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Effects of an 8-Week Mindfulness Course in People With Voice
Disorders
⁎,†
Catherine Kay Brown,
‡
Julinette Vazquez,
‡
Stacie M. Metz, and
⁎
Donald McCown, ⁎‡West Chester, and
†Immaculata, Pennsylvania
Summary: Objectives. Nearly every modern textbook on the etiology and treatment of voice disorders (VD)
recommends stress reduction for VD patients. The benets of mindfulness for stress reduction are well docu-
mented, but published literature on mindfulness and VD is sparse. Our objective was to determine whether an 8-
week mindfulness course could increase mindfulness and lower stress in people with VD, leading to a decrease in
vocal handicap.
Study Design. Mixed methods study.
Methods. Participants: 69 individuals with VD: 39 were mindfulness course participants (MCP), 30 were in a
waitlist control group (WCG). Exclusionary criteria: patients in voice therapy. Before and after the 8-week
timeframe, participants took the Mindful Attention and Awareness Scale (MAAS), Perceived Stress Scale-10
(PSS-10), Voice Handicap Index (VHI), and—for singers (n = 36)—the Singing Voice Handicap Index (SVHI).
Follow-up interviews were conducted with select participants.
Results. In the MCP, each of the outcomes signicantly changed in the direction hypothesized, resulting in
increased MAAS (P = 0.000) and decreased PSS-10 (P = 0.007), VHI (P = 0.000), and SVHI (P = 0.021, n = 22)
scores. Using a 2 × 2 Repeated Measures ANOVA, two outcomes were statistically different for the MCP from
pre to postcourse—MAAS increased (P = 0.006, ES = 0.107) and VHI decreased (P = 0.034, ES = 0.065)—in
comparison to no change in the WCG. Follow-up interviews revealed increased acceptance of the VD; reduced
stress, physical tension, and pain/discomfort; increased somatic (or interoceptive) awareness; community with
other VD patients; and positive speaking and singing voice changes.
Conclusions. An 8-week mindfulness course shows promise for reducing stress in people with VD, lowering
voice handicap, and improving quality of life. Future research should evaluate mindfulness in patients with
specic voice disorders; patients with higher and lower VHI scores; singers; and patients who experience throat
pain. Mindfulness should also be evaluated within a standard voice therapy protocol.
Key Words: Mindfulness–Meditation–Mindfulness-based stress reduction–Voice disorders–Voice
therapy–Singing voice.
INTRODUCTION
People with voice disorders often experience high stress
levels
1,2
; physical tension, pain, or discomfort
3,4
; social
and emotional isolation
5
; and loss of work opportunities,
sense of self, and ability to communicate.
6
Nearly every
modern textbook on the etiology and treatment of voice
disorders recommends stress reduction as both a pre-
ventive and therapeutic tool for professional voice users
and patients with voice disorders. Many specically
mention meditation and yoga, with occasional references
to Mindfulness-Based Stress Reduction (MBSR).
7
How-
ever, published literature on mindfulness as an interven-
tion for patients with voice disorders is sparse,
8
though
several studies are underway. Any benets of mindfulness
that are cited typically come from studies that do not di-
rectly involve voice use, as there have been no studies
testing the effects of Mindfulness-Based Interventions
(MBIs) in people with voice disorders.
While mindfulness as a practice has been dened as in-
tentional “non-elaborative” awareness in the present mo-
ment without judgment,
9
MBIs are structured, multiweek
group mindfulness classes led by a trained mindfulness
instructor. The two most common MBIs are MBSR, which
is often recommended for people with chronic physical
health problems, and Mindfulness-Based Cognitive
Therapy, which was designed for people at high risk of
depressive relapse.
10
According to Shapero’s summary of
MBIs in psychiatry, the programs
generally consist of eight weekly 2- to 2.5-hour classes that
carry approximately 12 patients. Additionally, these pro-
grams also often include a one-day retreat. A key feature of
MBIs is the education in formal and informal mindfulness
meditation practices to train both the attentional control
component as well as the nonjudgmental attitudinal aspects
of mindfulness. … MBIs have a signicant homework com-
ponent with guided (often with audio recording) and un-
guided meditation practices that are assigned as daily home
practice. …
Accepted for publication October 26, 2023.
Journal of Voice, Vol xx, No xx, pp. xxx–xxx
0892-1997
© 2023 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jvoice.2023.10.031
Presentation: Presented as a poster at the Voice Foundation’s 52nd Annual
Symposium, Philadelphia, PA, June 1, 2023.
From the
⁎
West Chester University of Pennsylvania, Department of Public Health
Sciences, Center for Contemplative Studies, West Chester, Pennsylvania;
†Immaculata University, Department of Music, Immaculata, Pennsylvania; and the
‡West Chester University of Pennsylvania, Department of Public Health Sciences,
West Chester, Pennsylvania.
Address correspondence and reprint requests to Catherine Kay Brown, 239
Buchanan Court, Downingtown, PA 19335.
E-mail: catherine@catherinekbrown.com
Another important aspect of MBIs is a group-based ex-
ploration of individual experiences, referred to as inquiry.
During the group discussions, participants share their per-
sonal experiences of difculty and success in practicing
mindfulness. Through this discussion, participants learn
from one another via modeling and direct feedback.
11
Despite the dearth of research, there are many reasons to
think that structured mindfulness interventions would be
helpful for a voice disordered population. MBIs have been
shown to reduce stress
12
and help patients manage chronic
pain,
13
loneliness,
14
grief related to illness,
15
chronic ill-
ness,
16
and medically unexplained symptoms.
17
The group
format of MBIs provide participants with a sense of com-
munity, as they learn to practice mindfulness together.
Additionally, mindfulness encourages reappraisal, a pro-
cess by which we reframe the meaning of adverse events to
alter their emotional impact.
