The Role of Self-Regulation in Voice Therapy

*Lisa A. Vinney and *,†Lyn S. Turkstra, *yMadison, Wisconsin

Summary: Self-regulation (SR) is the ability to voluntarily control one’s thinking and behavior and is a core construct
in research on learning and behavior. SR plays a significant role in mastering and generalizing new skills, including
skills such as those taught in voice therapy. The ability to self-regulate thoughts and behaviors varies widely across
adults, changes in response to factors such as the cognitive load of the task, and predicts the likelihood of pursuing goals
and maintaining behavior change over time. We propose that self-regulatory capacity should be considered both in de-
termining candidacy for voice therapy and also in treatment planning. Thus, the goals of this article are to (1) introduce
concepts and models of SR; (2) apply these concepts to voice therapy from a motor learning framework; (3) discuss
considerations regarding the effects of SR failure on short- and long-term outcomes; and (4) suggest strategies to im-
prove SR and better facilitate vocal behavior change.
Key Words: Voice therapy–Motor learning–Self-regulation–Self-regulatory depletion–Self-regulatory repletion–
Implementation intentions.

INTRODUCTION ‘‘resource’’ that is limited is thought to be working memory

Voice treatment involves physical adjustments of the respira-
tory, laryngeal, and supralaryngeal musculature to achieve
changes in vocal quality, pitch, and/or loudness.1–7 The basic
premise underlying voice treatment is that individuals with
voice disorders are engaging in inefficient phonatory
behaviors that must be altered. Central to the concepts to be
discussed in this article, it has been speculated that these
inefficient vocal behaviors are learned and produced with
little if any awareness.8 Thus, voice therapy requires patients
to devote attention and effort to changing behaviors that were
not previously under conscious control. That is, therapy re-
quires self-regulation (SR).
SR refers to effort exerted by the self to modify or con-
trol thoughts, emotions, and behavior.9 SR also is some-
times referred to as self-control, and in the cognitive
psychology and neuropsychology literatures, it is viewed
as one aspect of executive functions.10 SR has been de-
scribed using a muscle metaphor, with strength in this
case referring to the ‘‘limited and depletable . internal re-
sources available to inhibit, override, or alter responses that
may arise as a result of physiological processes, habit,
learning, or the press of the situation.’’11(pp. 86–87) Following
this metaphor, each person is thought to have a certain self-
regulatory capacity. This capacity can be ‘‘strengthened’’ to
some extent through mechanisms such as repeated practice
and rest. As the term ‘‘depletable’’ suggests, SR also is
viewed as a limited resource or, as Schmeichel12 referred
to it, an expendable ‘‘fuel.’’ The limited resource view is
based on experimental evidence, some of which is discussed
below, that exertion of SR on one task results in poorer
SR on subsequent tasks. The limited resource view of
SR has strong theoretical and experimental support.10 The
Accepted for publication January 9, 2013.
From the *Department of Communication Sciences and Disorders, University of
Wisconsin-Madison, Madison, Wisconsin; and the yNeuroscience Training Program, Uni-
versity of Wisconsin-Madison, Madison, Wisconsin.
Address correspondence and reprint requests to Lisa A. Vinney, Department of Commu-
nication Sciences and Disorders, University of Wisconsin-Madison, Goodnight Hall, 1975
Willow Drive, Madison, WI 53706. E-mail: vinney@wisc.edu
Journal of Voice, Vol. 27, No. 3, pp. 390.e1-390.e11
0892-1997/$36.00
Ó 2013 The Voice Foundation
http://dx.doi.org/10.1016/j.jvoice.2013.01.003
capacity,13 defined as ‘‘the capacity (in terms of effective-
ness) with which the central executive can perform task-
relevant operations on the stored information, in the service
of the task, or goal at hand.’’13(p. 206) Low working memory
capacity has been linked to increased distractibility,14 mind-
wandering during challenging tasks,15 and decreased ability
to suppress unwanted thoughts,16 suppress emotions,17 and
inhibit undesirable responses on the Stroop and other inhi-
bition tasks.13,18
Self-regulatory effort that is sustained over time can be used up
(depleted), but with ‘‘rest,’’ it can be restored (repleted). Individ-
uals who are required to sustain SR can report ‘‘self-regulatory
fatigue’’ (sometimes reported as ‘‘mental fatigue’’), which can
occur when self-regulatory resources are depleted or inadequate
for the desired task.11 Self-regulatory resources also vary across
individuals as a function of individual differences in age, temper-
ament during development, personality, gender, fluid intelli-
gence, and tendencies such as procrastination or indecisiveness,
as well as differences in one’s environment.19–26
Indirect measures of self-regulatory resources have been
used to predict execution and maintenance of various health
behaviors. For example, self-reported increases in action
control (one aspect of SR) predicted reductions in smoking
behavior, overeating,27,28 and adherence to a low-fat diet.27
Self-report measures indicating strong SR have also exhibited
a negative relationship with binge eating, alcohol consump-
tion, and psychopathology.29 These and other studies provide
evidence that self-regulatory resources play an important role
in changing and maintaining health behaviors.
We propose that SR is a useful construct to consider in voice
therapy, and the role of SR in outcomes from voice therapy
should be examined. Previous research and reviews30–38 have
provided insights into differential responses to voice therapy
based on characteristics such as disorder type, self-efficacy,
and age. By contrast, the role of cognitive factors has received
little attention, although cognitive factors might be predict
long-term behavioral change. As a foundation for considering
SR in voice research, the following sections review key con-
structs and findings in SR research and then propose specific ap-
plications of SR to voice therapy in general and resonant voice
therapy in particular.

Descargado para Anonymous User (n/a) en University of the Rosary de ClinicalKey.es por Elsevier en abril 13, 2020.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados.
Lisa A. Vinney and Lyn S. Turkstra Self-regulation in Voice Therapy
SELF-REGULATORY DEPLETION
One of the major reasons SR may fail on a task is self-regulatory
depletion, sometimes referred to as ego depletion.11,39,40 Self-
regulatory depletion is typically studied in a two-task design:
Participants perform two consecutive self-regulatory-
demanding tasks, with the prediction that performance on the
second self-regulatory task will be negatively affected to the ex-
tent that self-regulatory resources were used up on the first (eg,
the requirement to be on one’s best behavior all day will de-
crease one’s patience with a house-mate in the evening). A large
body of recent literature has supported this prediction, showing
that SR of behavior or thought on one task results in degraded
performance on a subsequent task that also requires self-
regulatory resources.11,12,40–53 The following sections will
discuss how self-regulatory depletion may affect motivation,
working memory, cognitive task performance, motor behavior,
task persistence, results from cognitive and behavioral
control tasks, resisting temptation, interacting with others,
and engaging in impression management and emotion regula-
tion.12,44,54–58
Cognitive and behavioral control tasks affect
working memory
Self-regulatory depletion may manifest as degraded working
memory resulting from efforts at cognitive and behavioral con-
trol. For example, Schmeichel12 found that when undergraduate
students were asked to control the focus of their attention while
watching a video clip, their scores on a subsequent working
memory task were significantly lower than those of participants
who watched the same video with no requirement for atten-
tional control. Similarly, undergraduate student participants
who were asked to write a story without using the letters ‘‘a’’
or ‘‘n’’ had significantly lower scores on a subsequent working
memory task than participants who had written a story using
any letter they chose.12 In both cases, it was hypothesized
that students had ‘‘used up’’ their self-regulatory resources on
the first task and had fewer resources available for performing
the following task. These findings were not due to factors
such as mood, which did not differ between groups.
Resisting temptation affects task persistence
In addition to controlling thoughts and writing behavior, self-
regulatory depletion is a likely outcome of resisting temptation.
For example, when university students were asked to eat a food
they disliked (radishes) before performing a demanding cogni-
tive task (solving impossible anagrams), they persisted for sig-
nificantly less time on the cognitive task than did students who
ate cookies or candy before the cognitive task. The investigators
hypothesized that suppressing a preference (participants stated
they preferred sweets over radishes) depleted self-regulatory re-
sources, thus reducing available resources for the cognitive
task.
Social interaction affects cognitive task
performance
Social interactions also appear to tax self-regulatory resources
and negatively affect aspects of subsequent task performance.
Descargado para Anonymous User (n/a) en University of the Rosary de ClinicalKey.es por Elsevier en abril 13, 2020.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados.
