Logopedics Phoniatrics Vocology
ISSN: 1401-5439 (Print) 1651-2022 (Online) Journal homepage: http://www.tandfonline.com/loi/ilog20
Facilitating behavioral learning and habit change in voice therapy—theoretic premises and practical strategies Jenny Iwarsson To cite this article: Jenny Iwarsson (2015) Facilitating behavioral learning and habit change in voice therapy—theoretic premises and practical strategies, Logopedics Phoniatrics Vocology, 40:4, 179-186, DOI: 10.3109/14015439.2014.936498 To link to this article: http://dx.doi.org/10.3109/14015439.2014.936498
Published online: 23 Jul 2014.
Submit your article to this journal
Article views: 123
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ilog20 Download by: [Washington University in St Louis]
Date: 08 November 2015, At: 14:22
Logopedics Phoniatrics Vocology, 2015; 40: 179–186
Original article
Facilitating behavioral learning and habit change in voice therapy—theoretic premises and practical strategies
Downloaded by [Washington University in St Louis] at 14:22 08 November 2015
Jenny Iwarsson Audiologopedics, Department of Scandinavian studies and Linguistics, University of Copenhagen, Denmark
Abstract A typical goal of voice therapy is a behavioral change in the patient’s everyday speech. The SLP’s plan for voice therapy should therefore optimally include strategies for automatization. The aim of the present study was to identify and describe factors that promote behavioral learning and habit change in voice behavior and have the potential to affect patient compliance and thus therapy outcome. Research literature from the areas of motor and behavioral learning, habit formation, and habit change was consulted. Also, specific elements from personal experience of clinical voice therapy are described and discussed from a learning theory perspective. Nine factors that seem to be relevant to facilitate behavioral learning and habit change in voice therapy are presented, together with related practical strategies and theoretical underpinnings. These are: 1) Cue-altering; 2) Attention exercises; 3) Repetition; 4) Cognitive activation; 5) Negative practice; 6) Inhibition through interruption; 7) Decomposing complex behavior; 8) The ‘each time–every time’ principle; and 9) Successive implementation of automaticity. Key words: Behavioral learning, habit change, voice therapy
Background The most common treatment for functional dysphonia is behavioral voice therapy (1,2). For this and other diagnoses, among them transsexual voice, an important goal for intervention is that a new behavior is generalized and implemented in the patient’s spontaneous everyday communication. This carryover requirement should be a central aspect in planning of voice therapy programs, both when tailored to the individual patient and in strict therapy protocols aimed at groups of patients. Surprisingly little attention has been paid in the literature to practical tools or strategies which can be used to encourage stable long-term learning and generalization of new vocal behaviors. A common unstated assumption may be that the patient’s everyday speech will change simply by having achieved new skills. However, medical records for voice patients sometimes reveal the therapeutic challenge of a patient who is motivated, co-operative, and performing exercises impeccably in
therapy sessions, but not (yet) in spontaneous speech. This phenomenon—and who is responsible for it—is rarely addressed. Poor patient compliance or adherence may be a handy label, but a closer look into learning theory indicates that we as speech language pathologists (SLP) can have a greater role than we realize in eliciting patient adherence to behavioral change. Research in motor learning and skill acquisition has disclosed that particular strategies in training favor stable long-term learning more than others. For example, delayed feedback and feedback after only a few trials has been shown to be more effective for long-term learning than immediate feedback and feedback after every trial (3,4). As regards distribution of practice, it has been shown that a given number of sessions over a long period of time is more effective than massed practice, i.e. practice done for a short period of time (3,4). Most of these principles are based on research on limb movements, but some
Correspondence: Jenny Iwarsson, Audiologopædics, Department of Scandinavian studies and Linguistics, University of Copenhagen, Njalsgade 120, 2300 Copenhagen S, Denmark. Fax: 45-35 32 83 77. E-mail: [email protected] (Received 11 March 2014; accepted 13 June 2014) ISSN 1401-5439 print/ISSN 1651-2022 online © 2014 Informa UK, Ltd. DOI: 10.3109/14015439.2014.936498
Downloaded by [Washington University in St Louis] at 14:22 08 November 2015
180
J. Iwarsson
have been shown to be relevant also to learning in speech and voice (5–13). In a systematic review article by Bislick and colleagues (13), the authors conclude that the application of principles from motor learning to speech in terms of practice and feedback variables is promising and that continued investigation is warranted. In the application of motor learning theory to voice, it is important first to survey essential differences between various forms of speech and voice training and use. For example, speaking differs substantially from singing in many aspects, and normal voice function differs from abnormal. Most speech studies of the role of motor learning theory are carried out on patients with motor speech disorders (7-11). However, from a learning perspective, rehabilitation which focuses on relearning a lost skill or learning compensatory strategies differs from behavioral voice therapy for functional and organic voice disorders. A challenge for the SLP in the latter case is, in addition to teaching the patient a new skill, also to ensure that this new skill replaces an old, wellestablished automatic behavior. Aims and method of the study The present study is not a systematic literature review and contains no empirical data. The aim was to identify, describe, and discuss a list of factors that can promote a stable and automatized change in voice behavior of spontaneous speech. The method used can be described as a process of accumulated clinical reflections combined with a thorough but non-systematic literature study. My interest in the area was initiated by a slide presentation about skill acquisition in voice, given by Professor Katherine Verdolini at the PanEuropean Voice Conference in Regensburg in 1997. As a consequence of this, I consulted some early literature on motor control and learning (14–16). Beside the general aim to identify factors promoting vocal behavioral change, I wanted to find theoretic support for some specific therapeutic strategies that I have experienced as beneficial in clinical voice therapy, both for the automatization of patients’ new vocal behaviors and for the inhibition of inappropriate old ones. To do this, I continued to search research literature from the area of motor learning and skill acquisition, as well as literature on behavioral learning, habit formation, and habit change. Bibliographic databases used were Ovid MEDLINE, EMBASE, and PsychINFO. In the following, some basic principles of the speech process and the characteristics of habits will be described. Then I will present a list of nine factors relevant to behavioral learning and changing
voice behavior habits. These are: 1) Cue-altering; 2) Attention exercises; 3) Repetition; 4) Cognitive activation; 5) Negative practice; 6) Inhibition through interruption; 7) Decomposing complex behavior; 8) The ‘each time–every time’ principle; and 9) Successive implementation of automaticity.
The speech process and the characteristics of habits The time from stimulus (intention) to muscle activity response (movement) in the speech process is typically a couple of milliseconds, and several responses can be fired simultaneously in a quite stereotypic manner. Automatized muscle activation is the basis of various perceptuo-motor parameters ranging from voice quality and articulatory patterns to body language. The ability to speak without specifically attending to the process, established in early childhood, is a natural and important prerequisite for communication. It enables us to devote our full attention to cognitive functions in understanding and planning the content of the talk. However, the same muscles can also be activated in isolation and controlled as consciously intended actions. With focus on the goal to change an automatized voice and speech behavior it seems relevant to have a look at the nature of habits. The most prominent characteristic of a habit is that it occurs totally without any, or with a minimum amount of, awareness (17). Whether we think of the habit of drinking too much coffee, biting nails, or to sit with crossed legs, from a learning perspective a habit is defined as a learned sequence of actions that has become automatic as a response to a specific cue. To understand how a habit is established, we should remember that as an outset it is a functional and effective response to a given cue (18). But some habits unfortunately induce long-term negative side effects. This is apparent when we think of habits like using a hyperfunctional voice quality in order to be heard effectively, a near-sighted person who uses a posture with a forward head position or when, after a period of stress or anxiety, a person habitually continues using an upper costal or even clavicular breathing pattern. Habits, whether inefficient or purposive, seem established through implicit, procedural learning, often referred to as learning through experiential learning processes (12,14,19,20). Such learning is described to be formed by exposure and repetition, and it is slow to form and slow to change. This is fundamentally different from learning through rational processes, which is described to involve verbal, analytical, and associational operations and which are relatively quick to change (12,14,19,20).
