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The speech pathologist, the singing teacher, and the singing voice specialist: where's the line?

INTRODUCTION

[A]ll three organizations [ASHA, VASTA, and NATS] acknowledge that the most effective path to vocal recovery often will include an integrated approach to optimal voice care and production that addresses both speech and singing tasks. ASHA, NATS, and VASTA therefore collectively affirm the importance of interdisciplinary management of speakers and singers with voice problems and disorders, with the management team ideally consisting of some or all of the following individuals: an otolaryngologist, a speech-language pathologist, and a singing teacher, and/or speaking voice and speech trainer. [ASHA Ad Hoc Joint Committee With the National Association of Teachers of Singing and the Voice and Speech Trainers Association] (1)

ECENT DECADES HAVE SEEN increased interest in the treatment of Rvoice disorders in singers. While consensus exists that a visit to the laryngologist is the first step in determining the source of the problem, there is little consensus as to who should provide the rehabilitation services for voice disorders in singers--the speech-language pathologist, the singing teacher, or perhaps both--and no consensus on the role each discipline plays in the rehabilitative process. In 2006, Fields and Hapner queried speech-language pathologists about their clinical practice patterns and beliefs regarding who should treat voice disordered patients who were also singers) In their survey, 156 speech-language pathologists identified themselves as regularly working with voice disorders in singers. A little over half of those speech-language pathologists reported treating singers (51%, n=79), and of those treating singers, 83% treated both professional and avocational singers. There was little consensus on the qualifications needed to treat singers beyond the certificate of clinical competence from the American Speech Language and Hearing Association. Additional degrees in music and vocal music performance were reported as skills needed to treat singers. The results of the survey indicated that 89% of the fifty-seven speech-language pathologists who reported treating voice disorders in singers had completed additional degrees in music and/or had at least two years of private vocal training (51/57), 66% reported professional (paid) singing experience (n=38/57), and 10% reported no performing experience and little (less than one year) or no vocal training (n=6/57).

The aim of the current report is to present the results of a similar survey of the teaching practices and beliefs of vocal music teachers who treat voice disorders in singers. As a consequence of these two surveys, the secondary aim of this paper is to begin to develop consensus regarding the optimal team to treat singers with vocal pathologies and perhaps to offer a definition of the singing voice specialist

METHODS

A twenty-seven item multiple choice survey was distributed online via SurveyMonkey[TM] (www.surveymonkey. com), a secure online software program designed to collect responses anonymously. A link to the survey and a brief description of the study were sent via email to all 5682 members of NATS with email addresses on file as of fall 2009.

The survey consisted of questions including: the number of years of teaching experience; the teacher's highest degree of academic training and the date of completion of his or her most recent degree; the teacher's primary job description; amount of time spent in the studio; the context of his or her teaching (i.e., private studio, faculty position at a college, conservatory, or community music school, etc.); the demographics of the students he or she teaches; the genres taught and the genres he or she is trained in or feels most comfortable teaching. More specific to the aims of the project, additional questions were asked concerning whether the teacher interviews new students about their voice use and vocal health history; whether or not he or she accepts students with voice problems; what the teacher does when a student in his or her studio develops voice problems; whether the teacher consuits with a medical professional regularly, and if so, with which medical professional does he or she consult. Finally, respondents were asked several questions regarding the definition of the singing voice specialist: how does it differ from a singing teacher; is special training needed in order to become a singing voice specialist; does the respondent consider him- or herself to be a singing voice specialist, and if so, what qualifications does he or she possess.