18,19
The purpose of this study was to determine whether an 8-
week mindfulness course could increase mindfulness and
lower stress in people with voice disorders, leading to a
decrease in vocal handicap.
MATERIALS AND METHODS
Experimental Design
This study is a mixed-method, non-randomized investiga-
tion of the effects of an 8-week mindfulness course, mod-
eled after the MBSR curriculum, in people with voice
disorders. The West Chester University Institutional
Review Board approved the protocol (IRB-FY2022-11).
Participants
Inclusion criteria included the diagnosis of a voice disorder.
All participants were aged 18 years or older. Participants
self-identied as male or female. The ability to speak
clearly, loudly, or consistently was not required.
Individuals in voice therapy at time of the study were
excluded. As is standard practice in mindfulness research
studies, potential participants were cautioned that an 8-
week mindfulness course might not be appropriate for
people who have an active addiction; are suicidal; or have
untreated psychosis, post-traumatic stress disorder
(PTSD), depression, or anxiety that would interfere with
their ability to complete the course.
Recruitment occurred via emails sent to a list of several
hundred voice providers, including laryngology practices,
voice specialist speech-language pathologists, and singing
voice specialists; Facebook groups for voice providers,
voice disorder patients, and singing voice teachers; and a
listing on the National Association of Teachers of Singing
website.
Potential subjects were directed to a secure Qualtrics
online questionnaire to help determine eligibility.
Participants reported their diagnoses and any treatment
received through the online form. The form included a
drop-down menu of voice disorders that potential partici-
pants could select, as well as a write-in option. It also
included a drop-down menu of treatments received, plus a
write-in option.
Participants who t the criteria were contacted by email
and invited to participate in the study. No compensation
was given, but an 8-week mindfulness course is normally
valued from $250–$500.
Procedures
After signing an informed consent form and prior to the
start of the 8-week mindfulness course, participants lled
out the following validated self-report questionnaires:
Mindful Attention Awareness Scale (MAAS), Perceived
Stress Scale-10 (PSS-10), Voice Handicap Index (VHI),
and—for those who self-identied as singers—Singing
Voice Handicap Index (SVHI). All responses were collected
through Qualtrics.
The MAAS is a 15-item scale that measures dispositional
mindfulness, “the tendency to engage in self-examination,
reection, introspection, and related cognitive activities.”
20
The scale shows strong psychometric properties and has
been validated with various populations, including college
students, community members, and cancer patients. The
PSS-10 measures the degree to which an individual per-
ceives situations in their life as stressful.
21
The VHI is a 30-
question tool to assess a patient’s perception of the impact
of their voice disorder on daily life.
22,23
The SVHI is a 36-
question tool based on the VHI and adapted for the specic
needs of singers.
24
The mindfulness curriculum was developed and taught
by the rst author/primary investigator as part of a grad-
uate certicate in applied mindfulness at West Chester
University. She is a private voice teacher who was diag-
nosed with three voice disorders: post-viral vocal fold
paresis (twice, 20 years apart; rst unilateral, then bi-
lateral), secondary muscle tension dysphonia (MTD), and
sulcus. Her own experience with using mindfulness to
manage MTD led her to investigate whether mindfulness
could help others with voice disorders. She holds a B.A. in
music from St. Olaf College and recently became an ad-
junct voice instructor at Immaculata University.
The mindfulness course took place over 8 weeks (or, in
some cases, 9 weeks due to holidays or professional ob-
ligations). We chose a format that was modeled on the
MBSR curriculum and shaped by McCown’s books
Teaching Mindfulness: A Practical Guide for Clinicians and
Educators
25
and Resources for Teaching Mindfulness: An
International Handbook.
26
We made some adaptations that
we felt would be helpful for a voice disordered population.
(Mindfulness programs are frequently adapted for specic
populations, and guidelines exist to help practitioners make
appropriate changes.
27
) The course was delivered over
Zoom for several reasons. First, it allowed a greater
number of participants from the niche population. Second,
it gave participants the opportunity to contribute to class
discussions through the Chat feature, which allowed par-
ticipants to type their thoughts. We felt it was important to
acknowledge and accommodate the reality that many
Journal of Voice, Vol. xx, No. xx, xxxx 2
people with voice disorders need to carefully ration their
voice use to avoid vocal fatigue, pain, and/or temporary
voice loss. Also, as the classes took place during the global
coronavirus (SARS-CoV-2) pandemic, the Zoom format
allowed participants to avoid making stressful decisions
about whether in-person group meetings were safe for them
at the time. We felt this was particularly important for a
vocally vulnerable population, given that infection with
SARS-CoV-2 can cause a variety of voice disorders
28–33
and worsen existing symptoms.
Instead of the traditional MBSR format of eight 2.5-
hour sessions, plus one full day session, we did eight 2-hour
sessions and no full-day session, which we felt was better
suited to Zoom. However, we chose to avoid the 1-hour
class time popularized in low-dose MBSR
34
because we felt
that people with voice disorders would benet from longer
class times, which would allow for deeper discussion and
more meaningful connections among participants. While
traditional MBSR classes include an expectation of
30–45 minutes of home practice, we chose to follow the
low-dose expectation of 20 minutes.
Another minor departure from a typical MBSR class was
our approach to yoga (sometimes called mindful move-
ment). MBSR teachers frequently divide yoga into standing
postures and lying down postures, but the protocol allows
for exibility in this area. The primary investigator/mind-
fulness teacher worked with voice teacher and yoga
therapist Sarah Whitten to identify simple mindful yoga
exercises that address issues commonly experienced by
people with voice disorders (specically, exploring tension
in the neck, shoulders, thoracic spine, and pelvis). Whitten
has extensive experience using yoga as a tool to help people
with voice problems. She holds an M.A. in Vocal Pedagogy
and an M.M. in Vocal Performance (both from Ohio State
University) and has completed additional coursework in
voice disorders at the Massachusetts General Hospital
Institute of Health Professionals. She is a 500-hour
Certied Yoga Teacher, a Certied Yoga Therapist, and a
former member of the voice faculty at Harvard University.
