was a list of words. For the first time he could produce the words intelligibly. There was still a great deal of effort, and a lot of stoma noise, but the words were understandable. The look of satisfaction in his eye told me that he felt he had achieved another major victory in life, just as he thought he would. The experience of working with laryngectomees makes one appreciate the need for persistence, perseverance, and self-will. Just about anything can be accomplished with enough effort. Abe was in treatment for over a year, which was longer than most laryngectomees with whom I worked with at that time. While slow, his progress continued steadily. The gains were due solely to sheer will power. After the word lists we worked on phases, sentences, and ultimately story telling. When he completed treatment, most people could understand him completely. His stoma noise was never quite controlled, but it was reduced to the point where it did not interfere with intelligibility. I knew he was ready to be dismissed when he told me, with a self-satisfied grin, of getting in an argument with a waiter at a restaurant. He had completely forgotten that his speech was different during the exchange. In addition to speech, Abe adjusted well to the non-speech adjustments that a laryngectomee has to make. First of all, there is the adjustment to breathing. Air that is breathed in through the nose is warmed, moistened, and filtered when it reaches the lungs. Air coming through the stoma brings the characteristics of the weather with it. All laryngectomees can relate the feeling of the first time they took a deep breath on a cold day. They relate it as simply 'painful.' Most laryngectomees wear a cravat or scarf over the stoma. This is not only to hide the opening in the throat, but also to warm the air being breathed. Abe wore handsome, handmade cravats. Because air no longer is drawn through the nose, there is no filtering. Anything in the air can go straight into the trachea. Coughing is no longer possible (have to have vocal folds for that) so anything getting in has to be removed by sharp exhalations. Sharp exhalations can accomplish the task, but are not nearly as effectively as coughing. Like most laryngectomees, Abe had been a heavy smoker. He did not smoke after the operation, so the lungs began to clear themselves of 50 years of accumulating impurities. He told me that to break up the congestion, he laid across the bed, head off the side with stoma down, while his wife pounded on his back. This seemed to loosen the debris so he could expel it with the sharp exhalations. They did this daily for several months after the operation. Abe's once suggested with a grin that cancer was the ultimate method for quitting smoking. As the months progressed he gained some much-needed weight and indicated that he felt better than he had in years. The other non-speech adjustment with which Abe had to struggle was the loss of the sense of smell. Olfaction is the result of chemicals in the air coming into contact with sensors in the nasal cavity. If air is no longer being drawn into the nasal cavity, the sense of smell is greatly reduced. Most discomforting for the laryngectomee is the concomitant loss of the sense of taste. Taste is integrally related to smell. When the sense of smell is reduced, taste is similarly affected. Remember that I said Abe spent many evenings with friends. The primary activity was eating out. Abe stated more than once that losing the sense of taste was the most disagreeable aspect of being a laryngectomee. Although some sense of taste usually returns to laryngectomees, it is minimal. Abe said that a good dinner was never the same after the surgery. Abe's adjustments and recovery of speech were hard-fought. He was justifiably proud of his accomplishments. After he completed his treatment, I asked him to talk to other laryngectomees. He was good at motivating and raising the morale of others. He continued to stop by the clinic periodically to visit and made a generous donation at Christmas time. He was one of the most appreciative clients I've ever encountered. I found this to be true of laryngectomees as a group. Eleanor Eleanor was a 51 year-old female who came to the clinic with the complaint that she had “lost her voice.” She reported that she had awakened one morning and found that she could only speak in a whisper. She had gone to a physician who could find no problem and suggested that the voice would soon return. Several months passed and her voice did not return. She finally came to the conclusion that it was not going to return without help, so she came to the clinic for treatment. I spent the first hour of our session getting to know her situation. She was married and had two children. The youngest had left home two years ago. She had always been active in civic organizations and community activities, but grew more active when her last child left home. At that time she had been chairperson of several functions, which were extremely demanding in terms of time and commitment. She reported feeling tired and over- committed at the time she lost her voice. After losing her voice, she began relinquishing her commitments. The loss of voice had affected her ability to conduct meetings and talk on the telephone. Now about the only activity in which she still engaged was her bridge club. She appeared to have been relieved to give up the commitments, but now was hoping to return to a more active role. I asked her if she could cough, which she promptly did with ease. I asked if she laughed aloud on occasion. She indicated that she did laugh aloud, but only when something was particularly funny. This was all I needed to know to believe that I could “cure” her. I told her that the initial cause of her loss of voice would probably never be known, but it was no longer a factor in her speech. I told her that she had simply forgotten how to use the voice and all she needed was for us to do some exercises to get it started again. We started with the cough. I had her cough and make a speech sound with the cough. The instructions