390.e2
Finkel et al55 studied the effects of varying self-regulatory de-
mands on performance in interpersonal social interactions. Par-
ticipants engaged in social interactions that the authors
characterized as being either high maintenance (ie, requiring
high self-control) or low maintenance (ie, requiring mostly au-
tomatic processes). The term ‘‘maintenance’’ refers to ‘‘the de-
gree to which social coordination on an interpersonal task
requires energy exertions beyond those required to perform
the task itself.’’(p. 456) In high-maintenance interactions, the par-
ticipants in each group could have compatible goals but differ in
the interpersonal execution of those goals, such as when four in-
dividuals are deciding where to go for dinner. High-
maintenance interactions also are those in which participants
regulate affective displays, such as in conversations with rela-
tive strangers in which one participant was required to be on
his or her ‘‘best behavior.’’59 Consistent with the notion of re-
source depletion, high-maintenance interactions have been
associated with poorer SR on subsequent, unrelated tasks.55,59
For example, in one study,54 university students were asked to
trace an irregular maze that was obstructed from view on a com-
puter screen, while a partner who could see the maze gave di-
rections. Partners were confederates and either gave correct
directions (low-maintenance interactions) or made initial
errors and then self-corrections (eg, ‘‘Right . I mean left’’;
high-maintenance interactions). Thus, in both conditions,
confederates ultimately gave correct directions, but in the
high-maintenance interactions, participants had to suppress
the tendency to follow the partner’s initial directions and per-
haps also suppress their negative thoughts about the partner.
Participants in high-maintenance interactions were less moti-
vated to perform a subsequent high reward, cognitively difficult
tasks, and completed significantly fewer solvable anagrams
successfully than participants in low-maintenance interactions.
Impression management
Besides coordinating communication and interactions with
others, efforts to present oneself in a specific way when inter-
acting with others may tax self-regulatory resources. Vohs
et al60 described a series of studies on SR in relation to impres-
sion management that may have particular relevance to voice.
The studies were based on the previous findings that adults
are actively engaged in impression management a good part
of each day and that over time, people develop standard ways
to present themselves to others and these self-presentations
(also referred to as ‘‘display rules’’59) become automatic. The
authors hypothesized that changing these self-presentations
requires self-regulatory effort. In the studies by Vohs et al,60
participants engaged in social interactions with four different
manipulations: (1) bragging versus speaking modestly to
a friend versus a stranger; (2) presenting with a style that was
consistent versus inconsistent with gender stereotypes to
a same- versus opposite-sex partner; (3) presenting a competent,
likable image versus acting naturally to an audience that was ac-
cepting versus skeptical; and (4) speaking as a token of their
race versus one of many people of their race on a topic related
to race versus the environment. Studies were conducted in two
ways, first with the self-presentation manipulation followed
390.e3
by a self-regulatory-demanding task and then in the reverse or-
der. The latter order would be consistent with expecting a pa-
tient to monitor his or her vocal performance after the patient
has had to behave a certain way at work all day. The nonsocial
self-regulatory-demanding tasks included both cognitive tasks
(eg, persistence at solving unsolvable puzzles) and also motor
tasks (eg, handgrip stamina). Self-regulatory depletion effects
were reported in all four conditions, on cognitive and motor
tasks, and in both task orders, supporting the notion that SR
is a limited capacity resource that can be expended on any
task that requires conscious effort.
Goldberg and Grandey59 reported similar findings in another
study specifically relevant to voice therapy. In this study, re-
searchers manipulated expectations for display rules in simu-
lated customer service encounters. A local company told
participants that the research was being conducted to study
call-center jobs. Participants completed formal job ‘‘training,’’
were told that their performance would be evaluated as it would
in a ‘‘real job,’’ and were informed of consequences for good or
poor performance (eg, a ‘‘special bonus’’ versus more training).
Participants were randomized to one of two conditions. In the
display rules condition, they were told that customer service
was an organizational priority and they would be evaluated
accordingly:
Our organization and its customers value their employees be-
ing very friendly and outgoing. Our motto here is ‘putting
a smile on your face will put the smile in your voice!’58 (p. 307)
In the neutral condition, participants were told to ‘‘relax and
act yourself.’’ In both conditions, researchers emphasized the
importance of doing tasks correctly; that is, there was an expec-
tation for competent performance in both conditions, the only
difference was in effort related to interpersonal communication.
Trained researchers acted as call-center ‘‘customers’’ and were
randomly assigned to act in either a polite or hostile manner.
Participants in the display rules condition reported significantly
more emotional exhaustion and made significantly more errors
than those in the ‘‘act naturally’’ condition. This increase in
emotional exhaustion was a consequence of regulating vocal
and facial affect. In other words, effects were due to the cogni-
tive effort required to follow specific rules about how to act and
not to the emotional effort of being nice to customers.
Emotion regulation affects cognitive task
performance
Although SR of emotions was not a factor in the study just de-
scribed, other studies have shown that SR of emotions can lead
to depletion. For example, participants who were required to
suppress or exaggerate emotions and affect while watching
emotion-inducing video clips performed more poorly on subse-
quent cognitively demanding tasks than did participants who
watched the same videos but with no instructions for emotion
or affect control.12,56
Stroop task performance affects motor behavior
As in the study by Vohs et al60 discussed earlier, self-regulatory
depletion has been demonstrated on motor tasks and cognitive
Descargado para Anonymous User (n/a) en University of the Rosary de ClinicalKey.es por Elsevier en abril 13, 2020.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados.
Journal of Voice, Vol. 27, No. 3, 2013
tasks. This is relevant to voice therapy, which often involves
voluntary motor adjustments. For example, Bray et al48 found
that undergraduates maintained an isometric handgrip contrac-
tion for significantly fewer seconds after engaging in a modified
Stroop task, when compared with participants who engaged in
a prior task with similar surface features but no requirement for
response inhibition. Stroop-type tasks require suppression of an
automatic response in favor of an alternative response. The
classic Stroop task is an array of color names typed in different
ink colors, with some ink colors matching the color words (eg,
the word ‘‘green’’ typed in green ink) and others mismatched
(eg, the word green typed in red ink). Instructions are to
name the ink color and ignore the letters or vice versa, either
of which is more difficult for mismatched words than matched
words. In the study by Bray et al,48 despite identical motor re-
sponse requirements in the Stroop and non-Stroop groups, sur-
face electromyographic recordings from the wrist flexor in the
Stroop group showed significantly more activation (an indica-
tion of motor fatigue) than in the control group. Thus, self-
regulatory depletion was associated with greater activation of
motor units for the same degree of force.
SR failure and health behavior
The studies just discussed support the idea that SR relies on
a limited resource or strength that, when weakened through
use, can lead to self-regulatory depletion, fatigue, and failure.
SR failure has been linked to a wide range of negative behaviors
in the everyday world including impulsive purchasing, smok-
ing, drug and alcohol abuse, poor diet and exercise habits, crim-
inal behavior, and failure to change or engage in health
behaviors.61–69 The influence of depleted self-regulatory re-
sources on the execution of health behavior has been confirmed
repeatedly via controlled experiments. For example, when self-
regulatory resources were depleted in one study, participants
exhibited less commitment towards physical exercise.68 Specif-
ically, depleted individuals exerted less energy on a bicycle ex-
ercise and also planned to engage in a smaller amount of future
physical exercise than did a control group. Likewise, re-
searchers have also found that individuals were more likely to
drink more alcoholic beverages and not adhere to previously de-
termined personal limitations for drinking behavior on days
where they experienced more self-control demands.70 These
findings were independent of a person’s desire to drink and their
mood. In another study that examined alcohol consumption,
male volunteers who were asked to suppress thoughts of a white
bear for 5 minutes subsequently consumed significantly more
alcohol and had higher average blood-alcohol levels than volun-
teers whose alcohol consumption was preceded by 5 minutes of
solving simple two-digit addition problems.58 Similarly, re-
searchers have also found that smokers who resisted tempting
foods were more likely to smoke during a 10-minute break
than those who resisted less attractive foods (vegetables).69
Such outcomes indicate that attempting to regulate behavior
and cognition initially, may subsequently impair the ability to
refrain from unhealthy behaviors or engage in healthy ones.
