A professional voice user is a person whose job function critically depends on use of the voice. Not only singers and actors but teachers, lawyers, clergy, counselors, air traffic controllers, telemarketers, firefighters, police, and auctioneers are among those who use their voices significantly in their line of work.

Probably the preponderance of professional voice users who seek treatment for voice problems have voice_-induced conditions. Typically, such conditions involve either phonotrauma or functional problems. The full range of non-use-related vocal pathologies may occur in professional voice users as well, at about the same rate as in the population at large. However, special considerations may be required in therapy for professional voice users because of their job demands.

The teaching profession is at highest risk for voice problems. In 1999, teachers made up between 5% and 6% of the employed population in the United States. At any given time, between one-fifth and one-half of teachers in the United States and elsewhere are experiencing a voice problem (Sapir et al., 1993; Russell, Oates, and Greenwood, 1998; E. Smith et al., 1998). Voice problems appear to occur at about the same rates among singers. Other occupations at risk for voice problems are lawyers, clergy, telemarketers, and possibly even counselors and social workers. Increasingly, phonotrauma is considered an occupational hazard in these populations (Villkman, 2000).

A new occupational hazard for voice problems has recently surfaced in the form of repetitive strain injury. This condition, one of the fastest growing occupational injuries in the United States in symptoms may develop if the individual replaces the keyboard with voice recognition software.

The consequences of voice problems for professionals are not trivial and may include temporary or permanent loss of work. Conservative estimates of costs associated with voice problems general, involves weakness and pain from somatic overuse. Symptoms of repetitive strain injury typically begin in the fingers after keyboard use. However, laryngeal in teachers alone are on the order of $2 billion annually in the United States (Verdolini and Ramig, 2001). Thus, voice problems can be devastating both occupationally and personally to many professional voice users.

The goal of treatment for professional voice users is to restore the best possible voice use—and, where relevant, anatomy and physical function—relative to the job in question. Vocal hygiene, including hydration and reflux control, plays a role in most treatment programs for professional voice users (see vocal hygiene). Surgical management may be appropriate in selected cases. However, for most professional voice users, the mainstay of intervention for voice problems is behavioral work on voice production, or voice therapy.

Traditional therapy for phonotrauma in professional groups that use the voice quantitatively (e.g., teachers, clergy, attorneys), that is, over an extended period of time or at sustained loudness, has emphasized voice conservation. In this approach, however, individuals are limited at least as much by the treatment as by the disease. The current emphasis is on training individuals to meet their voice needs while they recover from existing problems, and to prevent new ones. An intermediate vocal fold configuration, involving slight separation of the vocal processes during phonation, appears relevant to this goal (Berry et al., 2001). A variety of training methods are available for this approach to vocalization, including Lessac-Madsen resonant voice therapy (Verdolini, 2000), Vocal Function Exercises (Stemple et al., 1994), the Accent Method (S. Smith and Thyme, 1976), and flow mode therapy (see, e.g., Gauffin and Sundberg, 1989). Training in this general laryngeal configuration appears to be more effective than vocal hygiene intervention alone and more effective than intensive respiratory training in reducing self-reported functional problems due to voice in at least one class of professional voice users, teachers (Roy et al., 2001).

Therapy for individuals with qualitative both qualitative voice needs recognizes that a special sound of the voice is required occupationally. Therapy for performers—singers and actors—with voice problems is conceptually challenging, for many reasons. Vocal performers have exacting voice needs, which may be complicated by pathology; the voice training of singers and actors is not standardized; few scientific studies on training efficacy exist; and performers are subject to a suite of special personality, career, and lifestyle issues. All of these factors make many speech-language practitioners feel that a specialty focus on vocology is important in working with performing artists.

Voice therapy for performers often replicates voice pedagogy methods. The primary differences are an emphasis on injury reduction and a shorter-term intervention, with specific, measurable goals, in voice therapy. The most comprehensive technical framework for professional voice training in general has been proposed by Estill (2000). The system identifies 11 or 12 physical “degrees of freedom,” such as voice onset type, false vocal fold position, laryngeal height, palatal position, and aryepiglottic space, that are independently varied to create “recipes” for a variety of sung and spoken voice qualities. Research conducted thus far has corroborated some aspects of the approach (e.g., Titze, 2002). The system recently has gained currency in voice therapy as well as vocal pedagogy. Voice training for acting tends to be less technically oriented and more “meaning driven” than singing training (e.g. Linklater, 1997). However, exceptions exist. Also, theatre and increasingly singing training and voice therapy incorporate general body work (alignment, movement) as a central part of training.