FINDINGS:

Survey responses were received from 429 participants, with 399 participants completing the entire survey. This total represented only 7% of the membership of NATS with email as of fall 2009. Responses came from forty-five of the fifty states. Roughly half (n=236, 56%) of the respondents reported having twenty-one or more years of voice teaching experience, Thirty-six percent (n=140) said they completed their degree within the last ten years. A majority of the respondents held masters (n=244, 59%) or doctorate degrees in voice performance (n=102, 25%). The vast majority (n=357, 85%) reported that most of their teaching time was spent as a singing teacher. In addition to teaching in the voice studio, many reported also coaching vocal repertoire, directing music theater, or choral conducting. Approximately 90% (n=325) reported teaching primarily preprofessional singers. Most students taught were between thirteen and twenty-four years of age, with 64% in the 18-24 year old age range.

When asked what styles they taught, most respondents reported teaching a variety of styles (genres) of music, with classical and music theater styles predominating. Jazz, rock, R&B, folk, country, and gospel were also extensively taught. Yet when asked which style(s) respondents felt most comfortable teaching, 84% (n=352) responded classical, 12% music theater (n=51), and only 1% felt most comfortable teaching jazz (n=5); (Figure 1).

Several questions queried the participants' definition of the training and qualifications of the singing voice specialist. Respondents were evenly split on whether or not they considered themselves a singing voice specialist. They were then asked whether they agreed or disagreed with the following four definitions of a singing voice specialist:

1) The singing voice specialist addresses the functionally and/or organically disordered singing voice in the voice studio or the voice clinic.

2) The singing voice specialist works only in the context of a specialty voice clinic.

3) The singing voice specialist works with singers only.

4) The singing voice specialist works with singers only focusing exclusively on technical issues.

As multiple responses were accepted, the percentages total more than 100%. Ninety-five percent agreed with the first definition, which stated that the singing voice specialist addresses the functionally and/or organically disordered singing voice in the voice studio or the voice clinic.

[FIGURE 1 OMITTED]

In response to the question "What do you do when a student appears to have a vocal problem such as hoarseness, reduced endurance, reduced range, etc.," 69% (n=290) responded that they try to solve the problem on their own and if necessary refer to a laryngologist. Only 16% (n=65) stated they would refer to a laryngologist immediately. Six percent (n=25) indicated they would continue working with the student to solve the problem. Of those who indicated they would try to solve the problem on their own, several indicated they would implement strategies such as voice rest, addressing postural considerations, providing traditional vocalises, focus on the passaggio transition, and attend to breath support, vowel modification, resonance, and repertoire work. In addition, many respondents focused on issues regarding performance anxiety or utilized specialized semioccluded vocal tract exercises (Figure 2).

Sixty-nine percent (n=290) of teachers responding indicated that they would accept students into their studio with a diagnosed voice problem, but those students made up less than 10% of their total student load. Referrals of singers with vocal problems came mainly by word of mouth (55%, n-203), from another voice teacher (45%, n=168), or from a medical professional, either a speech pathologist or a laryngologist (60%, n=221). As multiple responses were accepted, the percentages total more than 100% (Figure 3).

Training in voice disorders varied widely among respondents in general, and among those who considered themselves to be singing voice specialists in particular. Most indicated some coursework in the past ten years, but 20% indicated their formal academic training was more than twenty years ago. Respondents indicated that their training included courses in anatomy and physiology, observation in a medical clinic with a speech-language pathologist or someone who self-defined as a singing voice specialist, coursework in the clinical management of voice disorders, completion of the Summer Vocology program at the University of Iowa, or attending specialty voice conferences or workshops.

Other respondents indicated that their training included keeping up with current research articles; studio experience; personal experience with a voice problem and subsequent therapy; additional degrees in biology; teaching anatomy and physiology; specialty training from the McCloskey Institute, in the Alexander Technique, Feldenkrais[R] Method, training based on the work of Carl Stough (breathing coordination), or Body Mapping (Figure 4).

Finally, respondents were asked about their awareness of the 2005 Joint ASHA, NATS, VASTA statement, "The Role of the Speech-Language Pathologist, the Teacher of Singing, and the Speaking Voice Trainer in Voice Habilitation." (3) Sixty-seven percent (n=267) reported not being aware of the joint statement. Of those who self-designate as singing voice specialists, only two thirds indicated that they were aware of the joint statement.