Although performing high self-regulatory tasks seems to
decrease the ability to control drinking and smoking behavior,
Lisa A. Vinney and Lyn S. Turkstra Self-regulation in Voice Therapy
attempting to abstain from unhealthy behaviors also appears to
negatively impact future tasks requiring SR. Specifically, ex-
perimental findings have indicated that individuals who at-
tempted to abstain from drinking an alcoholic beverage,
performed more poorly on two subsequent self-regulatory
tasks (a cognitive task requiring inhibition and a handgrip mo-
tor task) than did individuals who were directed to abstained
from drinking water.71 Thus, resisting unhealthy behaviors
may negatively impact subsequent unrelated self-regulatory
behaviors. For further review of the effects of depletion on
health behavior, readers are referred to the review by Hagger
et al.72
Self-regulatory depletion and fatigue
Self-regulatory depletion effects are distinct from the effects
of motivation, general fatigue, mood, and learned helplessness
or low self-efficacy in everyday activities.22,39 For example,
when depleted individuals were highly rewarded and
therefore motivated to engage in more SR, they did so73; how-
ever, using already-depleted self-regulatory resources led to
even poorer performance on subsequent tasks.74 Depletion
effects are not related to general fatigue, as Vohs et al74 dis-
covered that individuals who were deprived of sleep for 36
hours showed similar self-regulatory effects to those who
had received a full night of sleep.75
Physiological underpinnings of self-regulatory
depletion
Self-regulatory depletion may occur independently of physical
fatigue, but it does appear to have a physiological basis. Acts of
SR such as regulating emotions, engaging in the Stroop task,
controlling one’s focus of attention, and suppressing thoughts
have been linked to significant reductions in blood glucose
levels, and low blood glucose levels before performing one
self-regulatory task are associated with impaired performance
on a subsequent task requiring SR.76 Engaging in SR is also as-
sociated with increased heart rate variability, and greater heart
rate variability at baseline has been associated with better per-
formance on tasks demanding SR.77,78 Thus, self-regulatory de-
pletion appears to have a physiological basis, or at least
physiological correlates, which may have implications for
changes in behaviors such as phonation.
SELF-REGULATORY REPLETION
Continuing the ‘‘fuel’’ and ‘‘muscle’’ metaphors for SR, there
is evidence that interventions may strengthen SR (ie, increase
capacity or resistance to depletion) or ‘‘replete’’ it. Brief pe-
riods of rest or relaxation, priming acts of SR, affirming
core values, and induction of positive affect have all been
found to reverse self-regulatory depletion on cognitive and
motor tasks.79–84
Rest and relaxation
When periods of rest and relaxation occur between two high
self-regulatory tasks, depletion may be prevented. Tyler and
Burns79 found that when undergraduate student participants
were given 10 minutes to fill out questionnaires between two
Descargado para Anonymous User (n/a) en University of the Rosary de ClinicalKey.es por Elsevier en abril 13, 2020.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados.
390.e4
self-regulatory tasks (ie, a self-regulatory ‘‘break’’), they did
not exhibit depletion. Similarly, participants who were directed
to relax while music was played for 3 minutes after a self-
regulatory task performed as well as controls on a second
task requiring SR. By contrast, participants who simply waited
3 minutes without music or being directed to relax still ex-
hibited depletion. Martijn et al81 found that when college stu-
dent participants read about a person who showed
perseverance after their completion of a high self-regulatory
task, these individuals did not show depletion effects on a sub-
sequent self-regulatory task. The personal example of persever-
ance was intended to serve as a ‘‘prime’’ to bias participants’
thinking toward success on the task. Priming participants with
the idea of dieting also has been found to reduce depletion as
determined by the amount of tempting foods participants ate
in an experimental setting.85
Positive affect induction
Tasks that induce a positive mood or affect also may reverse
self-regulatory depletion effects.86 For example, participants
in a depletion condition who had positive affect induced by
watching a comedic video or by being given a small, unex-
pected gift, performed as well on subsequent self-regulatory
tasks as non-depleted participants, and significantly better
than participants who were provided with a neutral stimulus
(a receipt for participation or a neutral film clip), a sad stim-
ulus (sad video clip), or a 5-minute break between depleting
tasks.83 Similarly, participants in a depletion condition who
were asked to write about their top-ranked core value after
a regulated writing task did not show depletion on a subse-
quent pain tolerance task.82
Strengthening SR
Simply practicing SR of a behavior appears to facilitate an over-
all increase in self-regulatory strength.22,87–90 For example,
Muraven et al87 found that depletion was reduced on a persis-
tence handgrip exercise task after a thought suppression task
(avoiding thoughts about a white bear for 5 minutes) after un-
dergraduate student participants had engaged in 2 weeks of
self-regulatory exercise. In that study, self-regulatory exercises
included maintaining good posture at all times and recording
progress on this goal, keeping a food diary, or regulating emo-
tions and attitudes. Similarly, Oaten and Cheng89 found that in-
dividuals who engaged in a consistent schedule of study across
2 months performed better on laboratory tasks requiring SR af-
ter the conclusion of the program. These students also reported
decreased stress during college examination week and better
SR of behavior (healthier eating, decreased smoking and alco-
hol consumption, adherence to commitments such as chores,
and more controlled monetary spending) when compared
with a group that was not involved in the study program. An-
other study by the same authors90 found similar outcomes (im-
proved daily SR as evidenced by performance on laboratory
tasks), when individuals engaged in a consistent program of
physical exercise across 2 months.
Self-regulatory ‘‘resistance training’’ effects were also evi-
dent in a study by Gailliot et al,88 who were interested in the
390.e5
interaction of SR and voluntary suppression of stereotypes.
The authors noted that people may attempt to suppress their
stereotypical thoughts for personal and social reasons, but cited
previous research showing that this suppression resulted in de-
pletion on subsequent tasks. They hypothesized that practicing
SR might build capacity and thus reduce depletion effects after
stereotype suppression. As ‘‘practice,’’ undergraduate student
participants were asked to modify their speaking style for 2
weeks and document their progress in a journal. Modifications
were saying ‘‘yes’’ and ‘‘no’’ instead of ‘‘yeah,’’ ‘‘nope,’’ or
other colloquialisms; speaking in complete sentences only;
and refraining from using slang, cursing, or starting sentences
with ‘‘I.’’ In pre- and post-training sessions, participants com-
pleted three tasks: (1) completing as many anagrams as they
could in 5 minutes, (2) a stereotype suppression task in which
they were shown a picture of a man who they were told was
a homosexual and asked to describe that person’s typical dress,
behavior, political beliefs, and leisure activities without men-
tioning any stereotypes about homosexual people in their
responses, and (3) another 5-minute session of solving ana-
grams. Groups were further divided into those with low versus
high motivation to suppress stereotypes, according to scores on
a scale for measuring motivation to respond without prejudice.
There was a significant effect of self-regulatory practice on
both stereotype suppression and also persistence at solving an-
agrams for the high-motivation group only. Results were repli-
cated for a second stereotype (about overweight people). In
both cases, practice reduced depletion effects but only in indi-
viduals who were motivated to regulate their own behavior.
These results indicate that repletion interventions may only
benefit a highly motivated depleted individual and that high
motivation alone will not counteract self-regulatory depletion.
SUMMARY OF SELF-REGULATORY EFFECTS
Several key findings of the studies just discussed have implica-
tions for voice therapy. First, SR appears to be a unitary re-
source that is depleted when used and can be exhausted,
leading to SR failure. Individuals with depleted SR can be mo-
tivated to push themselves to exert additional effort on subse-
quent self-regulatory tasks, but this comes at a high cost for
those tasks. Second, it appears that SR can be ‘‘boosted’’ by
priming with positive stimuli and ‘‘restored’’ with rest or activ-
ities such as positive mood induction. Third, consistent with the
muscle metaphor, SR may be improved with ‘‘exercise’’ (prac-
tice), even with practice over a relatively short period. Practice
can occur on unrelated self-regulatory tasks (eg, saying ‘‘yes’’
instead of ‘‘yeah’’ had positive effects on subsequent stereotype
suppression), consistent with the notion that all self-regulatory
tasks rely on a unitary resource. Fourth, self-regulatory capacity
and depletion effects vary across individuals and effects of
practice and rest likewise vary according to factors unrelated
to SR like motivation. Finally, depletion effects seem to be at
least partly independent of factors such as physical fatigue
and mood, and thus cannot be inferred by signs and symptoms
related to these other factors.