In keeping with MBSR practices, the course followed a
clear structure with teaching intentions, discussion topics,
and assigned homework for each week. Each class, except
for the nal week, included 10–20 minutes of yoga. The
following mindfulness exercises, all standard in any MBSR
class, were assigned as homework: body scan, sitting
meditation, walking meditation, a 20-minute yoga practice,
mountain meditation, loving kindness meditation, and ex-
panding awareness meditation. Participants were given
access to recordings of each meditation practice recorded
by the primary investigator/mindfulness teacher. They also
had access to a video of the 20-minute yoga practice, plus
four additional shorter videos of yoga sequences that were
used in class but were not assigned as homework. This
allowed participants the exibility to choose movement
practices based on their own physical condition and/or
limitations. In keeping with MBSR best practices, the vi-
deos were created by and featured the mindfulness teacher.
Discussion topics included the differences between formal
practice and mindful awareness in everyday life, the stress
response, the toll of emotional reactivity on health (in-
cluding the voice) and responding to grief, loss, and phy-
sical and emotional discomfort. The nal class included an
introduction to additional resources for living mindfully
with a voice disorder.
After the nal class, participants lled out the ques-
tionnaires again. Follow-up interviews with select partici-
pants were conducted after the mindfulness course was
complete.
Participant Recruitment
Mindfulness course participants (MCP) were recruited for
a course that ran from March to May 2022 and was divided
into three sections to keep class sizes conducive to discus-
sion. Thirty-eight people signed the informed consent form,
and 17 of those who attended the mindfulness course ended
up meeting the criteria for inclusion in the study. (This
required completing all relevant questionnaires and at-
tending at least six of the eight mindfulness classes.) We
recruited again for a course that ran from October to
November 2022 and was divided into two sections. An
additional 42 people signed the informed consent form, and
22 people ultimately met the inclusion criteria. We re-
cruited a third time at the beginning of 2023. This group
was assigned to a waitlist control group (WCG). Forty-one
people signed the informed consent form, and 30 met the
inclusion criteria. (This required completing all relevant
questionnaires both before and after an 8-week waiting
period.) All control group participants were offered the
opportunity to take a mindfulness course that ran from
April to June 2023.
Participant Demographics
Most participants were female in both the MCP (92.31%)
and the WCG (83.33%) (Table 1). Data show that women
are more likely than men to seek health care, particularly if
their symptoms cause psychosocial distress.
35
Epidemiolo-
gical research by Roy et al suggest that women may be close
to twice as likely as men to have a voice disorder.
36
Fur-
thermore, women are more likely than men to participate in
mindfulness-based research. Waldron et al conducted a
systematic review of the demographic characteristics of
participants in US-based randomized controlled trials of
MBIs. They calculated: “Of all participants in the 67 studies,
3492 out of 4958 (70%) were women.”
37
We did not limit our research to specic voice disorders or
categories of voice disorders. Because we were not recruiting
through a voice center, we were concerned about our ability to
recruit enough participants. Therefore, we wanted to recruit as
broadly as possible. The most common voice disorders in-
cluded MTD (MCP 37.26%, WCG 41.67%), spasmodic dys-
phonia (SD) (MCP 21.57%, WCG 30.56%), and vocal fold
paresis/paralysis (VFP/P) (MCP 19.61%, WCG 19.44%).
Other voice disorders included vocal fold (VF) lesions,
Catherine Kay Brown, et al Effects of a Mindfulness Course in Voice Disordered People 3
essential vocal tremor (EVT), velopharyngeal insufciency
(VPI), laryngospasms, and VF web (Table 1).
Because the mindfulness course was delivered over
Zoom, we accepted participants from across the United
States (MCP 71.80%, WCG 63.33%) and around the world
(Table 1).
Additionally, we chose not to exclude patients who had
undergone surgery for their voice disorder or SD patients who
were receiving Botox. We felt Botox patients with SD could
still benet from the course and did not want to ask them to
stop treatment that they found helpful. Additionally, for long-
term Botox patients, Botox treatment has become part of their
normal experience, and we wanted to see how mindfulness
might impact that norm. Of the 69 study participants, 12
(8.28%) received Botox prior to or during the mindfulness
study period; this included MCG Spring (n = 3) and MCG
Fall (n = 2) (Table 4a) and WCG (n = 7) (Table 4b).
The participants’ beginning mean VHI score indicated a
relatively high level of disorder. The MCP had a mean VHI
of 62.31 (SD = 22.69, range = 13–103), and the WCG had a
mean VHI of 71.13 (SD = 20.44, range = 30–115). A score
of 31–60 indicates moderate vocal handicap and 61–120 is
severe.
38
These scores are particularly high given that all
patients had received treatment and nearly all had received
voice therapy (Table 1), indicating that the study had at-
tracted participants with voice disorders that were both
chronic and severe.
Statistical Analysis
Descriptive statistics were computed using SPSS 29.0 sta-
tistical software. In the MCP, paired t-tests examined sta-
tistical change in each outcome from pre to postcourse. A
2 × 2 Repeated Measures Analysis of Variance (ANOVA)
computed group * time interaction results. These tests
Table 1.