DISCUSSION

There is little consensus regarding who should work to rehabilitate voices of singers with voice disorders. While the Voice Foundation has worked diligently since the 1970s to bring together the medical, speech-language pathology, and singing voice communities to better treat the unique needs of the singer with a voice pathology, there remains little agreement on the skills and credentials needed to treat singers with voice pathologies after diagnosis and medical treatment by the otolaryngolo gist. While the American Speech-Language and Hearing Association has developed the certificate of clinical competence, and while most states require licensure for speech-language pathologists to practice, there are not competencies, guidelines, or licensure for singing teachers. In addition, despite the efforts of many leading teachers, not all singing teachers are members of NATS. There remains a problem with consensus within the singing voice community on the qualifications and training necessary to practice teaching.

The first step in working toward consensus is to understand the care practices of people who are presently treating singers with voice pathologies. The authors attempted to replicate and expand the survey completed by Fields and Hapner in 2006 by addressing the questions to the members of the National Association of Teachers of Singing. The goal of both surveys was to determine who is working with singers with voice pathologies, the training of those working with singers with voice disorders, the referral patterns from and to medical professionals (including the otolaryngologist and speech-language pathologist) with regard to the diagnosis and care of singers, the referral patterns to and from singing voice teachers in the treatment of singers with voice disorders, and the treatment practices of those working with singers with voice disorders. The results of this survey demonstrate that one half of the singing teachers already consider themselves to be singing voice specialists. If the singing voice specialist is defined as someone who is thoroughly versed in training the singing voice, then the singing teacher of course is a singing voice specialist. If, however, the definition of the singing voice specialist is seen within the context of the medical profession, then it assumes, as did Heman-Ackah, Sataloff, and Hawkshaw, (4) Sataloff et al., (5) Riley and Carroll, (6) and Radionoff (7) that the term "specialist" implies an area of specialization within a larger field, not a separate field itself. The definition most respondents agreed upon was: "The singing voice specialist addresses the functionally and/or organically disordered singing voice in the voice studio or the voice clinic." This definition mentions not only the scope of practice, but also the location of that practice. Many laryngologists and speech pathologists recognize the need for a team approach. Including a singing teacher to work with a singer with a voice disorder can and should be an essential part of the rehabilitative team.

[FIGURE 4 OMITTED]

Results of the survey indicate that singing teachers who report working with the injured singing voice for the most part have made an effort to learn about voice disorders, through a variety of courses, workshops, observations, and personal experiences. There is no dispute that their expertise lies in understanding and training the normal singing voice. Training for rehabilitation, however, includes not only acquiring an understanding of what is involved in singing, but also securing a basic understanding of vocal pathologies and the functional impact of pathology on voice production. Anatomy and physiology courses teach normal structure, that is, anatomy, not pathology. Workshops and observation in voice clinics are an invaluable part of training, but these alone are not truly sufficient to qualify someone for providing rehabilitation. Training in Alexander Technique, the Feldenkrais Method[R], and Body Mapping are not medical modalities. Feldenkrais himself was adamant that his method not be considered a medical cure. These somatic modalities are very beneficial in working with singers as both a habilitative and rehabilitative tool, but they should not be considered as equating with specialized training in working with voice disordered singers. Likewise, regarding personal experience in rehabilitating from a voice injury, it is essential to point out that while such a life experience can be very valuable to a teacher or therapist, and although it provides some insight into how voice disorders are managed, this experience is not sufficient training to rehabilitate another individual. Finally, with respect to coursework in vocology, Dr. Titze makes it clear to graduates of the Summer Vocology Institute that completing the program of courses "is not in any way an accredited certification or license." (8)

There seems to be confusion among singing teachers as to the difference between habilitation of the singing voice and rehabilitation of the singing voice. In medical terms, habilitation is defined as "the process of supplying a person with the means to develop maximum independence in activities of daily living through training or treatment." (9) Rehabilitation, on the other hand, is defined as "the process of restoration of skills by a person who has had an illness or injury so as to regain maximum self-sufficiency and function in a normal or as near normal manner as possible." (10) In other words, habilitation is enhancement of function, while rehabilitation is restoration of function.