Descargado para Anonymous User (n/a) en University of the Rosary de ClinicalKey.es por Elsevier en abril 13, 2020.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados.
Journal of Voice, Vol. 27, No. 3, 2013
SR AND VOICE THERAPY
In the following sections, SR is discussed in the context of voice
therapy. We propose that an understanding of self-regulatory ef-
fects may be important for the evaluation of voice clients, struc-
turing voice therapy, designing directions for home practice,
and facilitating generalization and maintenance of gains on
voice therapy tasks. The following discussion focuses on
physiological voice therapy.1,91,92 Although SR may have
applications to other types of voice therapy, SR effects seem
particularly appropriate for physiological voice therapy
because physiological therapy typically involves voluntary
behavior change using specific exercise regimes or
programs including Lessac-Madsen Resonant Voice Therapy
(RVT),93–95 confidential voice therapy,94 vocal function exer-
cises,96,97 Lee Silverman Voice Treatment,4,98,99 and the
accent method of voice therapy.6,8,100 The commonality
across these physiological approaches is their emphasis on
changing motor behavior related to respiration, muscular
effort, and resonance via specific formal exercises and motor
adjustments. Also, these approaches typically emphasize
generalization of new vocal behavior into everyday life. For
example, RVT uses exercises like humming and chanting to
facilitate improved oral resonance and decreased muscular
effort in patients.95 The program progresses from these basic
exercises to using newly learned forward oral resonance and re-
duced muscular effort first in sounds, then in words, sentences,
and finally conversation.95 Generalizing a newly learned, vol-
untary behavior from isolated sounds in a clinic room to conver-
sation in everyday life, and then sustaining use of the new vocal
behavior over time is highly likely to require self-regulatory
resources.
The following discussion focuses on RVT as an example of
physiological voice therapy. RVT, like several other physiolog-
ical therapies, is based on a phase-based model of motor learn-
ing. According to this model, motor learning is defined as
‘‘permanent improvement in a skill,’’101 (p. 411) and occurs in
three phases: skill acquisition, habit formation, and habit
change.101 During skill acquisition, the learner acquires the
ability to perform a particular motor task or skill in optimal cir-
cumstances (eg, in the clinic room, with instruction and moni-
toring by a clinician). The second phase of motor learning, habit
formation, involves acquiring the ability to produce the new
motor behavior with limited attentional resources.101 Perfor-
mance of a habituated motor behavior will not degrade when
it is performed simultaneously with another task, and the behav-
ior can be performed consistently across situations. Before
a motor behavior is habituated and, as a result automatized,
self-regulatory resources will be necessary to control that
behavior. Habit formation is likely to be difficult initially be-
cause phonation in a communication context requires dividing
attention among multiple tasks that require cognitive effort,
including formulation and production of spoken messages,
self-monitoring of verbal content and pragmatic aspects of
communication, monitoring verbal and nonverbal feedback
from the listener, and making adjustments according to that
feedback. During the third phase of learning, habit change,
Lisa A. Vinney and Lyn S. Turkstra Self-regulation in Voice Therapy
old habitual behaviors should be inhibited and replaced with the
newly acquired behavior.101 As habitual behavior (ie, using
a hyperfunctional voice) is typically activated automatically
by any stimulus for phonation,101 using a new behavior in place
of the habituated one will require conscious mental effort, oth-
erwise known as SR.
SR DURING SKILL ACQUISITION
SR of vocal behavior during therapy likely can be modeled
by a feedback loop meant to allow for adjustments and even-
tually a decrease in the discrepancy between a standard or
goal and behavioral outcomes.102–105 Figure 1 depicts the
proposed self-regulatory process invoked during the phase
of skill acquisition. In this phase, the patient’s task is to
learn how to produce particular vocal behaviors or tech-
niques. The patient’s regulation of vocal behavior is not
completely self-mediated because the clinician is shaping
what we will call the patient’s ‘‘mental representation and
motor program’’ for voice production. Upon starting voice
therapy, the patient will have a mental representation of pho-
nation and an associated motor plan that leads to dysphonic
vocal productions. However, external influences (eg, instruc-
tion from the therapist) will be combined with internal feed-
back and used to adjust the original mental representation of
phonation and its associated motor plan. Adjustments to this
mental representation and motor plan will take place many
times before the patient has a stable, consistent, and accurate
representation of the desired vocal behavior as well as an
associated motor plan that allows him or her to use that
behavior. Depending on the type of physiological therapy
used, skill acquisition may be relatively brief. For example,
most patients probably already have acquired the skill to
produce a loud or soft voice but perhaps need to work on
habitually phonating loudly or softly. Thus, they will be fur-
ther along in the process of motor learning, yet need to work
FIGURE 1. Proposed model for the process of regulating vocal be-
havior to acquire target vocal act during skill acquisition.
Descargado para Anonymous User (n/a) en University of the Rosary de ClinicalKey.es por Elsevier en abril 13, 2020.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados.
390.e6
on habit formation and change to generalize the use of
a new level of vocal intensity into their everyday verbal
communication.
SR DURING HABIT FORMATION AND HABIT CHANGE
During the phases of habit formation and habit change, the
objective is to consistently produce the newly acquired vocal
behavior with decreasing attentional demands across various
environments and levels of difficulty. During these phases,
the regulatory process changes to the one depicted in Figure 2
(adapted from Carver and Scheier102). In this model, the clini-
cian may also provide external feedback to facilitate the
patient’s activation of the goal for a particular vocal technique,
but because the individual has already acquired the ability to
perform the desired vocal behavior during skill acquisition,
this process proceeds relatively independently. In fact, produc-
ing the target vocal behavior in many different environments
will require significant work and SR outside the therapy
room. The patient is now aware of the vocal goal and will use
perceptual feedback and possibly input from external sources
(eg, clinician and conversational partners) to determine whether
vocal output is in line with that goal. The comparator in the
model represents the process of examining how closely the in-
ternal perceptual and/or external inputs match the vocal goal. If
no discrepancy is detected, then the vocal behavior will not
change. If there is a discernable difference, however, then the
vocal behavior should be modified. During habit formation,
this process should require fewer cognitive resources, and mod-
ifications to the target vocal behavior should decrease as it is
performed with greater consistency.
During habit change, the goal will consist of not only per-
forming the target vocal behavior but also doing so in place
of the previous habitual vocal behavior (eg, pressed voice).
When habit change is completed, individuals will no longer
be monitoring their vocal behavior by examining how it com-
pares to the conceptualized goal. Instead, the new habit is per-
formed relatively unconsciously because it has become the
dominant vocal behavioral response pattern. At this point,
FIGURE 2. Proposed model for the SR of vocal behavior
during habit formation and habit change. Adapted from Carver and
Scheier.102
390.e7 Journal of Voice, Vol. 27, No. 3, 2013

self-regulatory resources will no longer be necessary to main-
tain the newly adopted behavior.
SELF-REGULATORY DEPLETION IN RVT
More than 100 published studies now provide strong evidence
that when adults engage in SR, their ability to regulate subse-
quent tasks diminishes. How does this relate to RVT? It is pro-
posed that SR relates to RVT in two ways. First, participating in
a SR-demanding task before phonation may deplete the self-
regulatory resources needed to change vocal behavior (eg, to
use newly learned vocal behaviors in a conversation after
a long work day). Second, self-regulatory resources required
to perform newly learned vocal behaviors may deplete re-
sources needed for other self-regulatory tasks related to vocal
rehabilitation, such as adherence to practice schedules and vo-
cal hygiene regimes.
The idea that depletion may be affecting voice patients re-
ceiving RVT is indirectly supported by one recent interview
study by van Leer and Connor.33 In that study, voice patients re-
ported that the constant need to attend to and be in control of
phonation was a barrier to voice therapy success. Patients
also reported that their extraneous cognitions and emotions,
as well as situational factors, affected their ability to use healthy
vocal technique and accurately assess their vocal practice.33
These findings suggest that voice patients are aware of the ne-
cessity for regulation of thought and action during voice prac-
tice and therapy but that the effort required to use these skills
can make the therapeutic process very difficult.
The preceding interview study indicates how depletion may
result in failures to advance through motor learning during
RVT. The general reasons that SR failure may occur include:
(1) the lack of a goal or standard for completing a task; (2) a
goal or standard being too high or too low relative to an individ-
ual’s capacity; (3) multiple incompatible goals or standards
activated at once; and (4) insufficient self-regulatory capacity
resulting in insufficient monitoring of current conditions and
undetected discrepancies between goal standards and actual
states.11 Please refer to Table 1 for more information on how
each of these issues may impact each phase of motor learning
in RVT.