Downloaded by [Washington University in St Louis] at 14:22 08 November 2015
Cue-altering A common part of voice therapy is education in voice ergonomics, where the patient is given information about vocal tract hygiene and voice conservation (21–23). Advice and information may incite explicit, rationally processed learning and have been shown to effectively influence intentions and attitudes but not necessarily behavior (18). A factor that, on the other hand, has been found to influence behavior and support habit change is so-called cue-altering techniques, which means that the cue firing the (negative) response is modified (24). Cue-altering in a weight-loss program, for example, could be to use small plates and cutlery in order to break the habit of serving and eating large portions of food (25). Equivalent to this in a vocal hygiene context could be making physical adjustments to better enable face to face communication, such as refurnishing the classroom, readjusting daily schedules and routines to include pauses for voice rest and liquid intake, altering auditive feedback or reinforcing one’s own voice, or dampening surrounding sound sources which might lead to increased vocal effort or hyperfunctional speaking behavior. Many of these strategies are well-known environmental adjustments in occupational voice care (26–28).
Attention exercises Conscious awareness is not in itself a prerequisite for skill acquisition. On the contrary, Verdolini and Lee (12) describe how most of our habits and behaviors are established implicitly, over time, and without verbal conscious awareness. However, awareness may still play a significant role in the inhibition of an old habit. In this process, explicit, rational learning appears to be important (20). As mentioned, a habit can be described as an activity performed with minimum awareness. Expressed the other way round, awareness and attention to details seem to be the automatized habit’s enemy. Attention is thereby a factor of relevance to behavioral change, which explains why exercises that may be categorized as ‘attention exercises’ seem to be a wise choice as one kind of ingredient in voice therapy. In attention exercises, the patient’s detailed attention to sensory information is central. One way to achieve this is through questions from the SLP that require the patient to discover, analyze, and describe a specific sensation or voice quality. The patient could be asked to pay attention to, and describe with his or her own words, a certain sound quality in the voice, first after listening to a recording and then in real-time production. The patient could also be instructed to choose a word for a sensation in the
Habit change
181
throat at a certain moment or during the production of a certain sound, or asked to describe details in the form or size of ‘openness’ in a cavity. The SLP should ensure calm circumstances and time enough for the patient to discover and analyze sensory experiences. This type of question has been inspired by the verbal instruction method practiced by AnneChristine Ohlsson (29), and similar approaches are described in the work of Moshe Feldenkrais and in the Alexander technique (30–32). One theoretical explanation for the experience of a positive contribution of attention exercises to behavioral learning may be that sensory information is central and critical in experiential learning processes (12). The SLP guides the patient to interpret her own internal feedback that is always available (16). Attention exercises can furthermore include having the patient experience the sensory difference between two opposed settings of an isolated aspect of the speech process, such as a tensed versus relaxed muscle activity, a fast versus slow speaking rate, or pressed versus flow phonation type. To let the patient or student experience the difference is a common and probably very old exercise in various types of voice training. The attention to the difference is extra helpful in cases where a habitual constant tension in e.g. the jaw or shoulders is perceived as a natural state for the patient, until a difference in sensation is experienced. Attention may, as mentioned, play an important role in breaking the condition of automatization in the speech process, and thus supports inhibition. Thus, it seems reasonable to assume that attention exercises constitute an element with the double capacity to break down existing habits and create good prerequisites for establishing new ones.
Repetition Repetition is a factor that has been shown to have a very strong impact on effective motor learning (4,13,16). Therefore, instructions and home training tasks that request the patient to repeat the same task several times should be rewarding in terms of behavioral learning. Furthermore, attention and repetition may be fruitfully combined through instructions where the patient is asked to make voluntary variations in parameters such as tempo, loudness, or pitch. This increases the patient’s control of the behavior in terms of consciously intended muscle activity. Cognitive activation The described approach of guiding the patient through questions includes a cognitive activation of
Downloaded by [Washington University in St Louis] at 14:22 08 November 2015
182
J. Iwarsson
the patient. Activation of the learner is a generally admitted goal in contemporary pedagogy (see e.g. 33), although the explanation to this counsel is not always made explicit. Analyzing one’s own voice and interpreting intrinsic feedback through answering questions can be presumed to activate the working memory of the patient, which may have the impact to accelerate and stabilize learning in voice therapy. This specific hypothesis has not been confirmed through the literature, but the activation is closely related to a phenomenon described in motor learning literature, called cognitive effort. It means that the establishment of information as long-term learning is enhanced when the patient is introduced to some difficulties, has to struggle a bit on her own, build her own hypotheses, or meet cognitive challenges, e.g. by retrieving information to answer a question (3,16). Thus introducing a decision-making activity or requiring a patient to approach a task by developing a strategy or plan of action is probably far more effective for long-term learning than e.g. passively listening to an expert performing the skill (16). The role of cognitive effort may also be involved in the finding that delayed and low-frequency feedback during training are more effective for long-term learning than immediate and high-frequency feedback, even though the latter strategy improves the immediate performance (4,13). This contradictory effect on long- and short-term learning of concurrent feedback, which is only revealed by effect studies including retention measures, therefore suggests that the SLP gives a restricted amount of feedback in order to allow the patient’s own analysis and cognitive activation. Negative practice Negative practice means that the patient is instructed to produce an unwanted behavior or component of voice or speech on purpose. We know this approach from voluntary stuttering where the effect of producing stuttering by will in suppressing true stuttering is undeniable (34–36). The underlying mechanism of this phenomenon is not completely understood, but it has been suggested to be related to a perception–production link, where a person’s own speech may prime the auditory cortex, possibly helping to evoke patterns of cortical activation and inhibition consistent with fluent speech production, as opposed to the patterns the brain nerves of the person who stutter habitually evoke (36). My personal experience from speech therapy for people who stutter has encouraged me to use the element of negative practice also in voice therapy, and the approach has often shown a positive and immediate
behavioral change. This can take place, for example, after the patient has been guided to identify a vocal fry (or hard glottal attacks, or excessive glottal hyperfunction). The SLP may in a playful and experimental mood ask the patient to produce the specific vocal feature on purpose, first isolated and then in a natural phrase. Another application can be to assume a certain body posture or tension that constitutes a frequent habit. An empathetic and confident atmosphere is crucial here, because the negative practice can sometimes be a sensitive task for the patient. To produce an unwanted sound or behavioral component on purpose seems to add to the patient’s ability to control voluntarily that particular behavior, not only its initiation but paradoxically also the inhibition of it. Inhibition through interruption Many behavioral researchers describe that a promising strategy for habit change is to combine learning and performing new goal-consistent patterns of response with effortful inhibition (17,24). Inhibition means a mental process that blocks, restricts, prevents, or weakens a behavior or impulse. In voice therapy, specific focus on inhibition has not been traditionally described, but clinical experience and published documentation imply that it can be rewarding, e.g. in cases of unconscious and repetitive habits such as in habitual throat-clearing (37). Here the patient can be instructed to interrupt this activity in spontaneous speech, e.g. on a given hand-sign from the SLP. The interruption should optimally take place right before the behavior is realized and followed by immediate questions about details in sensory information at that particular moment. By introducing such a time gap between stimulus and response, the habit is concretely prevented and prerequisites for replacement with an alternative behavior are promising (such as a soft humming or sinking of saliva) (20). The inhibitory effect of subsequent questions to the patient regarding details of sensory information, both in negative practice and in inhibition through interruption, is probably associated with the combination of consciously attending to sensory input and cognitive effort. Also, the task to perform an unwanted vocal gesture extremely slowly can be useful in order to break automaticity. From a theoretical point of view, these approaches of inhibition may be considered rewarding also for the management of behaviors such as paradoxical vocal cord movements and involuntary vocal tics. It should be emphasized, however, that the actual explanation to the described experiences as well as scientific evidence of their effect through controlled research studies is lacking.
