Psychosocial Perspectives on the Management of Voice Disorders

Implications for Clients. Options and Strategies for Clinicians
Janet Baker, Ph.D.

‘This great book offers riches of the mind and heart to anyone working with the disturbed voice. Jan Baker's writing is comprehensive, erudite, original, accessible and eclectic. The book offers a thorough theoretical background, and clear ideas for working with clients who have a voice disorder; her approach superbly blends art and science with the humanity that joins them’. Christina Shewell,FRCSLT , Speech and Language Therapist; Theatre Voice Coach and Teacher; Honorary Lecturer, University College London; and author of Voice Work: Art and Science in Changing Voices.

‘This book represents a major contribution to the field of voice. It is special in its devotion to broadening our understanding of psychogenic voice disorders and the psychological skills and approaches required in their therapeutic management. Jan Baker has succeeded in giving us a rich and inspiring text that no voice practitioner, whether student, researcher or clinician, should be without.’ From the Foreword by Annie Elias, FRCSLT, Consultant Speech and Language Therapist in Voice and Author, Understanding and Treating Psychogenic Voice Disorder: A CBT Framework (with Peter Butcher and Lesley Cavalli)

 ‘Janet Baker inspires, challenges and clarifies. This unique and important book reflects the skill, experience, intellectual rigor and brave generosity of spirit, which have marked her career as therapist, teacher, mentor and academic. A gift to all practitioners involved in the care of individuals with voice disorders.’ Johanna Flavell, BA. BAppSc (Speech Pathology) Hons., Voice Consultant in private practice; Senior Speech Pathologist, Voice Analysis Clinic and Botox Clinic for Spasmodic Dysphonia, The Queen Elizabeth Hospital, Adelaide

Bringing to bear her extensive experience as a speech-language pathologist, with additional credentials in psychotherapy and family therapy, Jan Baker clearly, succinctly, and authoritatively presents clinical and empirical evidence for psychosocial factors related to the onset, aggravation, and outcomes of functional and organic voice disorders, and offers treatment strategies and approaches that are centred not only on traditional approaches to voice therapy, but also incorporate and demonstrate appropriate models of counselling.

A brief overview of several models of counselling and psychotherapy is given, with particular emphasis on the principles of systems theory and family therapy practice. Psychosocial factors that become evident during the different stages of voice therapy are discussed, including ways in which these issues may shape the therapeutic process and influence longer-term outcomes. These factors may occur, for instance, during the initial consultation and psychosocial interview; following assessment when explaining diagnostic findings; when clients ask searching questions about the ‘mind-body’ relationship; during therapy as sensitive information emerges; or towards the final stages of therapy when helping clients and families grieve over permanent changes to their voice or and an altered sense-of-self. They may become more pronounced in response to a client’s challenging behaviours, or as a reflection of problems in the therapeutic relationship. Strategies for speech-language pathologists to integrate appropriate counseling strategies in their voice work are proposed, with clinical vignettes to illustrate and support these approaches. These strategies are presented in a way that is in keeping with the professional scope of SLP practice, with criteria for recognizing the need for supervision, collaboration with other mental health professionals, or referring on.

Jan Baker’s book takes voice therapy for this challenging population into a new dimension; aside from its clear coverage of psychosocial factors and options for clinical treatment, the incorporation of counseling considerations and strategies gives speech pathologists and their clinical colleagues a powerful, holistic management tool.


Foreword. Preface. About the author. About the book. Acknowledgements

Part I: Evidence for Psychosocial Factors Contributing to Theoretical and Causal Models for Voice Disorders 

Making sense of the different clinical presentations of voice disorders

Diverse terminologies and different diagnostic classification systems. Implications for clinical work and research data across clinics and countries. Different emphases on neurophysiology, cognition, behavior and emotions. Assumptions about psychosocial factors and functional voice disorders. Paucity of assumptions about psychosocial factors and organic voice disorders. Psychosocial factors relevant to the clinical presentation of all voice disorders. Implications for clients. Options for clinicians. Case examples. References.

Psychosocial factors in health, disease and disorders of the voice

What do we mean by psychosocial factors? How do they differ from social determinants of health? The International Classification of Functioning, Disability and Health (ICF). Evidence for the role of negative emotions in health and disease. Evidence for the role of psychosocial factors in health and disease. Hypotheses about the pivotal role of negative emotions and voice disorders. Broad areas of research into psychosocial factors and voice disorders. Implications for clients. Options for clinicians. Case examples. References.

Demographics and biographical details of clients with voice disorders

Not what we are but who we are that matters. Evidence for prevalence and demographics related to age and gender. Occupations with high vocal load and vulnerability to voice disorders. Limited biographical details about individuals and their social context. The Family Life Cycle and its relevance to understanding voice disorders. Identifying the current family structure and links to family-of-origin. Social supports and community networks, religion, culture and ethnicity. Implications for clients. Options for clinicians. Case examples. References.

Stressful situations in the lives of clients with voice disorders

Clinical evidence for stressful incidents associated with onset. Current and remote traumatic stress situations. Measures and evidence for stressful life events and difficulties. Stressful situations imbued with dilemma or conflict over speaking out. Propositions about powerlessness in the system (PITS). Situations requiring significant communicative responsibility. High psychological demands and low job control. The costs and rewards of emotional labour in occupations and relationships. Combinations of factors leading to vocal, personal, or professional burnout. Implications for clients. Options for clinicians. Case examples. References.