SUMMARY OF SR DURING MOTOR LEARNING IN
VOICE THERAPY
SR is necessary to facilitate progress in motor learning and vo-
cal behavior change in RVT and other physiological voice ther-
apies. During skill acquisition, self-regulatory efforts are
required to refine vocal behavior until the vocal target can be
produced correctly. During habit formation, the new vocal be-
havior will need to be produced consistently across situations
and levels of difficulty with decreasing demands on attention
and cognition. When habit change begins, the older habitual vo-
cal behavior will need to be consistently replaced with the new
one. Eventually, exchanging the old behavior for the new
should become habitual and require fewer and fewer self-
regulatory resources until virtually none are required. Poor
monitoring of behavior, goals that are not in line with an indi-
vidual’s abilities or compete with producing and maintaining
the target vocal behavior, or the lack of any standard or goal
for vocal behavior may all occur when self-regulatory resources
are insufficient, and this may lead to failure during the motor
learning process. Learning failure may manifest as the inability
to either produce the target vocal behavior or generalize desired
phonatory behavior to everyday communication situations.
SUPPORTING SR DURING VOCAL BEHAVIOR
CHANGE
One way to support SR and decrease the demands it places
on cognition is to facilitate patients’ development of goal
implementation intentions.106–108 Goal implementation
intentions are statements that specify conditions under which
the person will take steps toward achieving a goal. A generic
goal intention would be ‘‘I intend to attain goal X!’’ and
a generic implementation intention would be, ‘‘I will initiate

TABLE 1.
SR Failure and Voice Therapy
Categories of SR Failure
Individual lacks standard or goal
Goal or standard is too high/low
Discrepancies between goal standards and Patient does not detect difference between goal and
actual states not monitored/detected
Goal/standard is activated with other
incompatible goals
Phase(s) of Motor
SR Failure in Voice Patients Learning
Patient unable to form mental representation/motor Skill acquisition
program for resonant voice
Patient has mental representation/motor program Habit formation/change
for resonant voice but is not activating it
Patient has accurate mental representation/motor Habit formation/change
plan for resonant voice but is unable to produce it
due to current lack of self-regulatory resources
Patient has inaccurate mental representation/motor Skill acquisition
program associated with resonant voice
Habit formation/change
actual vocal behavior
Patient activates goal for producing resonant voice Habit formation/change
at the same time that other incompatible goals
are activated

Descargado para Anonymous User (n/a) en University of the Rosary de ClinicalKey.es por Elsevier en abril 13, 2020.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados.
Lisa A. Vinney and Lyn S. Turkstra Self-regulation in Voice Therapy
goal-directed response Y when situation Z arises!’’108 (p. 124)
Implementation intentions provide patients with criteria for
when to initiate a goal like producing and maintaining target
vocal behavior. Implementation intentions are different than
goal intentions. In the goal intention above, X represents an out-
come or behavior; but this sort of statement does not provide a
direct link between a behavior and a specific situation. By
specifying the ‘‘when, where, and how of goal-directed re-
sponses,’’109 (p. 947) individuals are more likely to automatically
respond with the desired behavior when the appropriate situa-
tion is encountered.
One of the most promising findings about implementation in-
tentions is that they appear to lead to automatic action initiation
and place a minimal load on cognitive resources.109 This find-
ing is supported by evidence that implementation intentions im-
prove goal-directed behavior in dual task situations, when
attentional resources are divided between the goal behavior
and a competing task.109 Research in this area provides support
for integrating implementation intentions into voice therapy.
For example, having participants generate implementation in-
tentions as to when, where, and how they will implement spe-
cific vocal techniques (eg, ‘‘I will use my front voice when I
am at the dinner table this evening) or practice vocal exercises
(eg, ‘‘At 9 PM, I will practice my vocal exercises in my room us-
ing the audio recording from my therapist’’) would likely be
beneficial to voice patients.
Unlike habits, implementation intentions require a single
mental act to lay the foundation for automatic processes.109
As described in the motor learning phases explained above, mo-
tor behaviors are thought to become automatic only through
conscious and consistent repetition of the desired behavioral re-
sponse. On the other hand, it is thought that once implementa-
tion intentions are formulated via a singular cognitive effort,
action can proceed automatically and with minimal cognitive
resources. Unlike habits, a less routine behavior may benefit
most from the support of implementation intentions.109
Implementation intentions have led to the adoption of many
health-related behaviors, including regular exercise,110–112
attendance at cancer screening appointments,112 decreasing or
abstaining from alcohol consumption,113–115 and eating healthy
foods.116–118 Many studies have found that implementation
intentions are helpful in sustaining new health behaviors
across weeks and months.116,119 Indeed, it appears that
implementation intentions may be another bridge to facilitating
the use of a particular vocal behavior in everyday life without
increasing demands on SR. Specifically, implementation
intentions seem to help individuals ‘‘establish new behavioral
routines’’ without much cognitive effort.109 Implementation in-
tentions are particularly relevant to voice therapy, as their formu-
lation may aid in improving adherence to vocal practice and
hygiene recommendations, using new vocal techniques consis-
tently and in place of inefficient phonation in everyday life, and
keeping regular voice therapy and laryngology appointments.
As implementation intentions may decrease self-regulatory
demands and lead to automatic action initiation, their use
may counteract the effects of depletion.120–122 For example,
when individuals generated implementation intentions about
Descargado para Anonymous User (n/a) en University of the Rosary de ClinicalKey.es por Elsevier en abril 13, 2020.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados.
390.e8
a subsequent anagram task (‘‘I will find as many solutions
as possible and if I have solved one anagram, then I
will immediately start to work on the next’’ (p.5)) after
suppressing laughter and amusement in response to a funny
film clip, they solved a similar number of anagrams as did
individuals who did not suppress emotions initially.123 The
same effect was not seen when participants were only assigned
a goal intention without more specific plans (‘‘I will find as
many solutions as possible’’(p. 5)). Webb and Sheeran120 found
similar results in a study in which they attempted to induce de-
pletion via a Stroop task. In that study, depleted individuals who
formed implementation intentions about performing the Stroop
as quickly as possible (‘‘As soon as I see the word I will ignore
its meaning, for example, by concentrating on the second letter
only, and I will name the color ink it is printed in’’ (p. 281)), per-
sisted at a subsequent impossible task for significantly more
time than did depleted individuals who did not form implemen-
tation intentions. The depleted group that had formed imple-
mentation intentions persisted for a similar amount of time as
a non-depleted group. In a second experiment, participants
who were depleted and formed implementation intentions
about completing a subsequent Stroop task as quickly as possi-
ble, performed the Stroop as rapidly and with a similar amount
of errors as did those who had not participated in a previous
depletion task.120 They also performed significantly better
than depleted individuals who had not formed implementation
intentions (ie, fewer errors and faster performance).
Implementation intentions and associated research findings
are likely very applicable to the motor learning process in
RVT and other physiological voice therapy programs. During
skill acquisition, using implementation intentions to maintain
specific vocal practice recommendations may be especially
helpful in establishing the ability to perform a new vocal behav-
ior. During habit formation and change, implementation inten-
tions could be helpful in automatically activating new vocal
behaviors via environmental and situational triggers (eg, using
resonant voice every time one is at the dinner table). Implemen-
tation intentions may benefit associated behaviors that affect
vocal health by leading to diet modifications, adhering to
a schedule for taking reflux medications, regularly engaging
in vocal practice, and keeping voice therapy and laryngology
appointments. It appears that by making specific plans in ad-
vance, desired behaviors may be automatically activated in
specified conditions and environments, thereby reducing self-
regulatory demands and freeing up cognitive resources for vo-
cal control. As a result, depletion may be prevented and vocal
behaviors may be improved.
CONCLUSION
Voice therapy is extremely complex, and a number of factors are
likely to play a role in patient outcomes. Although anatomic,
physiological, and psychological contributors to outcomes in
voice therapy have been well studied, cognitive contributors to
therapy success and failure have received less attention. Results
of the studies discussed here suggest that SR is one cognitive
factor that could have a significant influence on outcomes
from voice therapy, particularly in relation to treatment
390.e9
adherence and generalization of clinical gains into everyday life.