Participant Demographics
MCP Spring 2022
(n = 17)
MCP Fall 2022
(n = 22)
MCP Combined
(n = 39)
WCG
(n = 30)
Age—Mean (SD) 50.35 (14.59) 53.18 (14.10) 51.95 (14.19) 50.10 (11.46)
Sex, n (%)
Male 1 (5.88%) 2 (9.09%) 3 (7.69%) 5 (16.67%)
Female 16 (94.12%) 20 (90.91%) 36 (92.31%) 25 (83.33%)
Diagnosis* (% of total VDs) Total # of VDs = 21 Total # of VDs = 30 Total # of VDs = 51 Total # of VDs = 36
MTD 10 (47.62%) 9 (30.00%) 19 (37.26%) 15 (41.67%)
SD 4 (19.05%) 7 (23.33%) 11 (21.57%) 11 (30.56%)
VFP/P 3 (14.29%) 7 (23.33%) 10 (19.61%) 7 (19.44%)
VF lesions 1 (4.76%) 4 (13.33%) 5 (9.80%) 1 (2.78%)
EVT 2 (9.52%) 2 (6.67%) 4 (7.84%) 0 (0.0%)
VPI 1 (4.76%) 0 (0.0%) 1 (1.96%) 1 (2.78%)
Laryngospasms 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (2.78%)
VF web 0 (0.0%) 1 (3.33%) 1 (1.96%) 0 (0.0%)
Number of VDs, n (% of
participants)
1 VD 12 (70.59%) 15 (68.18%) 27 (69.23%) 24 (80.0%)
2 or more VDs 4 (23.53%) 7 (31.82%) 11 (28.21%) 6 (20.0%)
Unsure* 1 (5.88%) 0 (0.0%) 1 (2.56%) 0 (0.0%)
Beginning VHI—Mean (SD, range) 56.00 (21.20, 13−96) 67.18 (23.07,
13−103)
62.31 (22.69,
13−103)
71.13 (20.44,
30−115)
Received voice therapy, n (%)
Yes 16 (94.12%) 20 (90.91%) 36 (92.31%) 28 (93.33%)
No 1 (5.88%) 2 (9.09%) 3 (7.69%) 2 (6.67%)
Location, n (%)
USA 12 (70.59%) 16 (72.73%) 28 (71.80%) 19 (63.33%)
Canada 3 (17.65%) 3 (13.64%) 6 (15.39%) 4 (13.33%)
UK 1 (5.88%) 0 (0.0%) 1 (2.56%) 5 (16.67%)
Australia 0 (0.0%) 0 (0.0%) 0 (0.0%) 2 (6.67%)
Finland 1 (5.88%) 0 (0.0%) 1 (2.56%) 0 (0.0%)
Greece 0 (0.0%) 1 (4.55%) 1 (2.56%) 0 (0.0%)
Latvia 0 (0.0%) 1 (4.55%) 1 (2.56%) 0 (0.0%)
Pakistan 0 (0.0%) 1 (4.55%) 1 (2.56%) 0 (0.0%)
Abbreviations: EVT, essential vocal tremor; MTD, muscle tension dysphonia; VFP/P, vocal fold paresis/paralysis; VPI, velopharyngeal insufficiency; SD,
spasmodic dysphonia.
*
In the MCP Spring cohort, one participant (not accounted for in the diagnoses above) said her doctor was unsure whether she had MTD, SD, or both.
Journal of Voice, Vol. xx, No. xx, xxxx 4
examined if the outcomes were statistically different be-
tween groups (MCP vs WCG) and over time (pre vs post).
Signicance level was set at < 0.05. The produced partial
eta squared effect size (ES) estimates measured the mag-
nitude of treatment effect and are interpreted as small
(0.01-0.05), medium (0.06-0.13), and large (0.14 or higher).
Participant qualitative interview responses were tran-
scribed, and thematic content was coded and analyzed in
the qualitative research software program Dedoose.
RESULTS
Summary of Outcomes
In the MCP, each of the outcomes signicantly changed in
the direction hypothesized (Table 2). When compared to
the WCG, two outcomes were statistically different be-
tween the two groups pre vs postcourse: MAAS increased
and VHI decreased (Table 3), as hypothesized.
Follow-up interviews revealed increased acceptance of
the voice disorder(s); reduced stress, physical tension, and
pain/discomfort; increased somatic (or interoceptive)
awareness; community with other voice disorder patients;
and positive speaking and singing voice changes. Highly
trained classical singers who were active professional
performers experienced no vocal benet, but the small
sample (n = 3) may not be representative of that popu-
lation.
Primary Outcomes
In the MCP group alone, paired t-tests assessed statistical
differences in mean outcomes from pre to posttest
(Table 2). On average, the MCP (n = 39) experienced sta-
tistically signicant changes as hypothesized. MAAS
(P = 0.000*) scores increased while PSS-10 (P = 0.007),
VHI (P = 0.000), and SVHI (P = 0.021, n = 22) scores
decreased. The mean VHI score of 62.3 decreased to 51.5
after the course. This is nearly an 11-point change. Per
Barsties’ article, “The effectiveness of voice therapy on
voice-related handicap: A network meta-analysis,” the
average change in VHI scores pre-post voice therapy is 13
points.
39
Additionally, the VHI can be broken down into
three subscales: functional, emotional, and physical. Each
of these individual measures also decreased, as hypothe-
sized (Table 2).
Two-way repeated measures ANOVA tests examined
whether the outcomes were statistically different between
groups (MCP vs WCG) and over time (pre vs postcourse).
When the MCP was compared to the WCG, group-by-time
interactions were signicant for the MAAS (P = 0.006,
ES = 0.107) (Figure 1) and VHI (P = 0.034, ES = 0.065)
(Figure 2), but not for the PSS-10 (P = 0.057, ES = 0.053)
or SVHI (P = 0.084, ES = 0.086) (Table 3). The SVHI had
a smaller sample size (MCP, n = 22; MCG, n = 14) than the
other measures, as not all participants identied as singers.
Of the three subscales of the VHI, only functional
(P = 0.034, ES = 0.066) showed signicant interactions
(Table 3).
Qualitative Analysis of Participant Experiences
The rst author/primary investigator conducted semi-
structured follow-up interviews with nine MCP parti-
cipants (four from the spring cohort, ve from fall). The
goal of the interviews was to gather more detail on the
Table 2.
