It’s Not Just the Voice—It’s the Whole System: Rethinking Care for Today’s Professional Voice Users

For a long time, when I heard the phrase professional voice user, I pictured singers and performers. People on stages. People behind microphones. And of course, they are professional voice users. But over the years, as I’ve worked with more and more clients, that definition has changed for me.

Some of the most vulnerable voices I see don’t belong to performers at all. They belong to teachers who speak over classroom noise all day. Clinicians who educate patients nonstop. Caregivers who manage families with constant vocal demands. Ministers, coaches, sales professionals—people whose voices carry their work, their relationships, and often their identity.

That shift in perspective changed everything about how I approach voice care. Because once you stop seeing the voice as just an instrument and start seeing it as part of a whole system, you begin to practice differently.

Why this shift matters clinically

Many clinicians are trained to start with what is most visible: tissue, pathology, and mechanics at the level of the vocal folds. And that matters. But in practice, many professional voice users don’t struggle because something is structurally “wrong.” They struggle because their system is overloaded.

They manage long vocal hours in poor acoustic environments.

They work under constant performance pressure.

They compensate with effort when coordination would serve them better.

They push through fatigue because rest feels like failure.

When the voice is viewed only as a structure, the real drivers of strain can be missed. When the lens widens to include the whole system, the clinical picture—and the clinical impact—becomes clearer.

Voice is a system, not a structure

I often remind clinicians that the voice doesn’t live in isolation. It’s the result of a relationship between multiple systems—respiratory, phonatory, and resonatory—working together in real time.¹ When something feels “off,” it’s rarely just one piece that needs attention. More often, it’s an imbalance.

I see so many voice users working harder than they need to. Pushing when what they really need is better coordination. Adding force when what would help more is efficiency. Trying to muscle their way through a task that their system simply isn’t set up to sustain.

This is where clinical framing becomes essential. If voice challenges are viewed as a weakness, treatment focuses on strength. If they are viewed as an imbalance, treatment focuses on coordination. If they are viewed as overload, the focus shifts to pacing, environment, and sustainability.

Before we ever choose a voice therapy exercise, we have to understand the system that’s driving the behavior.

Diagnosis and assessment: Why evaluation guides treatment 

As much as I believe in viewing the voice as a coordinated system, I’m equally clear about this: not all voice disorders are the same, and they shouldn’t be treated the same way. The way a voice presents—and the diagnosis driving it—directly shapes how we evaluate, set goals, and ultimately choose intervention.

In clinical practice, voice disorders are often described across several broad categories. These categories aren’t meant to box patients in, but to help clinicians understand what’s driving the voice behavior they’re seeing.

Organic voice disorders

Some voice disorders are organic in nature, meaning they stem from physiological changes within the respiratory, laryngeal, or vocal tract systems.

Within this group, structural voice disorders reflect physical changes to the vocal mechanism itself—such as tissue changes (e.g., edema, nodules) or structural alterations associated with aging.

Neurogenic voice disorders

Neurogenic voice disorders result from disruptions in central or peripheral nervous system control of the larynx. Conditions such as vocal tremor, spasmodic dysphonia, and vocal fold paralysis fall into this category.

These presentations require a very different clinical lens than functional voice concerns, particularly in how assessment findings are interpreted and how treatment goals are framed.

Functional voice disorders

Functional voice disorders are frequently seen in professional voice users due to the vocal load required by their day-to-day occupational demands.

In these cases, the vocal mechanism itself is structurally intact, but the way it’s being used is inefficient or maladaptive. Presentations such as muscle tension dysphonia, vocal fatigue, aphonia, diplophonia, or ventricular phonation often reflect how a system is responding to load, stress, and demand rather than a primary tissue problem.

Psychogenic voice disorders

Voice can also be affected by psychological stressors that lead to habitual, maladaptive voice use. These presentations are commonly described as psychogenic voice disorders or psychogenic conversion aphonia or dysphonia.¹ While the origin may be different, the impact on communication and identity is just as real.

What’s important to recognize is that many professional voice users don’t fit neatly into a single category. It’s common to see overlap—functional patterns layered on top of structural change, or compensatory behaviors that persist long after an organic issue has resolved. This is one of the reasons a systems-based perspective is so essential in voice care.

Why evaluation has to come first

Accurate diagnosis doesn’t happen without a thorough and intentional voice evaluation. Before exercises are selected or protocols are introduced, clinicians need a clear understanding of what the voice is dealing with, how the system is functioning, and what demands are being placed on it.

For professional voice users especially, evaluation should go beyond perceptual listening alone. Best-practice voice assessment typically includes multiple components working together:

• A behavioral voice assessment, including detailed case history, analysis of vocal demands, perceptual evaluation of voice quality, and patient-reported outcome measures.

• Aerodynamic and acoustic measures, which provide objective insight into airflow, pressure, efficiency, and overall vocal function.

• A visual examination of the larynx, most often using videostroboscopy, to assess vocal fold structure, vibration, closure patterns, and mucosal wave behavior.

Videostroboscopic assessment is a critical part of voice evaluation and should be completed by a voice-specialized speech-language pathologist in collaboration with, or by, a laryngologist with expertise in voice. This visual information often reveals details that cannot be identified through auditory-perceptual assessment alone and is essential for differentiating among functional, structural, neurogenic, and organic voice disorders.

Without this level of evaluation, treatment risks becoming reactive—focused on symptoms rather than the underlying drivers of the voice problem. When assessment findings guide clinical reasoning, intervention can be targeted with much greater precision: supporting tissue healing when needed, improving coordination when inefficiency is the issue, or addressing endurance, recovery, and sustainability when vocal load exceeds capacity.

