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Voice disorders associated with hyperfunction 123

versy as to whether effective management of hyperfunctionally related

voice problems requires approaches such as affective counselling or
psychotherapy. It is widely accepted that a therapeutic relationship charac-
terized by empathy, active listening, and encouragement on the part of the
clinician is associated with effective intervention (Rollin, 1987; Wilson,
1987; Aronson, 1990; Stemple et al., 1995a), but whether or not successful
intervention requires a psychological approach is not clear. Research
evidence which demonstrates the efficacy of counselling and
psychotherapy for clients with hyperfunctional voice disorders is scarce
(see for example, Mosby, 1970, 1972) and the majority of authors focus on
voice therapy techniques rather than psychological interventions in their
recommendations for management of clients with these voice disorders
(e.g. Boone and McFarlane, 1994; Stemple et al., 1995a; Colton and Casper,
1996). Nevertheless, clinicians are advised to be alert to the possibility that
personality characteristics, emotional reactions to life stressors, dysfunc-
tional interpersonal relationships and emotional disturbances may prevent
the client from being able to change their vocal behaviours (Brodnitz, 1981;
Rollin, 1987; Roy et al., 1997a). This may occur, for example, when a child’s
vocal hyperfunction is a response to disturbed family relationships (Wilson,
1987; Andrews, 1991; Morrison and Rammage, 1994). In such cases, the
clinician will need to address the psychological contributors underlying
vocal hyperfunction and referral to mental health professionals may be
required. A more extensive discussion of the role of the psychological
approach to voice therapy is provided in Chapter 8 of this book.

Reduction or elimination of specific hyperfunctional vocal

A traditional intervention approach for voice disorders related to vocal
hyperfunction has been to employ a behaviour modification programme
to eliminate specific hyperfunctional behaviours such as yelling, loud
talking and speaking with hard glottal attack. Such programmes typically
involve identification of hyperfunctional behaviours and the situations in
which those behaviours occur, educating the client about the rationale for
reduction of hyperfunction, teaching the client to recognize when they are
using hyperfunctional voicing, collecting baseline data on the frequency of
each behaviour, self-monitoring and regular charting or graphing of the
incidence of hyperfunctional behaviours, and providing positive reinforce-
ment or rewards for reductions in those behaviours. Examples of such
behavioural programmes include Boone’s ‘Voice Program for Children’
(Boone, 1993), Johnson’s ‘Vocal Abuse Reduction Program’ (Johnson,
1985a) and Wilson’s ‘10-step Outline for Voice Abuse’ (Wilson, 1987).