MCP Outcomes at Pre to Posttest (n = 39)
Pre Post
Outcome Mean SD Mean SD t P
MAAS 55.1 9.5 60.9 9.7 −4.0 0.000*
PSS-10 22.9 3.2 21.4 2.6 2.9 0.007*
VHI Total 62.3 22.7 51.5 19.7 5.2 0.000*
VHI Functional 21.1 9.4 17.4 8.0 3.9 0.000*
VHI Emotional 20.4 7.7 16.6 7.0 3.9 0.000*
VHI Physical 20.7 7.8 17.5 6.4 4.4 0.000*
SVHI (n = 22) 94.2 23.8 84.9 19.6 2.5 0.021*
*
P < 0.05.
Table 3.
2 × 2 Repeated Measures ANOVA Interactions of Outcomes by Group and Time
MCP (n = 39) WCG (n = 30)
Pre Post Pre Post
Outcome Mean SD Mean SD Mean SD Mean SD F P ES
MAAS 55.1 9.5 61.0 9.7 53.5 13.1 53.9 13.7 8.0 0.006* 0.107
PSS-10 22.9 3.2 21.4 2.6 22.6 3.6 22.6 3.2 3.7 0.057 0.053
VHI Total 62.3 22.7 51.5 19.7 71.1 20.4 67.3 23.6 4.7 0.034* 0.065
VHI Functional 21.1 9.4 17.4 8.0 23.2 8.8 22.6 8.7 4.7 0.034* 0.066
VHI Emotional 20.4 7.7 16.6 7.0 24.5 7.4 23.0 9.8 2.6 0.114 0.037
VHI Physical 20.7 7.8 17.5 6.4 23.4 7.1 21.7 7.8 1.9 0.176 0.027
SVHI
†
94.2 23.8 84.9 19.6 93.4 30.7 93.7 31.1 3.2 0.084 0.086
Abbreviation: ES, interaction effect size (partial eta square).
*
P < 0.05.
†
Sample size is n = 22 for MCP and n = 14 for WCG.
Catherine Kay Brown, et al Effects of a Mindfulness Course in Voice Disordered People 5
Table 4a.
Botox Recipients: Mindfulness Course Participants
Course Dates (Length in Days) Patient # Gender Age
Botox Date/s (Days Between Treatment
Date and Start of Study)
VHI Pre/Post (Points
Change)
MAAS Pre/Post (Points
Change)
Spring, 3/27/22−5/24/22 (58 d) SBR-1* F 51 8/26/21
†
(213 d) 96/89 (−7 pts) 57/66 (+9 pts)
Spring, 3/27/22−5/24/22 (58 d) SBR-2 F 31 1/7/22 (79 d) 68/69 (+1 pt) 53/57 (+4 pts)
Spring, 3/27/22−5/24/22 (58 d) SBR-3 F 41 12/9/21
†
(108 d) 71/61 (−10 pts) 36/48 (+12 pts)
12/28/21
†
(89 d)
Fall, 10/2/22−11/22/22 (51 d) FBR-1
‡
F 70 8/23/22 (41 days) 88/64 (−24 pts) 58/69 (+11 pts)
11/22/22 (−52 d; took VHI 8 d later)
Fall, 10/2/22−11/22/22 (51 d) FBR-2 M 59 9/10/22 (33 d) 65/60 (−5 pts) 64/65 (+1 pt)
Mean age (SD) = 50.40 (15.19).
Mean VHI pre/post (SD) [pts change] = 77.60 (13.61)/68.60 (11.93) [−9.0 pts change].
Mean MAAS pre/post (SD) [pts change] = 53.60 (10.60)/61.0 (8.51) [+7.40 pts change].
*
Spring Botox Recipient.
†
Treatment not effective.
‡
Fall Botox Recipient.
Table 4b.
Botox Recipients: Waitlist Control Group
Course Dates (Length in Days) Patient # Gender Age
Botox Date/s (Days Between
Treatment Date and Start of Study)
VHI Pre/Post (Points
Change)
MAAS Pre/Post (Points
Change)
Waitlist, 2/19/23−4/22/23 (62 d) WBR-1* F 61 2/13/23 (6 d) 82/98 (+16 pts) 64/70 (+6 pts)
4/27/23 (−68 d)
Waitlist, 2/19/23−4/22/23 (62 d) WBR-2 F 61 12/2/22 (80 d) 90/80 (−10 pt) 48/48 (0 pt)
3/10/23 (−12 d)
Waitlist, 2/19/23−4/22/23 (62 d) WBR-3 F 67 4/18/23 (−59 d) 58/51 (−7 pts) 79/76 (−3 pts)
Waitlist, 2/19/23−4/22/23 (62 d) WBR-4 F 25 1/27/23 (23 d) 85/82 (−3 pts) 54/48 (−6 pts)
Waitlist, 2/19/23−4/22/23 (62 d) WBR-5 F 52 3/16/23 (−26 d) 55/45 (−10 pts) 58/57 (−1 pts)
Waitlist, 2/19/23−4/22/23 (62 d) WBR-6 M 50 11/11/22 (101 d) 92/96 (+4 pts) 56/55 (−1 pts)
3/10/23
†
(−12 d)
Waitlist, 2/19/23−4/22/23 (62 d) WBR-7 F 55 12/20/22 (62 d) 61/62 (+1 pts) 59/65 (+6 pts)
Mean age (SD) = 53 (13.68).
Mean VHI pre/post (SD) [pts change] = 74.71 (16.06)/73.43 (21.10) [−1.28 pts change].
Mean MAAS pre/post (SD) [pts change] = 59.71 (9.81)/59.86 (10.82) [+0.14 pts change].
*
Waitlist Botox Recipient.
†
Treatment not effective.