The question remains, what are the qualifications needed to work with this specialized population, and is there currently a professional group that possesses all the necessary qualifications? If for no other reason than the legal liability issues, the singing voice specialist should be someone who has knowledge of voice technique, understands the vocal demands of professional singing, and possesses a comprehensive knowledge of voice disorders, including how the disorders impact vocal fold vibration, resonance, and overall function, in addition to clinical management skills. The speech-language pathologist working with the elite in this population should then have extensive singing and perhaps performing experience. The singing teacher should then be well versed not only in anatomy and physiology, but also voice disorders, how disorders impact vocal fold posturing and vibration, resonance, and endurance, and the clinical management of disorders, including post-surgical implications for rehabilitation. Equally important is the understanding that most voice disorders, whether they are benign lesions such as nodules or hoarseness due to a laryngeal cancer, present in very similar ways. While there are distinct patterns of patient voice use history, and limitations in the flexibility, range, and quality of the voice common to specific disorders, one cannot determine solely by sound or history the nature of a lesion. Only a laryngeal examination can determine conclusively the cause of a problem. Referral to a laryngologist is imperative!

The authors set out to better understand who works with singers with vocal pathologies, who considers him-or herself to be a singing voice specialist and why, whether or not he or she works with singers with voice disorders, and the extent of his or her training in singing and voice disorders. Based on the Fields and Hapner survey of a small group of speech-language pathologists working in the area of voice, the speech-language pathologists have a solid foundation in anatomy and physiology of the larynx; however, the survey indicated that many lack sufficient training in the singing voice. The results of this survey indicate that singing teachers lack a solid foundation in anatomy, physiology, voice disorders and their impact on vocal function, as well as lack clinical management skills, though they are adept at the habilitation of the healthy singing voice. At this time, there is no single professional group with expertise in anatomy and physiology of laryngeal structure and function, voice disorders and their impact on laryngeal structure and function, and habilitation and/rehabilitation of the singing voice.

The clinical management of singers with voice disorders requires an understanding of the differences between a singing lesson and a voice therapy session. In working with a singer, the limitations that voice disorders place on the voice must be taken into account and the appropriate facilitation techniques must be implemented. While many of these facilitation techniques overlap with exercises traditionally used in the voice studio, how they are used is different. The short term goals are different. For example, in a healthy singer with increased breathiness in the voice, especially in the upper range, a typical pedagogic approach might be to help the student acquire greater precision and coordination of the adductory muscles through the use of onset exercises, as well as promoting optimal resonance and breath support. Scales and arpeggios might be used to facilitate better intrinsic muscle control and to help balance the registers. In the singer with vocal fold nodules, the breathiness is the result of the pathology. Impact of the vocal folds needs to be decreased, not increased, so the lesions can heal. Balancing the registers is contraindicated since it is the lesion that is interfering. Scales and arpeggios can be effective, but the focus should be on optimizing resonance and breath support while at the same time encouraging a reduction in vocal fold contact forces.

The speech-language pathologist needs to understand both the lifestyle demands and the vocal demands on the singer as well as how those demands impact vocal health. Is it enough then for the speech-language pathologist to have some voice training or some choral training? How much voice training is enough for a speech-language pathologist to be considered a singing voice specialist? Some would argue that only speech-language pathologists who have taught singing and/or had a singing career should be considered a singing voice specialist. Others might argue equally well that a general understanding of the voice is sufficient.