Self-regulatory phenomena are well studied in the psychology
literature, but application of that research to speech and voice
is still needed to determine methods for assessing and improving
self-regulatory ability in the voice clinic and characterizing how
depletion manifests in disordered and normal vocal behavior.
Recognizing depletion as a real phenomenon inside and outside
the clinic will be important in making sense of clinical outcomes
and patients’ progress in the motor learning process. Further-
more, developing a better understanding of how to best support
self-regulatory efforts, counteract depletion, and promote reple-
tion in voice patients will be an important future step in improv-
ing clinical voice care.
Acknowledgments
The authors acknowledge Dr. Nadine Connor for her assistance
with editing and clarifying ideas for this manuscript and
Dr. Mary Kennedy for contributing her expertise on the topic
through consultation on this manuscript.
REFERENCES
1. Stemple JC, Glaze L, Klaben B. Clinical Voice Pathology: Theory and
Management. 4th ed. San Diego, CA: Plural Publishing Inc.; 2010.
2. Boone DR, McFarlane SC, Von Berg SL, Zraick RI. The Voice and Voice
Therapy. 8th ed. Boston, MA: Pearson Education Inc.; 2010.
3. Ruotsalainen J, Sellman J, Lehto L, Verbeek J. Systematic review of the
treatment of functional dysphonia and prevention of voice disorders. Oto-
laryngol Head Neck Surg. 2008;138:557–565.
4. Fox CM, Ramig LO, Ciucci MR, Sapir S, McFarland DH, Farley BG. The
science and practice of LSVT/LOUD: neural plasticity-principled ap-
proach to treating individuals with Parkinson disease and other neurolog-
ical disorders. Semin Speech Lang. 2006;27:283–299.
5. Holmberg EB, Hillman RE, Hammarberg B, Sodersten M, Doyle P.
Efficacy of a behaviorally based voice therapy protocol for vocal
nodules. J Voice. 2001;15:395–412.
6. Deem JF, Miller L. Manual of Voice Therapy. 2nd ed. Austin, TX: PRO-
ED; 2000.
7. Andrews ML. Manual of Voice Treatment: Pediatrics through Geriatrics.
San Diego, CA: Singular Pub. Group; 2006.
8. Colton R, Casper JK. Understanding Voice Problems: A Physiological
Perspective for Diagnosis and Treatment. 2nd ed. Baltimore, MD:
Williams & Wilkins; 1996.
9. Vohs KD, Baumeister RF. Ego depletion, self-control, and choice. In:
Pyszczynski T, ed. Handbook of Experimental Existential Psychology.
New York, NY: Guilford Press; 2004:398–410.
10. Baddeley AD. Is working memory still working? Eur Psychol. 2002;7:
85–97.
11. Schmeichel BJ, Baumeister RF. Self-regulatory strength. In: Vohs KD, ed.
Handbook of Self-Regulation: Research, Theory, and Applications. New
York, NY: Guilford Press; 2004:84–98.
12. Schmeichel BJ. Attention control, memory updating, and emotion regula-
tion temporarily reduce the capacity for executive control. J Exp Psychol
Gen. 2007;136:241–255.
13. Hofmann W, Friese M, Schmeichel BJ, Baddeley AD. Working memory
and self-regulation. In: Baumeister RF, ed. Handbook of Self-
Regulation: Research, Theory, and Applications. 2nd ed. New York,
NY: Guilford Press; 2011:204–225.
14. Fukuda K, Vogel EK. Human variation in overriding attentional capture.
J Neurosci. 2009;29:8726–8733.
15. Kane MJ, Conway ARA, Miura TK, Colflesh GJH. Working memory, at-
tention control, and the n-back task: a question of construct validity. J Exp
Psychol Learn Mem Cogn. 2007;33:615–622.
16. Brewin CR, Beaton A. Thought suppression, intelligence, and working
memory capacity. Behav Res Ther. 2002;40:923–930.
Descargado para Anonymous User (n/a) en University of the Rosary de ClinicalKey.es por Elsevier en abril 13, 2020.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados.
Journal of Voice, Vol. 27, No. 3, 2013
17. Schmeichel BJ, Volokhov RN, Demaree HA. Working memory capacity
and the self-regulation of emotional expression and experience. J Pers
Soc Psychol. 2008;95:1526–1540.
18. Houben K, Wiers RW. Response inhibition moderates the relationship be-
tween implicit associations and drinking behavior. Alcohol Clin Exp Res.
2009;33:626–633.
19. McCabe LA, Cunnington M, Brooks-Gunn J. The development of self-
regulation in young children: individual characteristics and environmen-
tal contexts. In: Vohs KD, ed. Handbook of Self-Regulation: Research,
Theory, and Applications. New York, NY: Guilford Press; 2004:
340–356.
20. Wagner DD, Heatherton TF. Giving in to temptation: the emerging cogni-
tive neuroscience of self-regulatory failure. In: Baumeister RF, ed. Hand-
book of Self-Regulation: Research, Theory, and Applications. 2nd ed. New
York, NY: Guilford Press; 2011:41–63.
21. Rothbart MK, Ellis LK, Posner MI. Temperament and self-regulation. In:
Vohs KD, ed. Handbook of Self-Regulation: Research, Theory, and Appli-
cations. New York, NY: Guilford Press; 2004:357–370.
22. Baumeister RF, Gailliot M, DeWall CN, Oaten M. Self-regulation and per-
sonality: how interventions increase regulatory success, and how depletion
moderates the effects of traits on behavior. J Pers. 2006;74:1773–1801.
23. Nolen-Hoeksema S, Corte C. Gender and self-regulation. In: Vohs KD, ed.
Handbook of Self-Regulation: Research, Theory, and Applications. New
York, NY: Guilford Press; 2004:411–421.
24. Ferrari JR. Procrastination as self-regulation failure of performance: ef-
fects of cognitive load, self-awareness, and time limits on ’working best
under pressure’. Eur J Pers. 2001;15:391–406.
25. Ferrari JR, Pychyl TA. Regulating speed, accuracy and judgments by
indecisives: effects of frequent choices on self-regulation depletion.
Pers Individ Dif. 2007;42:777–787.
26. Shamosh NA, Gray JR. The relation between fluid intelligence and self-
regulatory depletion. Cognit Emot. 2007;21:1833–1843.
27. Scholz U, Nagy G, G€ohner W, Luszczynska A, Kliegel M. Changes in
self-regulatory cognitions as predictors of changes in smoking and nutri-
tion behaviour. Psychol Health. 2009;24:545–561.
28. Oginska-Bulik N. Self-regulatory resources as predictors of eating behav-
ior change in overweight women participating in a weight-reduction pro-
gram. Polish Psychol Bull. 2005;36:35–42.
29. Tangney JP, Baumeister RF, Boone AL. High self-control predicts good
adjustment, less pathology, better grades, and interpersonal success.
J Pers. 2004;72:271–322.
30. Portone-Maira C, Wise JC, Johns MM 3rd, Hapner ER. Differences in
temporal variables between voice therapy completers and dropouts.
J Voice. 2011;25:62–66.
31. 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;51:350–366.
32. van Leer E, Connor NP. Use of portable digital media players increases
patient motivation and practice in voice therapy. J Voice. 2012;26:447–453.
33. van Leer E, Connor NP. Patient perceptions of voice therapy adherence.
J Voice. 2010;24:458–469.
34. Roy N, Bless DM. Personality traits and psychological factors in voice pa-
thology: a foundation for future research. J Speech Lang Hear Res. 2000;
43:737–748.
35. Smith BE, Kempster GB, Sims HS. Patient factors related to voice therapy
attendance and outcomes. J Voice. 2010;24:694–701.
36. Haselden K, Powell T, Drinnan M, Carding P. Comparing health locus of
control in patients with spasmodic dysphonia, functional dysphonia and
nonlaryngeal dystonia. J Voice. 2009;23:699–706.
37. van Mersbergen M, Patrick C, Glaze L. Functional dysphonia during men-
tal imagery: testing the trait theory of voice disorders. J Speech Lang Hear
Res. 2008;51:1405–1423.
38. van Leer E, Hapner ER, Connor NP. Transtheoretical model of health
behavior change applied to voice therapy. J Voice. 2008;22:688–698.