Journal of Voice, Vol. xx, No. xx, xxxx 6
participants’ experiences in the course, including in-
formation that may not have been captured by the
questionnaires, and to determine what, if any, outside
factors may have inuenced the questionnaire
scores.
Due to limited resources, the rst author/primary in-
vestigator—who also taught the mindfulness course—-
conducted the interviews, transcribed and coded them,
conducted thematic analysis of the content, summarized
the ndings, and chose examples that were representative
of each theme. Six interviewees (three from spring, three
from fall) were chosen because their scores changed dra-
matically in the direction hypothesized. They are subse-
quently referred to as the mindfulness-responsive
interviewees (MRI). The other three (one from spring, two
from fall), all highly trained classical singers who were
active performers, were chosen because their scores
changed very little or moved in the opposite direction hy-
pothesized. They are subsequently referred to professional
singer interviewees (PSI).
FIGURE 1. Mean MAAS scores by group and time.
FIGURE 2. Mean VHI scores by group and time.
Catherine Kay Brown, et al Effects of a Mindfulness Course in Voice Disordered People 7
Mindfulness-Responsive Interviewees
The MRI group began the mindfulness course with a
mean VHI of 74.83 (SD = 24.59), which decreased to
49.17 (SD = 23.33), a decrease of 25.66 points, after the
course ended. Their diagnoses were EVT, primary
MTD, MTD secondary to Ehlers-Danlos syndrome, SD
with secondary MTD, VFP/P with secondary MTD, and
VFP/P with secondary MTD and vocal nodules
(Table 5). (The interviewee with SD/MTD had not re-
ceived Botox for several years.)
The largest theme to emerge from the MRI group was
psychological change, which was mentioned 36 times.
Subthemes included acceptance, including acceptance of the
voice disorder itself (“Mindfulness … helped me be in a
more accepting state of mind …, just feeling more accepting
of having the disorder,” “You don’t have the voice you had,
you have the voice you have”), reduced stress (“I’m not as
stressed about little things”), increased condence (“I think
my voice just sounds a little more condent than it used to”),
gratitude (“[It was] helpful to tap into the emotional ex-
perience of living with a voice disorder and still nding
gratitude”), and reduced emotional reactivity.
The second largest theme was awareness (23 mentions),
including somatic (or interoceptive) awareness, with the
subtheme of awareness of physical tension (“I would say
that my biggest takeaway is recognizing when I start to feel
tense in my neck and throat area”), and awareness of voice
and breath (“I just will stop and think … and just pay
attention to my breathing”).
The third theme was community (21 mentions), in-
cluding connection with other people with voice disorders
(“Thank you for bringing me together with other voice
disordered people,” “Seeing other people with the same
conditions, similar conditions, hearing their stories, it was
incredible”), the ability to participate in community
without pressure to speak (“Being in a setting where you’re
free to be you, no demands, no shoulds, no have tos,” “I
found this course to be very effective for me because I was
able to show up however I needed to. Like, if I couldn’t
talk that day, I was still allowed to participate”), gaining
perspective from hearing people with more severe voice
disorders, support from the group, and increased commu-
nicative participation in everyday life (“I’m able to talk to
people for a long time, and it will vary, but I am having
those connections more”).
The fourth theme was physical changes (18 mentions),
including reduced pain/soreness, reduced physical tension
(“The overall level of physical tension has denitely gone
down”), and improved breathing (“I think the breathing
issues that I sometimes felt are not as prevalent”) and
posture (“After I am mindful or meditate, my neck is
elongated and it’s not all crunched up, my shoulders are
down, and I’m in the proper position”).
The fth theme was the singing voice (16 mentions): “It
was easier to sing. … And I became aware that I was able
to sing high notes.” “I started to feel a greater sense of
control in the [singing] voice.”
The sixth theme was the speaking voice (13 mentions),
including a stronger speaking voice (“It’s really helped me
get that strength back in the voice”), increased vocal ease,
(“[I have] a new sense of ease with speaking”), improved
intelligibility, increased vocal clarity, improved vocal re-
liability (“I’m no longer afraid that I will not be able to
produce voice at least four days a week”), reduced spasms,
increased stamina, and reduced vocal strain. (“I feel like
overall I noticed a stronger voice, and also fewer spasms
and greater vocal clarity.”).
The seventh theme was agency
40
(6 mentions), including
agency over physical symptoms and emotional reactivity
(“The fact that I can—that I—can reduce the pain myself,
calms everything else down”).
Professional Singer Interviewees
As expected for actively performing singers, the PSI group
began the mindfulness course with a relatively low mean
VHI of 27 (SD = 13.12). Their post mindfulness mean VHI
was 33.67 (SD = 8.14), an increase of 6.67 points. In con-
trast to the results from the mindfulness course group as a
whole, this subset experienced a decrease in mean MAAS
scores and increase in mean PSS-10 and SVHI scores. Their
diagnoses were MTD, VFP/P with vocal fold lesion, and
VPI (Table 5).
The interview themes centered around extraneous vari-
ables (50 mentions), including illness (16), performance-
related stress (14), voice-related stress (6), and general
stress (4). Near the end of the mindfulness course, one
participant became ill while performing in the world pre-
miere of a new opera. Another participant was diagnosed
with cancer, which her doctor believed had been slowly
developing over several years, a few months after the
course ended. The researchers believe these themes reect
the delicate interplay of performance stress, illness, and an
existing voice disorder in professional singers, whose in-
strument is part of their body.
Two singers said that being in a group with people who
were much more disordered than they were gave them a
sense of perspective on their own problems. However, one
singer expressed that it wasn’t the right group for her be-
cause there were so few singers in her section. “I was
thinking that … would’ve been an interesting experience …
if I were a singer with other singers. … Because I feel like
voice disorders in general are not things that are often
discussed. … So, when you’re a singer in that situation, it’s
very isolating.”