Downloaded by [Washington University in St Louis] at 14:22 08 November 2015
Habit change
183
Decomposing complex behavior
The ‘each time–every time’ principle
To break down a complex behavior into small parts is an old and wide-spread approach in many kinds of voice training and is probably essential to break automatization. Feldenkrais (30) in his exercises for ‘awareness through movement’ uses the word differentiation to describe how a complex activity can be divided into different elements during training. Bunton (38) refers to a motor task study by Wightman and Lintern (39) which describes how a complex behavior can be decomposed through either segmentation, fractionation, or simplification. Segmentation means that a task is divided in smaller spatial and temporal subcomponents, which means e.g. in phonological training to train a sound in isolation before it is integrated in a syllable context. An equivalent in voice therapy could be the training of soft glottal onsets in vowel initiation and then at word-level before using them in connected speech. Fractionation means to decompose elements which appear simultaneously in natural speech. This could be to focus on respiration, phonation, and articulation independently in different phases. For example, respiratory muscle control for subglottal pressure modulation can be established without phonation, using unvoiced fricatives. In the same way, phonation exercises can be practiced initially without natural articulation but using certain physiologically appropriate phonemes depending on the goal. Simplification means, according to Wightman and Lintern (39), that certain aspects of a task are adjusted to make correct production easier. Many examples of such simplifications can be identified in voice therapy. It could be the use of a rhyme or speech material including many phonemes of a specific type, e.g. rounded vowels in order to favor a certain phonatory setting by the patient (40). Paradoxically enough, an exercise may not necessarily from an outside view look simplified when adjustments are made which are appropriate from a physiological or learning point of view. For example, a simplification could be to make use of a supine body position during the introduction of a breathing exercise, with the specific aim for the patient to focus on sensing her breathing movements. Another simplification of an exercise that from an outside view may look quite exotic could be to instruct the patient to make use of full body movements, like sweeping or rocking, to maintain relaxation at the laryngeal level during voicing, when muscle tension has been an established habit for the patient for many years. Quite soon in such practice progress, the relaxation can be maintained by the patient also without the movements.
A factor described to be of relevance for a response to become automatic in perceptual learning is the ‘each time–every time’ principle (12). This means that a new behavior should preferably be fired consistently, each and every time a stimulus is presented, in order to become stable in the face of distractors. Verdolini and Lee (12) describe how this principle is much easier to cater to when training skiing, dancing, or playing golf than in speech training. The explanation for this difference lies in the risk that the patient, in her spontaneous speech outside the therapy sessions, gets distracted by communicative factors, and falls back into old patterns and thus interrupts the process of establishing a new automatic behavior. In this respect, singing training differs profoundly from speech therapy, as singing production allows a greater potential of realizing the principle of ‘each time–every time’ as compared to speech. In intensive therapy approaches, such as the Lee Silverman Voice Treatment (41–43) and ‘Boot-Camp’ therapy (44), there is a great potential to pursue consistently the ‘each time–every time’ principle as well as the factor of repetition. Successive implementation of automaticity A last factor of importance that will be described is the successive implementation of automaticity. Through the SLP’s conscious and careful selection of exercises requiring a specific grade of attention or automaticity, I suggest that the SLP can give the patient an ideal ‘dosage’ of distraction in terms of cognitive load in different phases of the training. The general progression of this process goes from full attention to a specific behavior (a certain voice quality, a specific respiratory technique, or a postural detail), i.e. a total focus on how to speak, towards the goal of complete automaticity in behavior and thus a total focus on what to say. Here the SLP can make use of implementation exercises including ‘automatic speech’, ‘phrases in a set form’, ‘listing words’, ‘answer simple questions’, and ‘semispontaneous speech’ exercises. The use of automatic speech (days of the week, months of the year, reciting name and address) requires a minimum of cognitive load and thus minimal attention to aspects of content and communication and is therefore well suited for an initial phase of implementation. Automatic speech material can also preferably be combined with the detailed sensory attention described. In this phase the SLP can also choose to minimize external factors including eye contact, which may compete with the patient’s attention. By this choice of speech material and
Downloaded by [Washington University in St Louis] at 14:22 08 November 2015
18 4
J. Iwarsson
elimination of distractors, the SLP creates an implementation exercise with optimal probability of success in realizing the ‘each time–every time’ principle. Reading a text may need to wait, because the requirement of attention to decoding represents cognitive load in itself. When the new behavior is regulated and controlled voluntarily by the patient in automatic speech, exercises that require double focus can be introduced. Still, most of the patient’s attention may be directed towards sensory information and to controlling the desired behavior. Double focus can be practiced using phrases in a set form that are repeated with only a minor element of the patient’s own choice. Examples of exercises with phrases in a set form are ‘imaginary week’, which is the days of the week the choice of an activity for each day (‘Monday I will ride my bike; Tuesday I will read; Wednesday I will meet a friend’ and so on) or ‘looking through the window’ where the patient and the SLP are standing beside each other in front of a window, describing the view through a turn-taking repetition of the phrase ‘I see …’. Gradually, the SLP can move on to choose exercises that require more and more attention to content, which helps the patient to maintain the desired production goal despite a decreasing focus on the activity of production itself. Examples of such exercises would be ‘listing words’ within a certain category (e.g. flowers, fruits, or countries) or to ‘answer simple questions’ from the SLP like ‘Which day comes after Wednesday?’ or ‘What color has the grass?’ and then with increasing cognitive challenge. Semi-spontaneous speech induces more communicative factors than ‘automatic speech’, ‘phrases in a set form’, and ‘answer simple questions’. Subjects for semi-spontaneous speech vary with regard to their demands on automatization; neutral tasks, such as to narrate the story of a book or film, to tell how to make a pasta sauce, or to describe the way to the airport, may allow the patient to keep on maintaining the important double focus in this first step of introducing spontaneous speech. To give an opinion on an actual political issue or to describe a strained relation to a mother-in-law may have to wait. In all implementation exercises, and especially in ‘semispontaneous speech’, the risk of distraction from communicative factors is high, and the task of the SLP is therefore to ensure that the patient is able to sustain a double focus long enough to abide by the ‘each time–every time’ principle as much as possible. By preparing the patient beforehand to the fact that she will be interrupted in her speaking, the SLP can intercalate questions now and then (such as ‘How would you describe the sensation in your throat right
now?’ or ‘Does your breathing apparatus do what you want it to now?’), to guide the patient back to sensory and auditory attention during speech production. This can be a very effective element in habit change, since such questions prevent a process where the matter of content and communication grab the patient’s full attention at a too early stage. Learning through experiential processes is described as sensitive to modality and physical environment (14). This learning is stereotypical in the sense that it is not necessarily generalized from one context to another on its own. Generalization therefore requires specific training (4,13). This is in accordance with the experience that for the patient to stick to the new vocal behavior outside the voice therapy session is a distractor in itself, which can preferably be successively distributed and thoroughly planned by the SLP and patient working together. The last stage of implementation aims at stabilizing and fortifying the new habit, e.g. through changes in context and situations. In addition, this means that the patient can come under pressure from paying more attention to communication as a whole, requiring skills such as turn-taking in dialogue. Pressure can also come from distractors in terms of emotional engaging content while taking part in a discussion. When the new voice behavior is established, automatic and robust despite content, context, and situation, the work of the SLP is done and the patient should be self-reliant and ‘carried-over’. In summary, voice and speech behaviors are formed by exposure and repetition. Principles of motor learning seem highly relevant and promising for the area of speech and voice, but the application to functional voice disorders may differ from interventions for motor speech disorders. Especially, the challenge of replacing an old automatic behavior may require specific consideration. Some vocal behaviors can be regarded as habits. Strategies like cue-altering techniques, attention exercises, negative practice, and inhibition through interruption have been described and suggested as practical tools to promote habit change. In establishing new motor skills, the factors of repetition, cognitive activation, and decomposing complex behavior are important, and, finally, to automatize a new vocal behavior in everyday speech, the ‘each time–every time’ principle and successive implementation of automaticity have been described. From a learning theory perspective, to include strategies for automatization is an important part in facilitating the patient’s behavioral change in everyday speech. To facilitate behavioral learning and habit change in voice therapy has the potential to minimize therapy dropout and to affect patient compliance and treatment outcome.
Habit change
Acknowledgements This study was inspired by the essential work of Professor Katherine Verdolini Abbott at the University of Pittsburgh, who has been a pioneer in the application of motor learning and skill acquisition to the area of speech and voice. My appreciation also goes to Professor Ann-Christine Ohlsson at the University of Gothenburg, Sweden, for her long experience and creative development of clinical and preventive voice training.
Downloaded by [Washington University in St Louis] at 14:22 08 November 2015
Declaration of interest: The author reports no conflicts of interest.