39. Muraven M, Baumeister RF. Self-regulation and depletion of limited re-
sources: does self-control resemble a muscle? Psychol Bull. 2000;126:
247–259.
Lisa A. Vinney and Lyn S. Turkstra Self-regulation in Voice Therapy
40. Baumeister RF, Muraven M, Tice DM. Ego depletion: a resource model of
volition, self-regulation, and controlled processing. Soc Cogn. 2000;18:
130–150.
41. Bauer IM, Baumeister RF. Self-regulatory strength. In: Baumeister RF, ed.
Handbook of Self-Regulation: Research, Theory, and Applications. 2nd
ed. New York, NY: Guilford Press; 2011:64–82.
42. Baumeister RF. Yielding to temptation: Self-control failure, impulsive
purchasing, and consumer behavior. J Consum Res. 2002;28:670–676.
43. Baumeister RF. Ego depletion and self-control failure: an energy model of
the self’s executive function. Self Identity. 2002;1:129–136.
44. Baumeister RF, Bratslavsky E, Muraven M, Tice DM. Ego depletion: is
the active self a limited resource? J Pers Soc Psychol. 1998;74:
1252–1265.
45. Baumeister RF, Bratslavsky E, Muraven M, Tice DM. Ego depletion: is
the active self a limited resource?. In: Baumeister RF, ed. The Self in So-
cial Psychology. New York, NY: Psychology Press; 1999:317–338.
46. Baumeister RF, Heatherton TF. Self-regulation failure: an overview. In:
Leary MR, ed. The Interface of Social and Clinical Psychology: Key Read-
ings. New York, NY: Psychology Press; 2004:51–69.
47. Baumeister RF, Vohs KD, Tice DM. The strength model of self-control.
Curr Dir Psychol Sci. 2007;16:351–355.
48. Bray SR, Martin Ginis KA, Hicks AL, Woodgate J. Effects of self-
regulatory strength depletion on muscular performance and EMG activa-
tion. Psychophysiology. 2008;45:337–343.
49. Demaree HA, Schmeichel BJ, Robinson JL, Everhart DE. Behavioural, af-
fective, and physiological effects of negative and positive emotional exag-
geration. Cogn Emot. 2004;18:1079–1097.
50. Demaree HA, Schmeichel BJ, Robinson JL, Pu J, Everhart DE,
Berntson GG. Up- and down-regulating facial disgust: affective, vagal,
sympathetic, and respiratory consequences. Biol Psychol. 2006;71:90–99.
51. Baumeister RF, Alquist JL. Self-regulation as a limited resource: strength
model of control and depletion. In: Forgas JP, Baumeister RF, Tice DM,
Forgas JP, Baumeister RF, Tice DM, eds. Psychology of Self-
Regulation: Cognitive, Affective, and Motivational Processes. New
York, NY: Psychology Press; 2009:21–33.
52. Muraven M, Tice DM, Baumeister RF. Self-control as a limited resource:
regulatory depletion patterns. J Pers Soc Psychol. 1998;74:774–789.
53. Vohs KD, Heatherton TF. Self-regulatory failure: a resource-depletion ap-
proach. Psychol Sci. 2000;11:249–254.
54. Fedorikhin A, Patrick VM. Positive mood and resistance to temptation: the
interfering influence of elevated arousal. J Consum Res. 2010;37:
698–711.
55. Finkel EJ, Campbell WK, Brunell AB, Dalton AN, Scarbeck SJ,
Chartrand TL. High-maintenance interaction: inefficient social coordina-
tion impairs self-regulation. J Pers Soc Psychol. 2006;91:456–475.
56. Schmeichel BJ, Vohs KD, Baumeister RF. Intellectual performance and
ego depletion: role of the self in logical reasoning and other information
processing. J Pers Soc Psychol. 2003;85:33–46.
57. Vohs KD, Baumeister RF, Schmeichel BJ, Twenge JM, Nelson NM,
Tice DM. Making choices impairs subsequent self-control: a limited-
resource account of decision making, self-regulation, and active initiative.
J Pers Soc Psychol. 2008;94:883–898.
58. Muraven M, Collins RL, Neinhaus K. Self-control and alcohol restraint:
an initial application of the self-control strength model. Psychol Addict
Behav. 2002;16:113–120.
59. Goldberg LS, Grandey AA. Display rules versus display autonomy: emo-
tion regulation, emotional exhaustion, and task performance in a call cen-
ter simulation. J Occup Health Psychol. 2007;12:301–318.
60. Vohs KD, Baumeister RF, Ciarocco NJ. Self-regulation and self-
presentation: regulatory resource depletion impairs impression manage-
ment and effortful self-presentation depletes regulatory resources.
J Pers Soc Psychol. 2005;88:632–657.
61. Herman CP, Polivy J. The self-regulation of eating: theoretical and prac-
tical problems. In: Baumeister RF, ed. Handbook of Self-Regulation:
Research, Theory, and Applications. 2nd ed. New York, NY: Guilford
Press; 2011:522–536.
62. Faber RJ, Vohs KD. To buy or not to buy?: Self-control and self-regulatory
failure in purchase behavior. In: Vohs KD, ed. Handbook of Self-
Descargado para Anonymous User (n/a) en University of the Rosary de ClinicalKey.es por Elsevier en abril 13, 2020.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados.
390.e10
Regulation: Research, Theory, and Applications. New York, NY: Guilford
Press; 2004:509–524.
63. Sayette MA. Self-regulatory failure and addiction. In: Vohs KD, ed. Hand-
book of Self-Regulation: Research, Theory, and Applications. New York,
NY: Guilford Press; 2004:447–465.
64. Sayette MA, Griffin KM. Self-regulatory failure and addiction. In:
Baumeister RF, ed. Handbook of Self-Regulation: Research, Theory,
and Applications. 2nd ed. New York, NY: Guilford Press; 2011:505–521.
65. Hull JG, Slone LB. Alcohol and self-regulation. In: Vohs KD, ed. Hand-
book of Self-Regulation: Research, Theory, and Applications. New
York, NY: Guilford Press; 2004:466–491.
66. Rothman AJ, Baldwin AS, Hertel AW. Self-regulation and behavior
change: disentangling behavioral initiation and behavioral maintenance.
In: Vohs KD, ed. Handbook of Self-Regulation: Research, Theory, and Ap-
plications. New York, NY: Guilford Press; 2004:130–148.
67. Nes LS, Roach AR, Segerstrom SC. Executive functions, self-regulation,
and chronic pain: a review. Ann Behav Med. 2009;37:173–183.
68. Ginis KAM, Bray SR. Application of the limited strength model of self-
regulation to understanding exercise effort, planning and adherence. Psy-
chol Health. 2010;25:1147–1160.
69. Shmueli D, Prochaska JJ. Resisting tempting foods and smoking behavior:
implications from a self-control theory perspective. Health Psychol. 2009;
28:300–306.
70. Muraven M, Collins RL, Shiffman S, Paty JA. Daily fluctuations in self-
control demands and alcohol intake. Psychol Addict Behav. 2005;19:
140–147.
71. Muraven M, Shmueli D. The self-control costs of fighting the temptation
to drink. Psychol Addict Behav. 2006;20:154–160.
72. Hagger MS, Wood C, Stiff C, Chatzisarantis NLD. Ego depletion and the
strength model of self-control: a meta-analysis. Psychol Bull. 2010;136:
495–525.
73. Muraven M, Slessareva E. Mechanism of self-control failure: motivation
and limited resources. Pers Soc Psychol Bull. 2003;29:894–906.
74. Muraven M, Shmueli D, Burkley E. Conserving self-control strength.
J Pers Soc Psychol. 2006;91:524–537.
75. Vohs KD, Glass BD, Maddox WT, Markman AB. Ego depletion is not just
fatigue: evidence from a total sleep deprivation experiment. Soc Psychol
Personal Sci. 2011;2:166–173.
76. Gailliot MT, Baumeister RF, DeWall CN, et al. Self-control relies on glu-
cose as a limited energy source: Willpower is more than a metaphor. J Pers
Soc Psychol. 2007;92:325–336.
77. Segerstrom SC, Nes LS. Heart rate variability reflects self-regulatory
strength, effort, and fatigue. Psychol Sci. 2007;18:275–281.
78. Geisler FCM, Kubiak T. Heart rate variability predicts self-control in goal
pursuit. Eur J Pers. 2009;23:623–633.
