Communicative and Situational Preparedness and Agility in Voice Therapy

Voice speech-language pathologists (SLPs) develop a routine for professional communication, a “spiel” as described by Helou et al[1] in this issue; yet, they adjust to turns in communication and situational changes skillfully. The roots of communicative preparedness are laid in student observations of various clinicians, academic and clinical coursework, clinical externships and fellowship, and continuing education. The agility improves with time and growing skills but could be fostered in the future by formalizing training of meta-therapy skills for voice therapy as advocated by Helou et al.[1] On top of that, 2020 required from patients and SLPs alike an unprecedented level of adjustment and situational flexibility and preparedness due to the COVID-19 pandemic. SLPs were able to swiftly change course delivering voice therapy, when supported by their administration. Patients who were technologically equipped and open to experience were at an advantage.

The following series of articles aim to offer in one issue original, educational, and forward-looking content on meta-therapy of voice therapy[1] and related concepts such as self-efficacy to improve treatment adherence,[2] which in combination with functional voice approaches presented here,[3] [4] serves as a layered roadmap for successful voice therapy. Moreover, mobile technology and telepractice can be effectively integrated to support adherence[2] and in turn treatment goals.[4] The issue also includes practical tips for effective telepractice with both pediatric[5] and adult populations.[4] [6] Finally, the contribution by Knickerbocker et al[7] draws attention to vocal health risks and communicative challenges for SLPs involved in telepractice.

Case studies supplement many of the articles, with examples describing successes, challenges, and also troubleshooting. The articles by Helou et al[1] and Gartner-Schmidt and Gillespie[3] also include a plethora of clinician language and analogies, making the volume attractive for students, novice voice clinicians, or clinicians who want to add voice therapy to their portfolio. While many barriers and limitations of telepractice are addressed, telepractice can take many forms and a variety of benefits are highlighted that outweigh the limitations.

The issue begins with an updated articulation of the meta-therapy conceptual framework for vocal rehabilitation[1] by drawing parallels to the rehabilitation treatment specification system.[8] [9] The article focuses on clinician and patient factors that likely make up the positive effects of meta-therapy. In short, clinician dialogue contains verbal cues and aims to modify, for example, patient's knowledge, beliefs, and attitudes about the patient's role in therapy, self-efficacy, and vocal identity, making the patient an active participant. Van Leer's[2] article elaborates on the concepts of self-efficacy and goal commitment, which are central in Social Cognitive Theory,[10] in relation to the common challenge of treatment adherence in voice therapy. The article ends with case scenarios that offer practical tips to common adherence problems so that clinicians can offer client-centered solutions.

Two articles illustrate how voice therapy can be structured and implemented in a manner that does justice to the goal of functional voice approaches. Gartner-Schmidt and Gillespie[3] illustrate conversation training therapy (CTT), where patient-driven spontaneous conversation is front and center from the outset, which is in contrast to how most readers probably learned voice therapy. In CTT, the clinician assumes the role of a guide for experiential learning and asks “nuanced questions” in conversation. To meet functional needs, both Gartner-Schmidt and Gillespie[3] as well as Grillo[4] highlight that each patient should have a versatile voice depending on situations and communication partners. Grillo's approach is also client centered and illustrates how telepractice and integration of app-based voice assessment and home practice monitoring support individualized goals and quick generalization of exercises. Thus, functional voice approaches intersect with meta-therapy concepts and self-efficacy to support ownership of one's voice.

Telepractice in speech-language pathology and voice therapy is not new but became mainstream overnight and is likely here to stay. The articles focusing on telepractice offer a long-term view and the need to minimize barriers and optimize this delivery mode. Becker and Gillespie[6] give us insight into a voice clinic operating in pandemic times with best practices for providing care over telepractice with a specific focus on voice disorder diagnosis and therapy. They take us on a history tour and overview of the existing research on efficacy of telepractice.[5] The current ASHA definition of telepractice can be found in their article as well as updated ASHA guidance on starting voice therapy prior to laryngoscopy. A model for virtual multidisciplinary clinics and medical record documentation provides practical information.