15.
16. 17.
18.
19. 20.
References 1. Routsalainen JH, Sellman J, Lehto L, Jauhiainen M, Verbeek JH. Interventions for treating functional dysphonia in adults. Cochrane Database Syst Rev. 2007;(3): CD006373. 2. MacKenzie K, Millar A, Wilson JA, Sellars C, Deary IJ. Is voice therapy an effective treatment for dysphonia? A randomized controlled trial. BMJ. 2001;323:1–6. 3. Schmidt RA, Bjork RA. New conceptualizations of practice: common principles in three paradigms suggest new concepts for training. Psychol Sci. 1992;3:207–17. 4. Schmidt RA, Lee TD. Motor control and learning: a behavioural emphasis. 3rd ed. Champaign, IL: Human Kinetics; 2005. 5. Ferrand CT. Effects of practice with and without knowledge of results on jitter and shimmer levels in normally speaking women. J Voice. 1995;9:419–23. 6. Steinhauer K, Grayhack JP. The knowledge of results in performance and learning of a voice motor task. J Voice. 2000;14:137–45. 7. Knock TR, Ballard KJ, Robin DA, Schmidt RA. Influence of order of stimulus presentation on speech motor learning: a principled approach to treatment for apraxia of speech. Aphasiology. 2000;14:653–68. 8. Maas E, Barlow J, Robin D, Shapiro L. Treatment of sound errors in aphasia and apraxia of speech: effects of phonological complexity. Aphasiology. 2002;16:609–22. 9. Maas E, Robin D, Hula SNA, Freedman SE, Wulf G, Ballard KJ, et al. Principles of motor learning in treatment of motor speech disorders. Am J Speech Lang Pathol. 2008; 17:277–98. 10. Schulz GM, Sulc S, Leon S, Gilligan G. Speech motor learning in Parkinson disease. J Med Speech Lang Pathol. 2000;8:243–7. 11. Adams SG, Page AD, Jog M. Summary feedback schedules and speech motor learning in Parkinson’s disease. J Med Speech Lang Pathol. 2002;10:215–20. 12. Verdolini K, Lee T. Optimizing motor learning in speech interventions. In: Sapienza C, Casper J, editors. Vocal rehabilitation for medical speech language pathology. Austin, Texas: Pro-Ed; 2004. p. 403–46. 13. Bislick LP, Weir PC, Spencer K, Kendall D, Yorkston KM. Do principles of motor learning enhance retention and transfer of speech skills? A systematic review. Aphasiology. 2012;26:709–28. 14. Verdolini-Marston K, Balota DA. Role of elaborative and perceptual integrative processes in perceptual-motor
21.
22.
23.
24. 25.
26.
27.
28.
29.
30.
31.
32.
33.
185
performance. J Exp Psychol Learn Mem Cogn. 1994;20: 739–49. Schmidt RA. Motor control and learning. A behavioral emphasis. 2nd ed. Champaign, IL: Human Kinetics Publishers, Inc.; 1988. Lee TD, Swinnen SP, Serrien DJ. Cognitive effort and motor learning. QUEST. 1994;46:328–44. Bartholomew LK, Parcel GS, Kok G, Gottlieb NH, Fernández ME. Planning health promotion programs. An intervention mapping approach. 3rd ed. San Francisco, CA: Jossey-Bass, Wiley Imprint; 2011. Verplanken B, Arts H. Habit, attitude, and planes behavior: is habit an empty construct or an interesting case of goal-directed automaticity? European Rev Soc Psych. 1999;10:101–34. Epstein S. Integration of the cognitive and the psychodynamic unconscious. Am Psychol. 1994;49:709–24. Neely JH. Semantic priming and retrieval from lexical memory: roles of inhibitionless spreading activation and limitedcapacity attention. Journal of Experimental Psychology: General. 1977;106:226–54. Behrman A, Rutledge J, Hembree A, Sheridan S. Vocal hygiene education, voice production therapy and the role of patient adherence: a treatment effectiveness study in women with phonotrauma. J Speech Lang Hear Res. 2008;51:350–66. Chan RWK. Does the voice improve with vocal hygiene education? A study of some instrumental voice measurements in a group of kindergarten teachers. J Voice. 1994;8:279–91. Pasa G, Oates J, Dacakis G. The relative effectiveness of vocal hygiene training and vocal function exercises in preventing voice disorders in primary school teachers. Logoped Phoniatr Vocol. 2007;32:128–40. Wood W, Neal DT. A new look at habits and the habit–goal interface. Psychol Rev. 2007;114:843–63. Sobal J, Wansink B. Kitchenscapes, tablescapes, platescapes, and foodscapes: influence of microscale built environments on food intake. Environment & Behavior. 2007;39: 124–42. Rantala L,Vilkman E, Bloigu R. Voice changes during work – subjective complaints and objective measurements for female primary and secondary schoolteachers. J Voice. 2002;16:344–55. Södersten M, Ternström S, Bohman M. Loud speech in realistic environmental noise: phonetogram data, perceptual voice quality, subjective ratings, and gender differences in healthy speakers. J Voice. 2005;19:29–46. Lyberg Åhlander V. Voice use in teaching environments, speakers’ comfort [doctoral dissertation]. Department of Logopedics, Phoniatrics and Audiology, Clinical Sciences, Faculty of Medicine, Lunds University. Doctoral dissertation series, 2011:24. Ohlsson AC, Dotevall H, Gustavsson I, Hofling K, Wahle U, Åvall M, et al. Prevention and voice therapy. In: Third occupational voice symposium – optimizing and managing the voice in the workplace. London, 23–24 April 2013. Feldenkrais M. Medvetenhet genom rörelse. Trans. Hagelthorn M. Lund: BookLund förlag; 1999. [Original title: Awareness through movement; 1972]. Emerich KA. Nontraditional tools helpful in the treatment of certain types of voice disturbances. Curr Opin Otolaryngol Head Neck Surg. 2003;11:149–53. Buchanan PA, Ulrich BA. The Feldenkrais Method®: A dynamic approach to changing motor behavior. Res Q Exerc Sport. 2001;72:315–23. Biggs J, Tang C. Teaching for quality learning at university. 3rd ed. Glasgow, UK: McGraw Hill Society for Research into Higher Education & Open University Press, 2007.
Downloaded by [Washington University in St Louis] at 14:22 08 November 2015
186
J. Iwarsson
34. Bloodstein O. A handbook on stuttering. 5th ed. San Diego: Singular; 1995. 35. Van Riper C. The treatment of stuttering. Englewood Cliffs, NJ: Prentice-Hall; 1973. 36. Saltuklaroglu T, Kalinowski J, Dayalu VN, Stuart A, Rastatter MP. Voluntary stuttering suppresses true stuttering: a window on the speech perception-production link. Percept Psychophys. 2004;66:249–54. 37. Vertigan AE, Theodoros DG, Winkworth AL, Gibson PG. A comparison of two approaches to the treatment of chronic cough: perceptual, acoustic, and electroglottographic outcomes. J Voice. 2008;22:581–9. 38. Bunton K. Speech versus nonspeech: different tasks, different neural organization. Semin Speech Lang. 2008; 29:267–75. 39. Wightman DC, Lintern G. Part-task training for tracking and manual control. Hum Factors. 1985;27:267–83.
40. Titze I. Voice training and therapy with a semi-occluded vocal tract: rationale and scientific underpinnings. J Speech Lang Hear Res. 2006;49:448–59. 41. Fox C, Ebersbach G, Ramig L, Sapir S. LSVT LOUD and LSVT BIG: behavioral treatment programs for speech and body movement in Parkinson disease. Parkinsons Dis. 2012;2012:391946. 42. Sapir S, Ramig L, Fox C. Intensive voice treatment in Parkinson’s disease: Lee Silverman Voice Treatment (LSVT). Expert Reviews in Neurotherapeutics. 2011; 11;815–30. 43. Fox C, Morrison C, Ramig L, Sapir S. Current perspectives on the Lee Silverman Voice Treatment (LSVT). Am J Speech Lang Pathol. 2002;11:111–23. 44. Patel RR, Bless DM, Thibeault SL. Boot camp: a novel intensive approach to voice therapy. J Voice. 2011;25: 562–9.