Another factor that came up in interviews is that one
singer had a longtime yoga practice, and another was an
experienced yoga teacher. While other patients may have
benetted from the somatic awareness that is incorporated
into mindfulness training, the professional singers probably
already had that awareness. Indeed, at the beginning of the
course, the yoga teacher had a much higher MAAS score
(69) than the group mean (M = 55.1, SD = 9.7).
Journal of Voice, Vol. xx, No. xx, xxxx 8
DISCUSSION AND FUTURE DIRECTIONS
In the MCP, each of the outcomes measured changed sig-
nicantly in the direction hypothesized. However, when
compared to the WCG, the changes to PSS-10 and SVHI
were not statistically signicant. While we expected the
increase in MAAS to be accompanied by a stronger de-
crease in PSS-10, we suspect that the pandemic and its
accompanying economic, societal, and political changes
may have kept stress scores from falling further. As men-
tioned earlier, the role of a virus that is known to cause and
worsen voice disorders should not be discounted.
Several factors may explain the smaller decrease in SVHI
when compared to VHI. Certainly, statistical signicance
was hindered by the smaller sample size (MCG, n = 22;
WCG, n = 14), as only about half the participants self-
identied as singers.
While we do not know exactly why or how the mind-
fulness course led to a decrease in VHI, the researchers
suspect that increased somatic (or interoceptive) awareness
played a role.
41
(Given the relatively small decrease in PSS-
10 scores, it is possible that somatic awareness is more
important to vocal improvement than the stress reduction
frequently recommended in voice textbooks.) Voice
therapy, which is typically part of the treatment plan for
any voice disorder, teaches behavioral change regarding
voice production. For voice disorder patients without prior
singing or speaking voice training, the process can feel
daunting. They may not have thought about their voice
until it was clear that something was wrong. For these
patients, the somatic awareness that is incorporated into
mindfulness training may be an entirely new area of ex-
ploration and may lead to quicker changes in vocal be-
havior.
In contrast, trained singers are experts in producing
nuanced vocal change. When something goes wrong and a
voice disorder develops, singers become even more aware
Table 5.
Demographics of Interviewees
MRI (n = 6) PSI (n = 3) MCP Combined (n = 39)
Age—M (SD) 52.50 (14.86) 42.67 (8.51) 51.95 (14.19)
Sex, n (%)
Male 0 (0.0%) 0 (0.0%) 3 (7.69%)
Female 6 (100%) 3 (100%) 36 (92.31%)
Diagnosis, n (% of total VDs) Total # of VDs = 10 Total # of VDs = 4 Total # of VDs = 51
MTD 5 (50.0%) 1 (25.0%) 19 (37.26%)
SD 1 (10%) 0 (0.0%) 11 (21.57%)
VFP/P 2 (20%) 1 (25%) 10 (19.61%)
EVT 1 (10%) 0 (0.0%) 4 (7.84%)
VF lesions 1 (10%) 1 (25.0%) 5 (9.80%)
VPI 0 (0.0%) 1 (25.0%) 1 (1.96%)
Laryngospasms 0 (0.0%) 0 (0.0%) 0 (0.0%)
VF web 0 (0.0%) 0 (0.0%) 1 (1.96%)
Number of voice disorders, n (% of
participants)
1 VD 3 (50.0%) 2 (66.67%) 27 (69.23%)
2 or more VDs 3 (50.0%) 1 (33.33%) 11 (28.21%)
Unsure 0 (0.0%) 0 (0.0%) 1 (2.56%)
Questionnaire scores, M (SD)
MAAS pre/post 53.17 (10.15) / 64.67 (6.68) 61.00 (6.93) / 54.00 (6.25) 55.10 (9.49) / 60.95 (9.71)
PSS-10 pre/post 24.50 (4.72) / 21.67 (1.37) 21.00 (1.0) / 22.33 (4.51) 22.87 (3.16) / 21.39 (2.64)
VHI pre/post 74.83 (24.59) / 49.17 (23.33) 27.00 (13.12) / 33.67 (8.14) 62.31 (22.69) / 51.54 (19.71)
SVHI pre/post 110.40 (4.88) / 82.80 (15.83) 55.00 (18.00) / 71.67 (19.50) 94.23 (23.83) / 84.96 (19.62)
Received VT, n (%)
Yes 16 (100%) 100 (100%) 36 (92.31%)
No 0 (0.0%) 0 (0.0%) 3 (7.69%)
Location, n (%)
USA 5 (70.59%) 3 (100%) 28 (71.80%)
Canada 1 (17.65%) 0 (0.0%) 6 (15.39%)
UK 0 (0.0%) 0 (0.0%) 1 (2.56%)
Australia 0 (0.0%) 0 (0.0%) 0 (0.0%)
Finland 0 (0.0%) 0 (0.0%) 1 (2.56%)
Greece 0 (0.0%) 0 (0.0%) 1 (2.56%)
Latvia 0 (0.0%) 0 (0.0%) 1 (2.56%)
Pakistan 0 (0.0%) 0 (0.0%) 1 (2.56%)
Catherine Kay Brown, et al Effects of a Mindfulness Course in Voice Disordered People 9
of the interplay between body and voice. Additionally, the
process of singing voice training has changed dramatically
over the past several decades, with a growing emphasis on
physiology and bodywork. Today’s singers are strongly
encouraged to practice body awareness through modalities
such as yoga, Alexander Technique, the Feldenkrais
method, and Pilates.
42
Indeed, a study by Schirmer-Mokwa
et al indicates that musicians may have higher interoceptive
awareness than non-musicians.
43
Despite the limited changes among professional singers,
the researchers suspect that highly trained, actively per-
forming singers who have recently been diagnosed with a
voice disorder could benet greatly from a mindfulness
course with others like them. Singers, particularly those
who depend on auditions to get performance opportunities,
typically do not discuss voice disorders openly for fear of
stigma and reprisal. In Psychology of Voice Disorders (2nd
ed.), Rosen et al maintain that for professional performers
being diagnosed with a voice disorder is a personal crisis, a
time of high stress and deep grief that may be accompanied
by anxiety and depression.