Personality traits, emotional expressiveness and coping   

Personality traits and vulnerability to particular voice disorders. Attachment profiles and implications for seeking social support. Pathological accommodation and compromised sense of self. Evidence for the ‘non-expression of emotion’ in health and disease. Emotional expressiveness and levels of emotional awareness. Repression and suppression of emotion. Fatigue and perfectionism and links to emotional labour and burnout. Psychological correlates that shape coping styles in response to stress. Standardized measures of coping with reference to voice disorders. Somatization and abnormal illness behaviours. Co-morbidity with psychiatric conditions such as anxiety and depression. Implications for clients. Options for clinicians. Case examples. References.

Psychosocial impact of a voice disorder on the client and their close ties

Clinical and empirical evidence for psychosocial impacts on the individual. Standardized instruments measuring the impact of changes to the voice. Standardized instruments measuring changes to quality of life International Classification of Functioning Disability and Health (ICF). Grief over loss of identity and an altered sense-of-self. Implications for partners and close ties. Implications for clients. Options for clinicians. Case examples. References.

Theoretical and causal models that incorporate psychosocial factors

The hard questions. Underlying aims of all theoretical and causal models. Trends towards a research emphasis on functional voice disorders. Strange omissions in relation to organic voice disorders. Poorly regulated muscle tension pattern in relation to vocal load and stress. Psychodynamic and reformulated analytic and psychodynamic models. Dispositional trait theories. Emotion processing deficits. Extrapolations from biopsychosocial models of medically unexplained symptoms. All integrating neurophysiological, cognitive, affective, and behavioural aspects. Implications for clients. Options for clinicians. Case examples. References.



Part II: Models of Counselling Appropriate for the Management of Voice Disorders           

Different models of counselling

Neurophysiological evidence for changes to the brain in response to psychotherapy. Can we differentiate between counselling and psychotherapy? Fundamental tasks of all models. Different levels of counselling for different stages of intervention. Overview of different models of counselling and psychotherapy. Priorities in facilitating changes in thinking, emotions, behaviours. Client-Centred and other Humanistic models. Attachment Theory and Relational Therapy. Cognitive Behavior Therapy (CBT). Transactional Analysis (TA). Narrative Therapy. Conversational Model-Psychodynamic Psychology of Self. Principles of Systems Theory and Family Therapy practice. Implications for clients. Options for clinicians. Case examples. References.

Therapeutic processes and the therapeutic relationship

Therapy and healers versus treatment manuals and technicians . Therapeutic processes and reflections on effective therapeutic practice. Client and therapist perspectives on the therapeutic processes. Recognized qualities of effective therapists. The role of hope and despair in the therapeutic process. Use of the self in professional practice. Evidence for the significance of the therapeutic relationship in treatment outcomes. Implications for clients. Options for clinicians. Case examples. References.

Part III Addressing Psychosocial Factors throughout the Therapeutic Process

One voice: Lost or mislaid, stolen or strayed?

Construing a voice disorder through different lenses. Using different levels of counselling during the therapeutic process. Welcoming the willing and the reluctant client. Conducting a systematic inquiry. Expanding the traditional case history to psychosocial interview. Introducing different styles of questioning which become interventions. Presenting and discussing assessment findings and diagnosis. Answering difficult questions about aetiology, course of disorder and prognosis. Contracting for change with attention to personal and contextual issues. Implications for clients. Strategies for clinicians. Case examples. References.

Working through the different phases of intervention

Systems need new information in order to change. Facilitating phonation with traditional and creative approaches. Working through different interpersonal and psychosocial issues. Giving advice – is it always taboo? Facilitating change with strategies often used by family therapists. Consolidating change with psychosocial support. Enabling implicit emotions to become explicit. Reaching an understanding of the meaning of the voice disorder. Ending therapy and implications for client and therapist. Finding the person’s voice, lost or mislaid, stolen or strayed. Implications for clients. Strategies for clinicians. Case examples. References.

Restraints to change and strategies for intervention

Reframing notions of resistance, non-compliance and defensiveness. Commonly recognized restraints to change. Overt and obvious restraints to change. Covert and less obvious restraints to change. A pivotal restraint to change – who me? Parallel processes between the client’s experience and the therapeutic relationship. Implications for clients. Strategies for clinicians. Case examples. References.

Complex voice disorders and associated psychosocial implications

Occupational groups prone to voice disorders-teachers. Professional voice users - singers and actors. Voice disorders associated with blunt injury to the larynx or traumatic brain injury. Worker’s Compensation and Medico-Legal ramifications. Voice disorders with concomitant psychiatric conditions. Progressive neurological disorder affecting the voice. Voice disorder associated with traumatic stress, sexual or physical abuse. Profound grief and loss associated with loss of identity and altered sense of self. Acknowledgement of personal and professional limitations. Indications for deeper psychological work and seeking help. Recognizing the need for more specialized professional knowledge and skills. Supervision, mentoring, co-therapy and referring on. Models of supervision in allied health and other professional domains. Options for further education and training in counseling and psychotherapy. Implications for clients. Strategies for clinicians. Case examples. References.