79. Tyler JM, Burns KC. After depletion: the replenishment of the self’s reg-
ulatory resources. Self Ident. 2008;7:305–321.
80. Smith RW. Effects of Relaxation on Self-Regulatory Depletion. Ann
Arbor, MI: ProQuest Information & Learning; 2002.
81. Martijn C, Alberts HJEM, Merckelbach H, Havermans R, Huijts A, De
Vries NK. Overcoming ego-depletion: the influence of exemplar priming
on self-control performance. Eur J Soc Psychol. 2007;37:231–238.
82. Schmeichel BJ, Vohs K. Self-affirmation and self-control: affirming
core values counteracts ego depletion. J Pers Soc Psychol. 2009;96:
770–782.
83. Tice DM, Baumeister RF, Shmueli D, Muraven M. Restoring the self: pos-
itive affect helps improve self-regulation following ego depletion. J Exp
Soc Psychol. 2007;43:379–384.
84. Isen AM. An influence of positive affect on decision making in complex
situations: theoretical issues with practical implications. J Consum Psy-
chol. 2001;11:75–85.
85. Papies EK, Hamstra P. Goal priming and eating behavior: enhancing self-
regulation by environmental cues. Health Psychol. 2010;29:384–388.
86. Ren J, Hu L, Zhang H, Huang Z. Implicit positive emotion counteracts ego
depletion. Soc Behav Pers. 2010;38:919–928.
87. Muraven M, Baumeister RF, Tice DM. Longitudinal improvement of self-
regulation through practice: building self-control strength through
repeated exercise. J Soc Psychol. 1999;139:446–457.
390.e11
88. Gailliot MT, Plant EA, Butz DA, Baumeister RF. Increasing self-
regulatory strength can reduce the depleting effect of suppressing stereo-
types. Person Soc Psychol Bull. 2007;33:281–294.
89. Oaten M, Cheng K. Improved self-control: the benefits of a regular
program of academic study. Basic Appl Soc Psychol. 2006;28:1–16.
90. Oaten M, Cheng K. Longitudinal gains in self-regulation from regular
physical exercise. Br J Health Psychol. 2006;11:717–733.
91. Stemple JC, Glaze L, Klaben B. Clinical Voice Pathology: Theory and
Management. 3rd ed. San Diego, CA: Plural Publishing Inc.; 2000.
92. Thomas L, Stemple JC. Voice therapy: does science support the art? Com-
mun Disord Rev. 2007;1:49–77.
93. Lessac A. The use and Training of the Human Voice. 2nd ed. Mountain
View, CA: Mayfield; 1967.
94. Verdolini-Marston K, Burke MK, Lessac A, Glaze L, Caldwell E. Prelim-
inary study of two methods of treatment for laryngeal nodules. J Voice.
1995;9:74–85.
95. Verdolini Abbott K. Lessac-Madsen Resonant Voice Therapy: Clinician
Manual. San Diego, CA: Plural Publishing; 2008.
96. Stemple JC. A holistic approach to voice therapy. Semin Speech Lang.
2005;26:131–137.
97. Stemple JC, Lee L, D’Amico B, Pickup B. Efficacy of vocal function ex-
ercises as a method of improving voice production. J Voice. 1994;8:
271–278.
98. Ramig LO, Sapir S, Countryman S, et al. Intensive voice treatment
(LSVT) for patients with Parkinson’s disease: a 2 year follow up. J Neurol
Neurosurg Psychiatry. 2001;71:493–498.
99. Smith S, Thyme K. Statistic research on changes in speech due to peda-
gogic treatment (the accent method). Folia Phoniatr. 1976;28:98–103.
100. Stone RE, Casteel RL. Restoration of voice in nonorganically based
dysphonia. In: Phonatory Voice Disorders in Children. Springfield, IL:
Charles C Thomas; 1982:132–150.
101. Verdolini K, Lee TD. Optimizing motor learning in speech interventions:
theory and practice. In: Sapienza CM, Casper J, eds. Vocal Rehabilitation
for Medical Speech-Language Pathology. Austin, TX: PRO-ED; 2004:
403–446.
102. Carver CS, Scheier MF. Control processes and self-organization as com-
plementary principles underlying behavior. Pers Soc Psychol Rev. 2002;6:
304–315.
103. Carver CS. Self-regulation of action and affect. In: Vohs KD, ed. Hand-
book of Self-Regulation: Research, Theory, and Applications. New
York, NY: Guilford Press; 2004:13–39.
104. Carver CS, Scheier MF. Feedback processes in the simultaneous regula-
tion of action and affect. In: Gardner WL, ed. Handbook of Motivation Sci-
ence. New York, NY: Guilford Press; 2008:308–324.
105. Carver CS, Scheier MF. Self-regulation of action and affect. In:
Baumeister RF, ed. Handbook of Self-Regulation: Research, Theory,
and Applications. 2nd ed. New York, NY: Guilford Press; 2011:3–21.
106. Gollwitzer PM, Fujita K, Oettingen G. Planning and the implementation
of goals. In: Vohs KD, ed. Handbook of Self-Regulation: Research,
Descargado para Anonymous User (n/a) en University of the Rosary de ClinicalKey.es por Elsevier en abril 13, 2020.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados.
Journal of Voice, Vol. 27, No. 3, 2013
Theory, and Applications. New York, NY: Guilford Press; 2004:
211–228.
107. Gollwitzer PM. Implementation intentions: strong effects of simple plans.
Am Psychol. 1999;54:493–503.
108. Gollwitzer PM, Schaal B. Metacognition in action: the importance of im-
plementation intentions. Pers Soc Psychol Rev. 1998;2:124–136.
109. Brandst€atter V, Lengfelder A, Gollwitzer PM. Implementation intentions
and efficient action initiation. J Pers Soc Psychol. 2001;81:946–960.
110. Milne S, Orbell S, Sheeran P. Combining motivational and volitional
interventions to promote exercise participation: protection motivation
theory and implementation intentions. Br J Health Psychol. 2002;7:
163–184.
111. Prestwich A, Lawton R, Conner M. The use of implementation intentions
and the decision balance sheet in promoting exercise behaviour. Psychol
Health. 2003;18:707–721.
112. Sheeran P, Orbell S. Using implementation intentions to increase atten-
dance for cervical cancer screening. Health Psychol. 2000;19:283–289.
113. Armitage CJ. Effectiveness of experimenter-provided and self-generated
implementation intentions to reduce alcohol consumption in a sample of
the general population: a randomized exploratory trial. Health Psychol.
2009;28:545–553.
114. Chatzisarantis NLD, Hagger MS. Effects of implementation intentions
linking suppression of alcohol consumption to socializing goals on
alcohol-related decisions. J Appl Soc Psychol. 2010;40:1618–1634.
115. Palfai T. Automatic processes in self-regulation: implications for alcohol
interventions. Cognit Behav Pract. 2004;11:190–201.
116. Armitage CJ. Effects of an implementation intention-based intervention
on fruit consumption. Psychol Health. 2007;22:917–928.
117. Chapman J, Armitage CJ, Norman P. Comparing implementation inten-
tion interventions in relation to young adults’ intake of fruit and vegeta-
bles. Psychol Health. 2009;24:317–332.
118. Verplanken B, Faes S. Good intentions, bad habits, and effects of forming
implementation intentions on healthy eating. Eur J Soc Psychol. 1999;29:
591–604.
119. Luszczynska A. An implementation intentions intervention, the use of
a planning strategy, and physical activity after myocardial infarction.
Soc Sci Med. 2006;62:900–908.
120. Webb TL, Sheeran P. Can implementation intentions help to overcome
ego-depletion? J Exp Soc Psychol. 2003;39:279–286.
121. Gollwitzer PM, Sheeran P. Implementation intentions and goal achieve-
ment: a meta-analysis of effects and processes. In: Zanna MP, ed. Ad-
vances in Experimental Social Psychology, Vol. 38. San Diego, CA:
Elsevier Academic Press; 2006:69–119.
122. Bayer UC, Gollwitzer PM, Achtziger A. Staying on track: planned goal
striving is protected from disruptive internal states. J Exp Soc Psychol.
2010;46:505–514.
123. Bayer UC, Achtziger A, Gollwitzer PM, Moskowitz GB. Responding to
subliminal cues: do if-then plans facilitate action preparation and initia-
tion without conscious intent? Soc Cognit. 2009;27:183–201.