In respect to training modalities, traditional speech_-language pathology models tend to be more analytical and less experiential than typical performing arts models of training. The motor learning literature indicates that the performers may be right. The literature describes a critical dependence of motor learning on sensory processing and deemphasizes mechanical instruction (Verdolini, 1997; see also Wulf, Höß, and Prinz, 1998). The motor learning literature also clearly indicates the need for special attention to transfer in training. Skills acquired in a clinic or studio may transfer poorly to untrained stimuli in untrained environments if less specific transfer exercises are used. Biofeedback may be a useful adjunct to voice therapy and training; however, cautions exist. Terminal biofeedback, provided after the completion of performance, contributes to greater learning than on-line feedback, which occurs during ongoing performance (Armstrong, 1970, cited in Schmidt and Lee, 1999, pp. 316–317). Also, systematic fading of biofeedback support appears critical for transfer.

The voice therapist may need to address special challenges in the physical and political environments of performers. Stage environments can be frankly toxic, and compromising to vocal and overall physical health. Specific noxious substances that have been measured on stages include aromatic diisocyanates, Penicillium frequentans and formaldehyde in cork granulate, cobalt and aluminum (pigment components), and alveolar-size quartz sand (Richter et al., 2002). Open-air performing environments can present particular vocal challenges to performers, especially if these are unmiked. Heavy costumes weighing 80–90 lb or more and unusual, contorted postures required during vocal performance may add further challenges and may even contribute to injury.

Politically, performers may find themselves contractually linked to heavy performance schedules without the possibility of rest if they are ill or vocally indisposed. Performers are threatened with loss of income, loss of health care benefits, and loss of professional reputation if they refuse to perform when they should not. Another political issue has to do with directors' drive toward meeting commercial goals. Such goals may dictate vocal practices that are at odds with performers' best interest. Directors and producers may sometimes show little concern for performers' vocal health, because numerous vocalists are available to replace injured ones who are unwilling or unable to perform.

It is probably safe to say that individuals who are drawn to vocal performance are more extroverted, and more emotionally variable, on average, than many individuals in the population at large. The vocal practitioner should be comfortable dealing with performers' individual personal styles. Moreover, mental attitude toward performance plays a central role in the performing domain. The principles of sports psychology fully apply to the performing arts. A robust finding is that intermediate anxiety levels, as opposed to low or high anxiety, tend to maximize physical performance. Performers need to find ways to establish intermediate arousal states and stay there even in high-stress situations. Also, the direction of attention appears key for distinguishing “chokers” (people who tend to perform poorly under pressure) from persons who perform well under high stress. According to some reports, chokers tend to show a predominance of left hemisphere activation when under the gun, implying verbal analytic thinking and evaluative self_-awareness. High-level performers tend to show more distributed brain activation, including right-hemisphere activity consistent with imagery and target awareness (Crews, 2001). Many other findings from the sports psychology literature are applicable to attitude issues in vocal performance.

Vocal performers may have erratic lifestyles that are linked to their jobs. Touring groups literally may live on buses. Exercise and fresh air may be restricted. Daily routines may be nonexistent. Pay may be poor and sporadic. Benefits often are not provided unless the performers belong to a union. Vocal performers with voice problems often cannot pay for treatment because their voice problems lead to lack of employment and thus lack of income and benefits. Clinics wishing to work with professional voice users should be equipped to provide some form of fiscal support for treatment.

Practitioners working with vocal performers agree that no single individual can fully assist a vocalist with voice problems. Rather, convergent efforts are required across specialities, to minimally include an otolaryngologist, speech-language pathologist, voice teacher or coach, and, patient. Different individuals take the lead, depending on the issues at hand. The physician is responsible for medical issues. The speech-language pathologist and voice teacher generally work together on technical issues. The voice teacher is the most appropriate person to address career issues with the performer, particularly issues that bear on a potential mismatch between the individual's aspirations and capabilities. The importance of communication across individuals within the team cannot be overemphasized.