ISSN: 1401-5439 (Print) 1651-2022 (Online) Journal homepage: http://www.tandfonline.com/loi/ilog20
Facilitating behavioral learning and habit change in voice therapy—theoretic premises and practical strategies Jenny Iwarsson To cite this article: Jenny Iwarsson (2015) Facilitating behavioral learning and habit change in voice therapy—theoretic premises and practical strategies, Logopedics Phoniatrics Vocology, 40:4, 179-186, DOI: 10.3109/14015439.2014.936498 To link to this article: http://dx.doi.org/10.3109/14015439.2014.936498
Published online: 23 Jul 2014.
Submit your article to this journal
Article views: 123
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ilog20 Download by: [Washington University in St Louis]
Date: 08 November 2015, At: 14:22
Logopedics Phoniatrics Vocology, 2015; 40: 179–186
Original article
Facilitating behavioral learning and habit change in voice therapy—theoretic premises and practical strategies
Downloaded by [Washington University in St Louis] at 14:22 08 November 2015
Jenny Iwarsson Audiologopedics, Department of Scandinavian studies and Linguistics, University of Copenhagen, Denmark
Abstract A typical goal of voice therapy is a behavioral change in the patient’s everyday speech. The SLP’s plan for voice therapy should therefore optimally include strategies for automatization. The aim of the present study was to identify and describe factors that promote behavioral learning and habit change in voice behavior and have the potential to affect patient compliance and thus therapy outcome. Research literature from the areas of motor and behavioral learning, habit formation, and habit change was consulted. Also, specific elements from personal experience of clinical voice therapy are described and discussed from a learning theory perspective. Nine factors that seem to be relevant to facilitate behavioral learning and habit change in voice therapy are presented, together with related practical strategies and theoretical underpinnings. These are: 1) Cue-altering; 2) Attention exercises; 3) Repetition; 4) Cognitive activation; 5) Negative practice; 6) Inhibition through interruption; 7) Decomposing complex behavior; 8) The ‘each time–every time’ principle; and 9) Successive implementation of automaticity. Key words: Behavioral learning, habit change, voice therapy
Background The most common treatment for functional dysphonia is behavioral voice therapy (1,2). For this and other diagnoses, among them transsexual voice, an important goal for intervention is that a new behavior is generalized and implemented in the patient’s spontaneous everyday communication. This carryover requirement should be a central aspect in planning of voice therapy programs, both when tailored to the individual patient and in strict therapy protocols aimed at groups of patients. Surprisingly little attention has been paid in the literature to practical tools or strategies which can be used to encourage stable long-term learning and generalization of new vocal behaviors. A common unstated assumption may be that the patient’s everyday speech will change simply by having achieved new skills. However, medical records for voice patients sometimes reveal the therapeutic challenge of a patient who is motivated, co-operative, and performing exercises impeccably in
therapy sessions, but not (yet) in spontaneous speech. This phenomenon—and who is responsible for it—is rarely addressed. Poor patient compliance or adherence may be a handy label, but a closer look into learning theory indicates that we as speech language pathologists (SLP) can have a greater role than we realize in eliciting patient adherence to behavioral change. Research in motor learning and skill acquisition has disclosed that particular strategies in training favor stable long-term learning more than others. For example, delayed feedback and feedback after only a few trials has been shown to be more effective for long-term learning than immediate feedback and feedback after every trial (3,4). As regards distribution of practice, it has been shown that a given number of sessions over a long period of time is more effective than massed practice, i.e. practice done for a short period of time (3,4). Most of these principles are based on research on limb movements, but some
Correspondence: Jenny Iwarsson, Audiologopædics, Department of Scandinavian studies and Linguistics, University of Copenhagen, Njalsgade 120, 2300 Copenhagen S, Denmark. Fax: 45-35 32 83 77. E-mail: [email protected] (Received 11 March 2014; accepted 13 June 2014) ISSN 1401-5439 print/ISSN 1651-2022 online © 2014 Informa UK, Ltd. DOI: 10.3109/14015439.2014.936498
Downloaded by [Washington University in St Louis] at 14:22 08 November 2015
180
J. Iwarsson
have been shown to be relevant also to learning in speech and voice (5–13). In a systematic review article by Bislick and colleagues (13), the authors conclude that the application of principles from motor learning to speech in terms of practice and feedback variables is promising and that continued investigation is warranted. In the application of motor learning theory to voice, it is important first to survey essential differences between various forms of speech and voice training and use. For example, speaking differs substantially from singing in many aspects, and normal voice function differs from abnormal. Most speech studies of the role of motor learning theory are carried out on patients with motor speech disorders (7-11). However, from a learning perspective, rehabilitation which focuses on relearning a lost skill or learning compensatory strategies differs from behavioral voice therapy for functional and organic voice disorders. A challenge for the SLP in the latter case is, in addition to teaching the patient a new skill, also to ensure that this new skill replaces an old, wellestablished automatic behavior. Aims and method of the study The present study is not a systematic literature review and contains no empirical data. The aim was to identify, describe, and discuss a list of factors that can promote a stable and automatized change in voice behavior of spontaneous speech. The method used can be described as a process of accumulated clinical reflections combined with a thorough but non-systematic literature study. My interest in the area was initiated by a slide presentation about skill acquisition in voice, given by Professor Katherine Verdolini at the PanEuropean Voice Conference in Regensburg in 1997. As a consequence of this, I consulted some early literature on motor control and learning (14–16). Beside the general aim to identify factors promoting vocal behavioral change, I wanted to find theoretic support for some specific therapeutic strategies that I have experienced as beneficial in clinical voice therapy, both for the automatization of patients’ new vocal behaviors and for the inhibition of inappropriate old ones. To do this, I continued to search research literature from the area of motor learning and skill acquisition, as well as literature on behavioral learning, habit formation, and habit change. Bibliographic databases used were Ovid MEDLINE, EMBASE, and PsychINFO. In the following, some basic principles of the speech process and the characteristics of habits will be described. Then I will present a list of nine factors relevant to behavioral learning and changing
voice behavior habits. These are: 1) Cue-altering; 2) Attention exercises; 3) Repetition; 4) Cognitive activation; 5) Negative practice; 6) Inhibition through interruption; 7) Decomposing complex behavior; 8) The ‘each time–every time’ principle; and 9) Successive implementation of automaticity.
The speech process and the characteristics of habits The time from stimulus (intention) to muscle activity response (movement) in the speech process is typically a couple of milliseconds, and several responses can be fired simultaneously in a quite stereotypic manner. Automatized muscle activation is the basis of various perceptuo-motor parameters ranging from voice quality and articulatory patterns to body language. The ability to speak without specifically attending to the process, established in early childhood, is a natural and important prerequisite for communication. It enables us to devote our full attention to cognitive functions in understanding and planning the content of the talk. However, the same muscles can also be activated in isolation and controlled as consciously intended actions. With focus on the goal to change an automatized voice and speech behavior it seems relevant to have a look at the nature of habits. The most prominent characteristic of a habit is that it occurs totally without any, or with a minimum amount of, awareness (17). Whether we think of the habit of drinking too much coffee, biting nails, or to sit with crossed legs, from a learning perspective a habit is defined as a learned sequence of actions that has become automatic as a response to a specific cue. To understand how a habit is established, we should remember that as an outset it is a functional and effective response to a given cue (18). But some habits unfortunately induce long-term negative side effects. This is apparent when we think of habits like using a hyperfunctional voice quality in order to be heard effectively, a near-sighted person who uses a posture with a forward head position or when, after a period of stress or anxiety, a person habitually continues using an upper costal or even clavicular breathing pattern. Habits, whether inefficient or purposive, seem established through implicit, procedural learning, often referred to as learning through experiential learning processes (12,14,19,20). Such learning is described to be formed by exposure and repetition, and it is slow to form and slow to change. This is fundamentally different from learning through rational processes, which is described to involve verbal, analytical, and associational operations and which are relatively quick to change (12,14,19,20).