6
The mindfulness course that
was part of this study included only a handful of profes-
sional performers, and may not have been the right en-
vironment for them to talk about their specic struggles,
particularly when some participants were clearly much
more disordered.
Unfortunately, the study is too small to draw statistically
signicant conclusions about which patients may benet
most from an 8-week mindfulness course. Some of the
patients who experienced the most dramatic decreases in
VHI had moderate to severe VHI scores before the course.
Similarly, several patients who experienced dramatic drops
in VHI had a diagnosis of primary or secondary MTD.
(The researchers hypothesize that the mindfulness course
may have helped reduce physical tension and, in some
cases, pain. This could explain why the VHI functional
subscale showed signicant interactions, while the emo-
tional and physical subscales did not.) Patients with SD
seemed to benet less vocally, but frequently expressed
gratitude for the chance to hear and talk with other people
with their relatively rare voice disorder. (SD is considered a
rare voice disorder, and studies estimate its prevalence as
5.2–13.7/100,000.
44
)
The researchers believe that clinicians may underestimate
the degree to which stress manifests physically in people
with severe and chronic voice disorders. Participants, in-
cluding those who were not formally interviewed, re-
peatedly expressed that, despite receiving a life-altering
diagnosis, they had no support system when they were
discharged from voice therapy. They also expressed feeling
that they had failed therapy because they continued to
experience debilitating voice problems after discharge. The
mindfulness course may have helped address some of the
physical manifestations of the disorder (tension and pain),
while also addressing the psychological fallout (loss, grief,
isolation, and anxiety and embarrassment about the dis-
ordered voice).
Future research should evaluate mindfulness in specic
populations. For example, patients with MTD should be
studied, given the role that mindfulness can play in redu-
cing tension and given the number of MTD patients in this
study who experienced dramatic decreases in VHI. Patients
with SD also warrant further study due to several factors:
their limited treatment options, the disorder’s rarity and
chronic and often debilitating nature, and the strong po-
sitive response of participants to experiencing community
with other SD patients. Additional populations to consider
include patients with chronic throat clearing; patients with
higher and lower VHI scores; singers; and—considering the
data on mindfulness and chronic pain
13
—patients who
experience throat pain. Future studies should use the
Multidimensional Assessment of Interoceptive Awareness-
2 to examine the role mindfulness plays in increasing so-
matic awareness in voice disorder patients.
41
Mindfulness
should also be evaluated within a standard voice therapy
protocol.
Finally, clinicians may want to evaluate the role of group
interventions for people with voice disorders.
45–47
The re-
searchers believe groups could be particularly helpful for
people (SD patients, singers) who experience shame and
stigma around their voice disorder. A study by Boyle found
that participation in support groups for stuttering was as-
sociated with lower internalized stigma.
48
LIMITATIONS
The study was a non-randomized investigation with a
waitlist control. It was challenging to recruit enough par-
ticipants at once to be able to divide them into an inter-
vention group and a control group. Instead, we recruited in
three stages, as described above. We did not have the re-
sources to compare the MCP and WCG groups to a group
who received a different intervention (support group,
breath work, journaling, etc).
Because participants were not recruited through a voice
center, there was no consistency in where or how they re-
ceived their diagnoses or what treatment or treatments they
received. Both inside and outside of the United States,
patients’ access to specialty voice clinics, fellowship trained
laryngologists, voice specialist speech-language patholo-
gists, and even health insurance can vary widely.
The study relied on self-report measures and did not
include any objective voice measures. The study is being
repeated in 2023 with objective voice measures. These in-
clude acoustic and aerodynamic measures and auditory-
perceptual assessment (Consensus Auditory-Perceptual
Evaluation of Voice).
We did not ask participants to disclose whether they
stopped or started any psychotropic medication or psy-
chological treatment during the study period. As stated
earlier, potential participants were cautioned that an 8-
week mindfulness course might not be appropriate for
people who have an active addiction; are suicidal; or have
untreated psychosis, PTSD, depression, or anxiety that
Journal of Voice, Vol. xx, No. xx, xxxx 10
would interfere with their ability to complete the course.
All but two study participants stated in their consent form
that none of those conditions applied to them. (One MCG
participant said that they had “received counseling,” and a
WCP stated that they had anxiety and depression that were
“treated and under control.”)
Due to limited resources, we could not conduct follow-
up interviews with all participants. Instead, we focused on
those who benetted most and least from the intervention.
Additionally, the rst author/primary investigator taught
the mindfulness course and conducted, coded, and ana-
lyzed the interviews. This could have introduced bias into
the interviews (as participants may have wanted to con-
tribute toward positive study outcomes) and the process of
coding and analysis. Finally, we did not follow up with
participants to see whether any positive results they ex-
perienced lasted beyond the time of the interview.
CONCLUSION
An 8-week mindfulness course shows promise for reducing
stress, lowering voice handicap, and improving quality of
life in people with voice disorders. Public interest in
mindfulness continues to be strong, and patients with
chronic and severe voice disorders seem eager to engage in
group mindfulness programs tailored to their needs. Even
those who do not experience a reduction in voice handicap
can gain tools to help them process and adjust to their
disorder.
Declaration of Competing Interest
None.
Acknowledgments
The rst author wishes to thank the following individuals
for their contributions to this study: voice specialist speech-
language pathologists Julia Gerhard, DMA, CCC-SLP, at
University of Miami, and Michelle Horman, MFA, CCC-
SLP, in private practice, for their advice and support; and
voice teacher and yoga therapist Sarah Whitten for her
expertise in developing the yoga routines used in the
mindfulness course.
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