If we assume that the needs of the singer with a vocal pathology might best be treated by someone with both a speech pathology background and training in voice pedagogy and that person should be called the singing voice specialist, then step one remains the development of a consensus definition of the singing voice specialist coupled with an end to the frivolous use of this term by any and all who deem themselves qualified. The next step will be to thoroughly define the qualifications of the singing voice specialist. While ASHA, NATS, and VASTA have worked to develop a consensus statement, few members surveyed in either organization are familiar with the document. Further, because there are no licensure laws governing the singing teacher, it is difficult to police ethical practice and to enforce guidelines among this group. Additionally, developing guidelines for practice might mean changing the practice patterns for both the speech-language pathologist and the singing teacher. However, if our ultimate goal is to provide the best care to singers with vocal pathologies, then the time has come to reopen the discussion, reexamine the terminology, reassess the possibility of specialty certification, and reaffirm our desire to work together. This will require an ongoing commitment to monitor our own members to provide quality care, to educate the public on who are qualified professionals to treat their voice problems, and to develop research into treatment outcomes and treatment efficacy.

[Acknowledgements: This research was conducted with the cooperation and support of the Voice Science Committee of the National Association of Teachers of Singing.]

NOTES

(1.) American Speech Language-Hearing Association, "The role of the speech-language pathologist, the teacher of singing, and the speaking voice trainer in voice habilitation," ASHA technical report, http://www.asha.org/policy (accessed June 1, 2010).

(2.) Amy Fields and Edie Hapner, "Survey of Speech-Language Pathologists and the Treatment of the Disordered Singing Voice" (paper presented at the Voice Foundation 35th Annual Symposium: Care of the Professional Voice, Philadelphia, PA, June 1-4, 2006).

(3.) American Speech Language-Hearing Association.

(4.) Yolanda Heman-Ackah, Robert Sataloff, and Mary Hawkshaw, "Who Takes Care of Voice Problems? A Guide to Voice Care Providers," Journal of Singing 59, no. 2 (November/December 2002): 139-146.

(5.) Robert Sataloffet al., "The Singing Voice Specialist," in Robert Sataloff, ed., Professional Voice: The Science and Art of Clinical Care, 3rd ed. (San Diego: Plural, 2005), 1021-1040.

(6.) William Riley and Linda Carroll, "The Role of the Singing Voice Specialist in the Non-Medical Management of Benign Voice Disorders," in John Rubin, ed., Diagnosis and Treatment of Voice Disorders (New York: Igaku-Shoin, 1995), 405-423.

(7.) Sharon Radionoff, "Preparing the Singing Voice Specialist," Journal of Voice 18, no. 4 (2004): 513-521.

(8.) Ingo Titze, e-mail message to the second author (November 4, 2009).

(9.) Medical dictionary, http://medical-dictionary.thefreedic tionary.com/habilitation (accessed June 1, 2010).

(10.) Medicine.net, http://www.medterms.com/script/main/art.asp? articlekey=5288 (accessed June 1, 2010).

Marina Gilman holds masters degrees in vocal performance and speech-language pathology. She has been a Guild Certified Feldenkrais Practitioner since 1996. In addition to her private voice and Feldenkrais studio, Ms. Gilman is a licensed speech-language pathologist with voice specialization at the Emory Voice Center, Emory University Department of Otolaryngology. Since becoming a Feldenkrais Practitioner she regularly incorporates Feldenkrais lessons into her studio as well as clinical practice. She has taught voice for speaking and singing for over 30 years privately as well as at Cornell University, Syracuse University, and DePaul University, as well as the School at Steppenwwolf summer program.

Ms. Gilman presents workshops and paper presentations at professional conferences, including the Voice Foundation Annual Symposium: Care of the Professional Voice, American Speech Hearing Association, University of California San Francisco Voice conference, the International Conference on the Physiology and Acoustics of the Singing Voice, and the British Voice Association Choice for Voice 2008 conference. In addition, she presents workshops for actors and singers in professional theater and opera companies across the country. Ms Gilman's performing career includes recitals as well as leading operatic roles.