Downloaded by [Washington University in St Louis] at 14:22 08 November 2015
Cue-altering A common part of voice therapy is education in voice ergonomics, where the patient is given information about vocal tract hygiene and voice conservation (21–23). Advice and information may incite explicit, rationally processed learning and have been shown to effectively influence intentions and attitudes but not necessarily behavior (18). A factor that, on the other hand, has been found to influence behavior and support habit change is so-called cue-altering techniques, which means that the cue firing the (negative) response is modified (24). Cue-altering in a weight-loss program, for example, could be to use small plates and cutlery in order to break the habit of serving and eating large portions of food (25). Equivalent to this in a vocal hygiene context could be making physical adjustments to better enable face to face communication, such as refurnishing the classroom, readjusting daily schedules and routines to include pauses for voice rest and liquid intake, altering auditive feedback or reinforcing one’s own voice, or dampening surrounding sound sources which might lead to increased vocal effort or hyperfunctional speaking behavior. Many of these strategies are well-known environmental adjustments in occupational voice care (26–28).
Attention exercises Conscious awareness is not in itself a prerequisite for skill acquisition. On the contrary, Verdolini and Lee (12) describe how most of our habits and behaviors are established implicitly, over time, and without verbal conscious awareness. However, awareness may still play a significant role in the inhibition of an old habit. In this process, explicit, rational learning appears to be important (20). As mentioned, a habit can be described as an activity performed with minimum awareness. Expressed the other way round, awareness and attention to details seem to be the automatized habit’s enemy. Attention is thereby a factor of relevance to behavioral change, which explains why exercises that may be categorized as ‘attention exercises’ seem to be a wise choice as one kind of ingredient in voice therapy. In attention exercises, the patient’s detailed attention to sensory information is central. One way to achieve this is through questions from the SLP that require the patient to discover, analyze, and describe a specific sensation or voice quality. The patient could be asked to pay attention to, and describe with his or her own words, a certain sound quality in the voice, first after listening to a recording and then in real-time production. The patient could also be instructed to choose a word for a sensation in the
Habit change
181
throat at a certain moment or during the production of a certain sound, or asked to describe details in the form or size of ‘openness’ in a cavity. The SLP should ensure calm circumstances and time enough for the patient to discover and analyze sensory experiences. This type of question has been inspired by the verbal instruction method practiced by AnneChristine Ohlsson (29), and similar approaches are described in the work of Moshe Feldenkrais and in the Alexander technique (30–32). One theoretical explanation for the experience of a positive contribution of attention exercises to behavioral learning may be that sensory information is central and critical in experiential learning processes (12). The SLP guides the patient to interpret her own internal feedback that is always available (16). Attention exercises can furthermore include having the patient experience the sensory difference between two opposed settings of an isolated aspect of the speech process, such as a tensed versus relaxed muscle activity, a fast versus slow speaking rate, or pressed versus flow phonation type. To let the patient or student experience the difference is a common and probably very old exercise in various types of voice training. The attention to the difference is extra helpful in cases where a habitual constant tension in e.g. the jaw or shoulders is perceived as a natural state for the patient, until a difference in sensation is experienced. Attention may, as mentioned, play an important role in breaking the condition of automatization in the speech process, and thus supports inhibition. Thus, it seems reasonable to assume that attention exercises constitute an element with the double capacity to break down existing habits and create good prerequisites for establishing new ones.
Repetition Repetition is a factor that has been shown to have a very strong impact on effective motor learning (4,13,16). Therefore, instructions and home training tasks that request the patient to repeat the same task several times should be rewarding in terms of behavioral learning. Furthermore, attention and repetition may be fruitfully combined through instructions where the patient is asked to make voluntary variations in parameters such as tempo, loudness, or pitch. This increases the patient’s control of the behavior in terms of consciously intended muscle activity. Cognitive activation The described approach of guiding the patient through questions includes a cognitive activation of
Downloaded by [Washington University in St Louis] at 14:22 08 November 2015
182
J. Iwarsson
the patient. Activation of the learner is a generally admitted goal in contemporary pedagogy (see e.g. 33), although the explanation to this counsel is not always made explicit. Analyzing one’s own voice and interpreting intrinsic feedback through answering questions can be presumed to activate the working memory of the patient, which may have the impact to accelerate and stabilize learning in voice therapy. This specific hypothesis has not been confirmed through the literature, but the activation is closely related to a phenomenon described in motor learning literature, called cognitive effort. It means that the establishment of information as long-term learning is enhanced when the patient is introduced to some difficulties, has to struggle a bit on her own, build her own hypotheses, or meet cognitive challenges, e.g. by retrieving information to answer a question (3,16). Thus introducing a decision-making activity or requiring a patient to approach a task by developing a strategy or plan of action is probably far more effective for long-term learning than e.g. passively listening to an expert performing the skill (16). The role of cognitive effort may also be involved in the finding that delayed and low-frequency feedback during training are more effective for long-term learning than immediate and high-frequency feedback, even though the latter strategy improves the immediate performance (4,13). This contradictory effect on long- and short-term learning of concurrent feedback, which is only revealed by effect studies including retention measures, therefore suggests that the SLP gives a restricted amount of feedback in order to allow the patient’s own analysis and cognitive activation. Negative practice Negative practice means that the patient is instructed to produce an unwanted behavior or component of voice or speech on purpose. We know this approach from voluntary stuttering where the effect of producing stuttering by will in suppressing true stuttering is undeniable (34–36). The underlying mechanism of this phenomenon is not completely understood, but it has been suggested to be related to a perception–production link, where a person’s own speech may prime the auditory cortex, possibly helping to evoke patterns of cortical activation and inhibition consistent with fluent speech production, as opposed to the patterns the brain nerves of the person who stutter habitually evoke (36). My personal experience from speech therapy for people who stutter has encouraged me to use the element of negative practice also in voice therapy, and the approach has often shown a positive and immediate
behavioral change. This can take place, for example, after the patient has been guided to identify a vocal fry (or hard glottal attacks, or excessive glottal hyperfunction). The SLP may in a playful and experimental mood ask the patient to produce the specific vocal feature on purpose, first isolated and then in a natural phrase. Another application can be to assume a certain body posture or tension that constitutes a frequent habit. An empathetic and confident atmosphere is crucial here, because the negative practice can sometimes be a sensitive task for the patient. To produce an unwanted sound or behavioral component on purpose seems to add to the patient’s ability to control voluntarily that particular behavior, not only its initiation but paradoxically also the inhibition of it. Inhibition through interruption Many behavioral researchers describe that a promising strategy for habit change is to combine learning and performing new goal-consistent patterns of response with effortful inhibition (17,24). Inhibition means a mental process that blocks, restricts, prevents, or weakens a behavior or impulse. In voice therapy, specific focus on inhibition has not been traditionally described, but clinical experience and published documentation imply that it can be rewarding, e.g. in cases of unconscious and repetitive habits such as in habitual throat-clearing (37). Here the patient can be instructed to interrupt this activity in spontaneous speech, e.g. on a given hand-sign from the SLP. The interruption should optimally take place right before the behavior is realized and followed by immediate questions about details in sensory information at that particular moment. By introducing such a time gap between stimulus and response, the habit is concretely prevented and prerequisites for replacement with an alternative behavior are promising (such as a soft humming or sinking of saliva) (20). The inhibitory effect of subsequent questions to the patient regarding details of sensory information, both in negative practice and in inhibition through interruption, is probably associated with the combination of consciously attending to sensory input and cognitive effort. Also, the task to perform an unwanted vocal gesture extremely slowly can be useful in order to break automaticity. From a theoretical point of view, these approaches of inhibition may be considered rewarding also for the management of behaviors such as paradoxical vocal cord movements and involuntary vocal tics. It should be emphasized, however, that the actual explanation to the described experiences as well as scientific evidence of their effect through controlled research studies is lacking.