Grillo[4] introduces a feasible and billable asynchronous voice evaluation protocol using a smartphone app for a 5-day “landscape” view of vocal function, which aligns with the trend to research and establish ambulatory clinical voice assessment to better serve patients. Generalization activities can also be facilitated and monitored by the app, which is also addressed by van Leer.[2] The contributions show the range of telepractice components including synchronous; asynchronous; monitored home practice per email, web, or app; offline upload and download of voice samples; and app-assisted voice assessment and adherence support. Kelchner et al[5] complement the articles focusing on adults by offering their expertise for pediatric telepractice, which is feasible and effective.

While teleconferencing is naturally limiting communicative content, the articles show a path to effective communication caring for the clinician's professional voice (literally and figuratively, see the article by Knickerbocker et al).[7] In times of telepractice, Knickerbocker et al[7] remind us that SLP's voice use in telecommunication clinical environments can be compared with that of call center workers with parallels in risk for vocal health. The article outlines prevention strategies tailored for telepractice using two injury prevention frameworks.[11] [12] [13] The authors essentially make the point that media training can optimize the online clinical environment and communication style and in turn promote healthy voicing, which is especially important for those who are not yet comfortable with telepractice.

Acceptance of telepractice and confidence levels are on the rise among patients, caregivers, and clinicians. As pointed out by the authors, the delivery mode is an opportunity to reach medically underserved populations, make specialty care broadly available including pediatric and adult voice care, address clinician shortages, and counteract national health disparities, possibly providing access to technology through partnerships.[5] [6] Notably, Kelchner et al[5] remark that the home environment created a relaxed atmosphere for children. Furthermore, parent engagement improved compared with in-person services while lifting some barriers for families to follow through with therapy. The ecologically valid generalization of newly trained voices can be tremendously facilitated by virtual or mobile technology[4] [5] [7] and also counteract attrition.[2] [6] The take-home message is that telepractice is more an opportunity than a burden and has enormous potential beyond the pandemic to support excellence in care. In conjunction with the articles under the broad umbrella for voice therapy and functional voice approaches, we hope that readers feel empowered and inspired.

Publication History

Article published online:
17 February 2021

• References

• 1 Helou LB, Gartner-Schmidt JL, Hapner ER, Schneider SL, Van Stan JH. Mapping meta-therapy in voice interventions onto the rehabilitation treatment specification system. Semin Speech Lang 2021; 42 (01) 5-18
• 2 van Leer E. Enhancing voice therapy adherence via social-cognitive strategies: a tutorial. Semin Speech Lang 2021; 42 (01) 19-31
• 3 Gartner-Schmidt JL, Gillespie AI. Conversation training therapy (CTT): let's talk it through. Semin Speech Lang 2021; 42 (01) 32-40
• 4 Grillo EU. Functional voice assessment and therapy methods supported by telepractice, VoiceEvalU8, and Estill Voice Training. Semin Speech Lang 2021; 42 (01) 41-53
• 5 Kelchner LN, Fredeking JC, Zacharias SC. Using telepractice to deliver pediatric voice care in a changing world: breaking down challenges and learning from successes. Semin Speech Lang 2021; 42 (01) 54-63
• 6 Becker DR, Gillespie AI. In the Zoom where it happened: telepractice and the voice clinic in 2020. Semin Speech Lang 2021; 42 (01) 64-72
• 7 Knickerbocker K, Bryan C, Ziegler A. Phonogenic voice problems among speech-language pathologists in telepractice: an overview and recommendations. Semin Speech Lang 2021; 42 (01) 73-84
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• 11 Haddon Jr W. A logical framework for categorizing highway safety phenomena and activity. J Trauma 1972; 12 (03) 193-207
• 12 Haddon Jr W. Advances in the epidemiology of injuries as a basis for public policy. Public Health Rep 1980; 95 (05) 411-421
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