were "say an 'a' sound while you are coughing." We went through the rest of the vowels with that exercises. Next I told her we were going to get her voice started by reversing the way it was normally used. I instructed her to talk on inhalation, rather than exhalation. (Try this yourself.) I modeled how to do it and after a few tries, she could produce a full sentence on inhalation. Next I told her to start the sentence on inhalation and complete it on exhalation. She did this with ease and was startled by the sound of her voice. We spent the next thirty minutes practicing talking on inhalation and exhalation, gradually decreasing the amount of inhalation and increasing the amount of exhalation. At the end of the session her voice was back. She was amazed. I told her she should not have any further problems with her voice. If she did, simply return to talking on inhalation and that would get the voice started again. This all took place at a university clinic with students watching. They were properly impressed. I was, indeed, a miracle worker. As much as I would like to be a miracle worker, I had to explain that what had just happened was not a miracle, but rather a typical response to treatment by clients with hysterical aphonia. Speech-language pathologists love to see clients with hysterical aphonia walk through the door, because they realize these clients will usually walk out in one session “cured” and singing the praises of the clinician. Hysterical aphonia is typically a functional disorder that occurs in middle-aged women. Usually they have just experienced the “empty nest” syndrome and often they are over-committed to activities outside the home. The disorder appears to have a psychological, rather than a physical, basis. It appears to be a defense mechanism that permits the individual to withdraw from the demands of social functions without consciously making that decision. Losing the voice is an excellent means of doing so, because the voice is needed to participate in social functions. Other people understand why they reduce the outside commitments without them having to provide an explanation. The person with hysterical aphonia is usually by nature a social being. In fact, it is that social nature that leads them to become over-committed in the first place. After they have experienced voice loss for a while, however, they begin to miss the contact with people. The loss of voice provides a respite, but once the stress is removed and the individual is rested, they want to return to social activities. They do not understand what happened in the first place, however, so they don't know how to start using the voice again. Once the stress is relieved, they are motivated to use the voice, so they seek out someone who can help them. Because they are ready to talk again, it is a simple matter for the clinician to provide some exercises to initiate the voice. The observer may suggest that persons suffering from hysterical aphonia should be confronted with the fact that they can use their voice. It is usually easy to point out that coughing requires using the vocal folds. If they can be convinced that they can use the voice, they should begin to use it again. This could be a major mistake and lead to undesirable results. First of all, people who suddenly lose their voice should be referred to a physician to determine if there is a physical basis for the loss. If the physical examination confirms that the problem is functional, people around the person with voice loss should be careful to give advice. Trying to force them to talk may result in deepening the resolve to not use the voice. Or it can lead to embarrassment and some other less acceptable defense mechanism may replace the loss of voice. It should be recognized that the loss of voice is a way of responding to a stressful situation. It is a socially acceptable excuse to be relieved of commitments. When the stress level is lowered, persons with hysterical aphonia will seek treatment on their own. As is the case with many functional disorders, the persons suffering from them cannot be 'cured' until they are ready to be cured. How To Treat Persons With Voice Differences Some basic rules for interacting with persons with voice differences follows. Most persons with voice differences are intelligible if you make an effort. Once you adjust to the difference, communication is usually comfortable. 1. Persons with voice differences report that the situation that bothers them most is when the person to whom they are speaking abruptly terminates the conversation. Some people simply turn and walk away from the individual. Others make remarks such as "that's all right, it wasn't important any way" and smile uncomfortably while they look for an exit. Use patience and let the person know you are going to stay with them until the communication act is complete. 2. It is all right to ask the person to repeat. You may have to have them repeat several times. Most people with voice differences will patiently go over the message repeatedly, if you give them time. 3. Consciously think about context clues. What does the person usually talk about? What are the names of people you both know? In what activities have the two of you been involved? Figuring out one or two words may give you the context needed to understand the rest of the conversation. 4. If you cannot understand them after repeated effort, simply say so and ask them to write the message for you. You do not have to be apologetic for not being able to understand them. 5. As persons with other types of communication differences, persons with voice differences don't want to be treated differently. Avoid treating them as if they have a handicapping condition or are inferior. Most people with voice differences become accustomed to uncomfortable looks from people they meet for the first time and work hard to make communication as comfortable for others as possible. By understanding the problem, and working with them through the communication task, you will find the effort produces a grateful individual and a very rewarding experience.