Downloaded by [Washington University in St Louis] at 14:22 08 November 2015
Habit change
183
Decomposing complex behavior
The ‘each time–every time’ principle
To break down a complex behavior into small parts is an old and wide-spread approach in many kinds of voice training and is probably essential to break automatization. Feldenkrais (30) in his exercises for ‘awareness through movement’ uses the word differentiation to describe how a complex activity can be divided into different elements during training. Bunton (38) refers to a motor task study by Wightman and Lintern (39) which describes how a complex behavior can be decomposed through either segmentation, fractionation, or simplification. Segmentation means that a task is divided in smaller spatial and temporal subcomponents, which means e.g. in phonological training to train a sound in isolation before it is integrated in a syllable context. An equivalent in voice therapy could be the training of soft glottal onsets in vowel initiation and then at word-level before using them in connected speech. Fractionation means to decompose elements which appear simultaneously in natural speech. This could be to focus on respiration, phonation, and articulation independently in different phases. For example, respiratory muscle control for subglottal pressure modulation can be established without phonation, using unvoiced fricatives. In the same way, phonation exercises can be practiced initially without natural articulation but using certain physiologically appropriate phonemes depending on the goal. Simplification means, according to Wightman and Lintern (39), that certain aspects of a task are adjusted to make correct production easier. Many examples of such simplifications can be identified in voice therapy. It could be the use of a rhyme or speech material including many phonemes of a specific type, e.g. rounded vowels in order to favor a certain phonatory setting by the patient (40). Paradoxically enough, an exercise may not necessarily from an outside view look simplified when adjustments are made which are appropriate from a physiological or learning point of view. For example, a simplification could be to make use of a supine body position during the introduction of a breathing exercise, with the specific aim for the patient to focus on sensing her breathing movements. Another simplification of an exercise that from an outside view may look quite exotic could be to instruct the patient to make use of full body movements, like sweeping or rocking, to maintain relaxation at the laryngeal level during voicing, when muscle tension has been an established habit for the patient for many years. Quite soon in such practice progress, the relaxation can be maintained by the patient also without the movements.
A factor described to be of relevance for a response to become automatic in perceptual learning is the ‘each time–every time’ principle (12). This means that a new behavior should preferably be fired consistently, each and every time a stimulus is presented, in order to become stable in the face of distractors. Verdolini and Lee (12) describe how this principle is much easier to cater to when training skiing, dancing, or playing golf than in speech training. The explanation for this difference lies in the risk that the patient, in her spontaneous speech outside the therapy sessions, gets distracted by communicative factors, and falls back into old patterns and thus interrupts the process of establishing a new automatic behavior. In this respect, singing training differs profoundly from speech therapy, as singing production allows a greater potential of realizing the principle of ‘each time–every time’ as compared to speech. In intensive therapy approaches, such as the Lee Silverman Voice Treatment (41–43) and ‘Boot-Camp’ therapy (44), there is a great potential to pursue consistently the ‘each time–every time’ principle as well as the factor of repetition. Successive implementation of automaticity A last factor of importance that will be described is the successive implementation of automaticity. Through the SLP’s conscious and careful selection of exercises requiring a specific grade of attention or automaticity, I suggest that the SLP can give the patient an ideal ‘dosage’ of distraction in terms of cognitive load in different phases of the training. The general progression of this process goes from full attention to a specific behavior (a certain voice quality, a specific respiratory technique, or a postural detail), i.e. a total focus on how to speak, towards the goal of complete automaticity in behavior and thus a total focus on what to say. Here the SLP can make use of implementation exercises including ‘automatic speech’, ‘phrases in a set form’, ‘listing words’, ‘answer simple questions’, and ‘semispontaneous speech’ exercises. The use of automatic speech (days of the week, months of the year, reciting name and address) requires a minimum of cognitive load and thus minimal attention to aspects of content and communication and is therefore well suited for an initial phase of implementation. Automatic speech material can also preferably be combined with the detailed sensory attention described. In this phase the SLP can also choose to minimize external factors including eye contact, which may compete with the patient’s attention. By this choice of speech material and
Downloaded by [Washington University in St Louis] at 14:22 08 November 2015
18 4
J. Iwarsson
elimination of distractors, the SLP creates an implementation exercise with optimal probability of success in realizing the ‘each time–every time’ principle. Reading a text may need to wait, because the requirement of attention to decoding represents cognitive load in itself. When the new behavior is regulated and controlled voluntarily by the patient in automatic speech, exercises that require double focus can be introduced. Still, most of the patient’s attention may be directed towards sensory information and to controlling the desired behavior. Double focus can be practiced using phrases in a set form that are repeated with only a minor element of the patient’s own choice. Examples of exercises with phrases in a set form are ‘imaginary week’, which is the days of the week the choice of an activity for each day (‘Monday I will ride my bike; Tuesday I will read; Wednesday I will meet a friend’ and so on) or ‘looking through the window’ where the patient and the SLP are standing beside each other in front of a window, describing the view through a turn-taking repetition of the phrase ‘I see …’. Gradually, the SLP can move on to choose exercises that require more and more attention to content, which helps the patient to maintain the desired production goal despite a decreasing focus on the activity of production itself. Examples of such exercises would be ‘listing words’ within a certain category (e.g. flowers, fruits, or countries) or to ‘answer simple questions’ from the SLP like ‘Which day comes after Wednesday?’ or ‘What color has the grass?’ and then with increasing cognitive challenge. Semi-spontaneous speech induces more communicative factors than ‘automatic speech’, ‘phrases in a set form’, and ‘answer simple questions’. Subjects for semi-spontaneous speech vary with regard to their demands on automatization; neutral tasks, such as to narrate the story of a book or film, to tell how to make a pasta sauce, or to describe the way to the airport, may allow the patient to keep on maintaining the important double focus in this first step of introducing spontaneous speech. To give an opinion on an actual political issue or to describe a strained relation to a mother-in-law may have to wait. In all implementation exercises, and especially in ‘semispontaneous speech’, the risk of distraction from communicative factors is high, and the task of the SLP is therefore to ensure that the patient is able to sustain a double focus long enough to abide by the ‘each time–every time’ principle as much as possible. By preparing the patient beforehand to the fact that she will be interrupted in her speaking, the SLP can intercalate questions now and then (such as ‘How would you describe the sensation in your throat right
now?’ or ‘Does your breathing apparatus do what you want it to now?’), to guide the patient back to sensory and auditory attention during speech production. This can be a very effective element in habit change, since such questions prevent a process where the matter of content and communication grab the patient’s full attention at a too early stage. Learning through experiential processes is described as sensitive to modality and physical environment (14). This learning is stereotypical in the sense that it is not necessarily generalized from one context to another on its own. Generalization therefore requires specific training (4,13). This is in accordance with the experience that for the patient to stick to the new vocal behavior outside the voice therapy session is a distractor in itself, which can preferably be successively distributed and thoroughly planned by the SLP and patient working together. The last stage of implementation aims at stabilizing and fortifying the new habit, e.g. through changes in context and situations. In addition, this means that the patient can come under pressure from paying more attention to communication as a whole, requiring skills such as turn-taking in dialogue. Pressure can also come from distractors in terms of emotional engaging content while taking part in a discussion. When the new voice behavior is established, automatic and robust despite content, context, and situation, the work of the SLP is done and the patient should be self-reliant and ‘carried-over’. In summary, voice and speech behaviors are formed by exposure and repetition. Principles of motor learning seem highly relevant and promising for the area of speech and voice, but the application to functional voice disorders may differ from interventions for motor speech disorders. Especially, the challenge of replacing an old automatic behavior may require specific consideration. Some vocal behaviors can be regarded as habits. Strategies like cue-altering techniques, attention exercises, negative practice, and inhibition through interruption have been described and suggested as practical tools to promote habit change. In establishing new motor skills, the factors of repetition, cognitive activation, and decomposing complex behavior are important, and, finally, to automatize a new vocal behavior in everyday speech, the ‘each time–every time’ principle and successive implementation of automaticity have been described. From a learning theory perspective, to include strategies for automatization is an important part in facilitating the patient’s behavioral change in everyday speech. To facilitate behavioral learning and habit change in voice therapy has the potential to minimize therapy dropout and to affect patient compliance and treatment outcome.
Habit change
Acknowledgements This study was inspired by the essential work of Professor Katherine Verdolini Abbott at the University of Pittsburgh, who has been a pioneer in the application of motor learning and skill acquisition to the area of speech and voice. My appreciation also goes to Professor Ann-Christine Ohlsson at the University of Gothenburg, Sweden, for her long experience and creative development of clinical and preventive voice training.
Downloaded by [Washington University in St Louis] at 14:22 08 November 2015
Declaration of interest: The author reports no conflicts of interest.
15.