This is why I consistently emphasize that exercises are tools, not treatments in isolation. Their effectiveness depends entirely on whether they are selected in response to the right diagnosis, the right system imbalance, and the real-life demands the voice is being asked to meet.

Using exercises and protocols to support the whole voice system

In clinical practice, patterns begin to emerge in how patients describe their voice concerns. When those descriptions are considered alongside a thorough voice assessment, they often point us toward the types of therapeutic exercises that will be most helpful.

Therapeutic and skill-based exercises are most effective when they are chosen not as drills, but as responses to what the system needs most. In clinical practice, when addressing a functional voice deficit, most decisions for professional voice users tend to fall into four targets:

• Coordination

• Endurance

• Efficiency

• Recovery

Here is how those priorities often show up in care.

Effort and coordination

When a voice user says, “I feel like I have to push to be heard,” the focus often turns to airflow and voicing coordination.

Tools such as flow phonation and semi-occluded vocal tract exercises (including straw phonation) become especially useful here.² Used within broader coordination-focused protocols, these approaches help shift effort away from the throat and toward a more balanced relationship between breath and sound.

Stamina and endurance

When someone reports, “My voice is fine in the morning, but I’m exhausted by the afternoon,” attention typically shifts to stamina and respiratory support.

In these cases, respiratory muscle training can be part of a larger endurance strategy. Tools such as The Breather and EMT-style trainers are not stand-alone fixes, but can support structured respiratory support protocols that help voice users manage long days of vocal demand without burning out early.³

These devices add gentle resistance during inhalation and exhalation, supporting breath efficiency and endurance for sustained voice use.

Tension and over-effort

When voice users describe feeling tight under pressure, exercises often target tension patterns and over-effort—not by forcing relaxation, but by helping the system respond to stress more efficiently.

Effort-reduction protocols may include:⁴

• Gentle voicing tasks to reduce excessive laryngeal effort

• Breath awareness to improve coordination

• Postural support to decrease unnecessary muscular tension

Together, these approaches help the system respond with efficiency rather than strain.

Recovery and pacing

For voice users returning from heavy use or vocal injury, recovery and pacing become central.

Warm-ups and cool-downs are not just routines. They are part of vocal recovery protocols that help the system:⁵

• Prepare for vocal load

• Recover more effectively afterward

• Build long-term sustainability rather than reactive care

Across all of these areas, the through-line is the same: exercises and protocols are chosen not for how impressive they sound, but for what the system needs most in that moment. The tools matter—but the clinical reasoning behind them matters more.

Professional voice users are everywhere

One of the most useful clinical questions is simple: Is this a voice issue—or a demand issue?

If difficulties only appear in certain rooms, settings, or times of day, the system may be capable—but the context is unsustainable.

This reframes the work from:

How do we change this person’s voice?

To:

How do we help this person survive the demands placed on their voice?

Often, the most therapeutic intervention is not changing the voice itself, but changing what the voice is constantly up against—loud rooms, poor acoustics, relentless background noise, environments that require more volume than any system can comfortably sustain.⁶

From recovery to longevity

One of the biggest shifts in my own practice has been moving from a recovery mindset to a longevity mindset.

Of course, helping someone feel better now matters. But just as important is whether their voice will still serve them five, ten, or twenty years from now—whether it will continue to support their career and daily demands.

When clinicians think in terms of longevity, voice care becomes less about perfection and more about sustainability. Less about pushing limits and more about respecting capacity. That shift changes how success is defined—not just by short-term improvement, but by long-term vocal health.

How to frame goals with professional voice users

When I talk about goals with professional voice users, I rarely frame them around sound alone.

Instead, I ask questions like:

• What do you need your voice to get you through each day?

• What would “less effort” look like in your real life?

• What would success feel like—not just sound like?

That keeps our work grounded in function, not performance alone—and it helps voice users feel supported rather than judged by their voice.

What comes next

Awareness is always the first intervention. When clinicians begin to see the whole system—body, environment, stress, lifestyle—they start asking better questions. And those questions lead to more intentional care.

The most powerful reframing often comes from moving away from “What’s wrong with this voice?” and toward “What is this system being asked to do?” That question reshapes assessment, goal-setting, and the way clinicians support the people whose voices carry their careers.

If this perspective resonates with you, I invite you to continue the work with me in my Medbridge courses.

• Therapeutic and Skill-Based Exercises for the Professional Voice User

• Functional Solutions for the Professional Voice User

• Singers and Voice Therapy: Uncovering Unique Targets and Challenges. 

In these courses, I go deeper into how we tailor evidence-based voice care for singers, educators, broadcasters, clergy, and other professional voice users—balancing clinical science with the realities of performance, injury, recovery, and career longevity. My hope is that you’ll leave not just with new tools, but with a stronger framework for supporting the whole system behind every professional voice you serve.

References

1. American Speech-Language-Hearing Association. (n.d.). Voice disorders. https://www.asha.org/practice-portal/clinical-topics/voice-disorders

2. Schneider, S. L., & Sataloff, R. T. (2007). Voice therapy: Clinical studies. Plural Publishing.

3. de Freitas Valadares, G., de Oliveira, A. H. M., Lima-Silva, T. B., Behlau, M., & de Britto Pereira, A. M. (2022). Sense of coherence and coping strategies in patients with dysphonia. Journal of Voice, 36(6), 802–807. https://www.jvoice.org/article/S0892-1997(20)30355-6/abstract

4. Arnold, R., Bless, D. M., & Woo, P. (2023). Behavioral management of voice disorders: A multidimensional approach. Journal of Speech, Language, and Hearing Research, 66(2), 511–526.

5. Sataloff, R. T. (2017). Professional voice: The science and art of clinical care (4th ed.). Plural Publishing.

6. American Speech-Language-Hearing Association. (n.d.). Occupational voice use and prevention of voice disorders. ASHA Practice Portal.