John Nix, tenor, Associate Professor of Voice and Voice Pedagogy at The University of Texas-San Antonio, teaches applied voice, vocal methods, a two course sequence in voice pedagogy for undergraduates, and a four course sequence in voice pedagogy for graduate students. He is the founder/director of the UTSA Vocal Arts Laboratory. Previously he was Director of Education/Special Projects and Summer Vocology Institute Coordinator for the NOVS in Denver, where he worked with Dr. Ingo Titze. Mr. Nix has also served on the music faculties of The University of Colorado at Denver and Eastern New Mexico University. Mr. Nix holds the MM in Vocal Performance from The University of Colorado-Boulder, Certification in Vocology from The University of Iowa, and pursued additional coursework towards the DMA degree. At Colorado, he studied voice and pedagogy with Dr. Barbara Doscher and Alexander Technique with James Brody. Mr. Nix was also a participant in the 1994 NATS Intern Program, where he worked with Thomas Houser and Barbara Honn. He received a BM in Vocal Performance from The University of Georgia and a MME in Arts Administration from Florida State. Current and former students include a member of the Mormon Tabernacle Choir, two Santa Fe Opera apprentices, members of the Army Soldiers' Chorus, a second place winner in the NFMC competition, a two-time finalist in the American Traditions competition, an international semifinalist in the Brahms Lied competition, and faculty members at universities in Montana, Texas, Wyoming, and New York. His work has been funded by The San Antonio Area Foundation, The Grammy Foundation, UT-San Antonio, and two R-13 grants from NIH. He has coordinated four international conferences on voice, including the Second and Fourth International Conferences on the Physiology and Acoustics of Singing. His published articles have appeared in The NATS Journal, The New York Opera Newsletter, Otolaryngology-Head and Neck Surgery, Journal of Voice, Journal of Singing, International Journal of Research in Choral Singing, Vocalease, Australian Voice, and Opera Journal. Mr. Nix is the editor and annotator of From Studio to Stage: Repertoire for the Voice, compiled by Barbara Doscher (Scarecrow Press, June 2002), Vocal Music section editor for the Oxford Handbook of Music Education (publication in June 2011), and co-general editor of the Oxford Handbook of Singing (publication in 2012).

Edie Hapner is the Director of Speech-Language Pathology at the Emory Voice Center and a faculty member in the Department of Otolaryngology, Emory University School of Medicine in Atlanta, GA. She is the Coordinator of the Division 3 Voice and Voice Disorders Steering Committee of ASHA, Past Chair of the Reimbursement Committee for Division 3, a member of the Communication Sciences and Disorders Research Group, and a Scientific Fellow for the American Academy of Otolaryngology. in 2006 she was awarded the Clinical Scholars designation from the American Academy of Otolaryngology. She served as ASHA's liaison to the Hoarseness (Dypshonia) Guidelines Development Committee for the American Academy of Otolaryngology in 2009. She has received numerous awards, including the Clinician of the Year Award from the Georgia Speech Language and Hearing Association in 2007 and Outstanding Alumnae from the University of Missouri-Columbia Department of Education the same year. She presents on the area of voice at national and international conferences, has numerous publications, and she serves as a reviewer for several peer reviewed journals.
Figure 2. What do you do when a student presents with
a vocal problem?

Continue working with the
student even though there are
limitations                               16%
Continue working with the
student to see if I can resolve
the problem                                6%
Try to resolve, if not refer to
laryngologist                              5%
Refer to laryngologist
immediately                               69%

Note: Note Table made from pie chart

Figure 3. Referral source for students with voice disorders.

Medical                        59.5%
Another teacher                45.3%,
Word of mouth                  54.7%
Do not accept
student with
voice disorders                21.0%

Note: Table made from bar graph.
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Title Annotation:VOICE PEDAGOGY
Author:Gilman, Marina; Nix, John; Hapner, Edie
Publication:Journal of Singing
Date:Nov 1, 2010
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