16. 17.
18.
19. 20.
References 1. Routsalainen JH, Sellman J, Lehto L, Jauhiainen M, Verbeek JH. Interventions for treating functional dysphonia in adults. Cochrane Database Syst Rev. 2007;(3): CD006373. 2. MacKenzie K, Millar A, Wilson JA, Sellars C, Deary IJ. Is voice therapy an effective treatment for dysphonia? A randomized controlled trial. BMJ. 2001;323:1–6. 3. Schmidt RA, Bjork RA. New conceptualizations of practice: common principles in three paradigms suggest new concepts for training. Psychol Sci. 1992;3:207–17. 4. Schmidt RA, Lee TD. Motor control and learning: a behavioural emphasis. 3rd ed. Champaign, IL: Human Kinetics; 2005. 5. Ferrand CT. Effects of practice with and without knowledge of results on jitter and shimmer levels in normally speaking women. J Voice. 1995;9:419–23. 6. Steinhauer K, Grayhack JP. The knowledge of results in performance and learning of a voice motor task. J Voice. 2000;14:137–45. 7. Knock TR, Ballard KJ, Robin DA, Schmidt RA. Influence of order of stimulus presentation on speech motor learning: a principled approach to treatment for apraxia of speech. Aphasiology. 2000;14:653–68. 8. Maas E, Barlow J, Robin D, Shapiro L. Treatment of sound errors in aphasia and apraxia of speech: effects of phonological complexity. Aphasiology. 2002;16:609–22. 9. Maas E, Robin D, Hula SNA, Freedman SE, Wulf G, Ballard KJ, et al. Principles of motor learning in treatment of motor speech disorders. Am J Speech Lang Pathol. 2008; 17:277–98. 10. Schulz GM, Sulc S, Leon S, Gilligan G. Speech motor learning in Parkinson disease. J Med Speech Lang Pathol. 2000;8:243–7. 11. Adams SG, Page AD, Jog M. Summary feedback schedules and speech motor learning in Parkinson’s disease. J Med Speech Lang Pathol. 2002;10:215–20. 12. Verdolini K, Lee T. Optimizing motor learning in speech interventions. In: Sapienza C, Casper J, editors. Vocal rehabilitation for medical speech language pathology. Austin, Texas: Pro-Ed; 2004. p. 403–46. 13. Bislick LP, Weir PC, Spencer K, Kendall D, Yorkston KM. Do principles of motor learning enhance retention and transfer of speech skills? A systematic review. Aphasiology. 2012;26:709–28. 14. Verdolini-Marston K, Balota DA. Role of elaborative and perceptual integrative processes in perceptual-motor
21.
22.
23.
24. 25.
26.
27.
28.
29.
30.
31.
32.
33.
185
performance. J Exp Psychol Learn Mem Cogn. 1994;20: 739–49. Schmidt RA. Motor control and learning. A behavioral emphasis. 2nd ed. Champaign, IL: Human Kinetics Publishers, Inc.; 1988. Lee TD, Swinnen SP, Serrien DJ. Cognitive effort and motor learning. QUEST. 1994;46:328–44. Bartholomew LK, Parcel GS, Kok G, Gottlieb NH, Fernández ME. Planning health promotion programs. An intervention mapping approach. 3rd ed. San Francisco, CA: Jossey-Bass, Wiley Imprint; 2011. Verplanken B, Arts H. Habit, attitude, and planes behavior: is habit an empty construct or an interesting case of goal-directed automaticity? European Rev Soc Psych. 1999;10:101–34. Epstein S. Integration of the cognitive and the psychodynamic unconscious. Am Psychol. 1994;49:709–24. Neely JH. Semantic priming and retrieval from lexical memory: roles of inhibitionless spreading activation and limitedcapacity attention. Journal of Experimental Psychology: General. 1977;106:226–54. Behrman A, Rutledge J, Hembree A, Sheridan S. Vocal hygiene education, voice production therapy and the role of patient adherence: a treatment effectiveness study in women with phonotrauma. J Speech Lang Hear Res. 2008;51:350–66. Chan RWK. Does the voice improve with vocal hygiene education? A study of some instrumental voice measurements in a group of kindergarten teachers. J Voice. 1994;8:279–91. Pasa G, Oates J, Dacakis G. The relative effectiveness of vocal hygiene training and vocal function exercises in preventing voice disorders in primary school teachers. Logoped Phoniatr Vocol. 2007;32:128–40. Wood W, Neal DT. A new look at habits and the habit–goal interface. Psychol Rev. 2007;114:843–63. Sobal J, Wansink B. Kitchenscapes, tablescapes, platescapes, and foodscapes: influence of microscale built environments on food intake. Environment & Behavior. 2007;39: 124–42. Rantala L,Vilkman E, Bloigu R. Voice changes during work – subjective complaints and objective measurements for female primary and secondary schoolteachers. J Voice. 2002;16:344–55. Södersten M, Ternström S, Bohman M. Loud speech in realistic environmental noise: phonetogram data, perceptual voice quality, subjective ratings, and gender differences in healthy speakers. J Voice. 2005;19:29–46. Lyberg Åhlander V. Voice use in teaching environments, speakers’ comfort [doctoral dissertation]. Department of Logopedics, Phoniatrics and Audiology, Clinical Sciences, Faculty of Medicine, Lunds University. Doctoral dissertation series, 2011:24. Ohlsson AC, Dotevall H, Gustavsson I, Hofling K, Wahle U, Åvall M, et al. Prevention and voice therapy. In: Third occupational voice symposium – optimizing and managing the voice in the workplace. London, 23–24 April 2013. Feldenkrais M. Medvetenhet genom rörelse. Trans. Hagelthorn M. Lund: BookLund förlag; 1999. [Original title: Awareness through movement; 1972]. Emerich KA. Nontraditional tools helpful in the treatment of certain types of voice disturbances. Curr Opin Otolaryngol Head Neck Surg. 2003;11:149–53. Buchanan PA, Ulrich BA. The Feldenkrais Method®: A dynamic approach to changing motor behavior. Res Q Exerc Sport. 2001;72:315–23. Biggs J, Tang C. Teaching for quality learning at university. 3rd ed. Glasgow, UK: McGraw Hill Society for Research into Higher Education & Open University Press, 2007.
Downloaded by [Washington University in St Louis] at 14:22 08 November 2015
186
J. Iwarsson
34. Bloodstein O. A handbook on stuttering. 5th ed. San Diego: Singular; 1995. 35. Van Riper C. The treatment of stuttering. Englewood Cliffs, NJ: Prentice-Hall; 1973. 36. Saltuklaroglu T, Kalinowski J, Dayalu VN, Stuart A, Rastatter MP. Voluntary stuttering suppresses true stuttering: a window on the speech perception-production link. Percept Psychophys. 2004;66:249–54. 37. Vertigan AE, Theodoros DG, Winkworth AL, Gibson PG. A comparison of two approaches to the treatment of chronic cough: perceptual, acoustic, and electroglottographic outcomes. J Voice. 2008;22:581–9. 38. Bunton K. Speech versus nonspeech: different tasks, different neural organization. Semin Speech Lang. 2008; 29:267–75. 39. Wightman DC, Lintern G. Part-task training for tracking and manual control. Hum Factors. 1985;27:267–83.
40. Titze I. Voice training and therapy with a semi-occluded vocal tract: rationale and scientific underpinnings. J Speech Lang Hear Res. 2006;49:448–59. 41. Fox C, Ebersbach G, Ramig L, Sapir S. LSVT LOUD and LSVT BIG: behavioral treatment programs for speech and body movement in Parkinson disease. Parkinsons Dis. 2012;2012:391946. 42. Sapir S, Ramig L, Fox C. Intensive voice treatment in Parkinson’s disease: Lee Silverman Voice Treatment (LSVT). Expert Reviews in Neurotherapeutics. 2011; 11;815–30. 43. Fox C, Morrison C, Ramig L, Sapir S. Current perspectives on the Lee Silverman Voice Treatment (LSVT). Am J Speech Lang Pathol. 2002;11:111–23. 44. Patel RR, Bless DM, Thibeault SL. Boot camp: a novel intensive approach to voice therapy. J Voice. 2011;25: 562–9.
