Investigating the Use of Neuro-Linguistic Programming in Clinical Voice Disorders.

Claire Bunce MRCSLTSpring 2013

USA and CanadaWinston Churchill Memorial Trust

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Acknowledgments.

Firstly I would like to thank the Winston Churchill Memorial Trust for awarding me the Fellowship and understanding the importance of my project. It has been the most amazing experience, so much has come out of it and I know that this is only the beginning.

Many thanks also go to all the people who so openly responded to my original emails and generously gave of their busy time to meet with me. I have learnt so much from you and was so impressed with the work that you do in your various areas. To the various extended family members and friends I stayed with and to all the nameless, wonderful strangers I met along the way - THANK YOU. Whether it was carrying my far too large suitcase up a broken escalator, giving me a lift when it appeared no public transport ran between two points or sharing food and stories with me on various buses, planes, and park benches - I appreciated you all.

A massive thank you to my family whose love and belief in me has given me the roots and wings I needed to get to this point and beyond. To my husband and best friend James - I love you. Thank you for being my rock.

One final little acknowledgment ... thank you to my unborn baby who travelled quietly everywhere with me. You didn’t make me sick, your first kicks filled my heart with love and I cannot wait to meet you in three weeks time!

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Index.

Page.

4! Itinerary6! Abstract8! Introduction10! Neuro-Linguistic Programming11! Clinical voice disorders13! Current issues within the NLP community14! Current issues within the voice community15! Findings 29! Conclusion30 ! References31 ! Appendix 1 - Article promoting the churchill fellowship and my project32! Appendix 2 - Article on the use of NLP in SLT36! Appendix 3 - Agenda of Mindfulness Conference

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Itinerary.

15.04.13! ! Plane!! London to New York

16.04.13! ! Meeting! New York: ! ! ! ! ! Patricia Angelin (Founding Instructor of The Alba ! ! ! ! ! Technique)

17.04.13! ! Bus! ! New York to Boston

18-20.04.13! ! Conference! Boston: 11th Annual International Scientific Conference ! ! ! ! ! in Mindfulness

21.04.13! ! Train! ! Boston to New York

22-24.04.13! ! Meeting! New York: ! ! ! ! ! Hillel Zeitlin (Psychotherapist. Director of the Maryland ! ! ! ! ! Institute for Ericksonian Hynosis and Psychotherapy) ! ! ! ! ! Rachel Hott (NLP trainer. Director of NLP Center of New ! ! ! ! ! York)

25.04.13! ! Plane!! New York to San Francisco

26-28.04.13! ! Meeting! San Francisco: ! ! ! ! ! Dicken Bettinger (Psychologist)! ! ! ! ! Ami Chen Mills-Naim (Director of the Center for ! ! ! ! ! Sustainable Change) ! ! ! ! Chantal Burns (NLP trainer)

30.04.13! ! Plane!! San Francisco to Vancouver

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01-18.05.13! ! Meeting! Vancouver: ! ! ! ! ! Linda Rammage (Principal Speech and Language ! ! ! ! ! Pathologist - Vancouver General Hospital)! ! ! ! ! Elsie Spittle (Co-founder of the 3 Principles Foundation)

19.05.13! ! Plane!! Vancouver - San Francisco

20-25.05.13! ! Meeting! San Francisco: ! ! ! ! ! Sarah Schnieder (Lead Speech and Language Therapist ! ! ! ! ! at UCSF Hospital).! ! ! ! ! Christina Hall (International trainer of NLP)

26.05.13! ! Plane!! San Francisco to London

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Abstract.

I travelled to the USA and Canada for six weeks to investigate the use of Neuro-Linguistic Programming (NLP) in clinical voice disorders. In my work as a Specialist Speech and Language Therapist (SLT) I work with adults with clinical voice disorders and my area of interest is psychogenic voice disorders. This is when a person presents with disordered or absent voice where the cause is not primarily physical but psychological. Whilst traditional voice therapy can achieve normal voice, if the underlying issues have not been explored, the results can be short-lived. Since training as a Master Practitioner of NLP I noticed that there could be real potential to using NLP techniques with this caseload. These could enable the patient to benefit not only in their voice but also in other aspects of their life e.g. improvement in general confidence. Whilst there has been a steady increase in interest and acceptance of other psychological approaches such as Cognitive Behavioural Therapy there is very little written about the use of NLP in SLT. NLP was founded in the USA and there is much going on in the areas of investigating and integrating psychological approaches into the field of health. I wanted to find out how this was being applied to NLP and SLT and how I could bring this back to the UK.

Before my travels, I researched extensively and contacted many professionals in the fields of NLP, SLT, Medicine and Psychology including Doctors, Clinicians, Teachers, Researchers, Authors and University Lecturers. Whilst on my travels, I attended practical study days, clinics, therapy sessions and meetings so was able to learn from direct observation, questioning, group discussion and presented research. Very surprisingly it became apparent that contrary to what I had originally believed, there was not a well connected network between NLP and SLT. Furthermore I was unable to find any specific group or therapist that was promoting their work in this area. I was very fortunate to be able to meet with one of the original students of NLP who has dedicated much of her professional life to investigating and using NLP in health (Suzi Smith - Author of ‘Beliefs - Pathways to Health and Well-Being’) who reminded me of one of the key presuppositions of NLP - ‘NLP is about the process NOT the content’. This gave me the confidence to continue with my project but to expand my vision of who I was able to learn from. I did not need to limit it solely to SLTs who work in the field of voice disorders and NLP but was free to learn from anyone in the areas of NLP or health. This meant that I may not have been able to copy a blueprint of how NLP is used in clinical voice disorders in the USA and Canada but I was able to generate my own from combining all of my learnings.

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I found that NLP in the USA and Canada was not being used as commonly or as openly as I had first thought. After it’s beginnings and initial surge in popularity in the 1970’s, various conflicts within the founding community caused this surge to stall and splutter. Whilst it ‘jumped’ over the ocean and spread to the UK, Europe and Asia (where it is becoming increasingly popular) it failed to continue it’s huge rise at home. It would not be accurate to say that NLP is not being used, indeed there is some groundbreaking research being done with NLP in many areas including Post Traumatic Stress Disorder as part of the recently formed ‘NLP Research and Recognition Project’ but rather that many ‘new’ approaches being used may look, sound and feel like NLP but are not ‘billed’ as NLP. Despite this history, when I spoke to people in related fields to NLP, rather than being cynical they were very interested and eager to talk more about its possible applications and where they could go to learn more. When I asked Jon Kabat-Zinn (founder of the eight-week based Mindfulness-Based Stress Reduction course) for his view on why NLP had failed to continue it’s rise in the USA, he told me that he felt it had not been integrated into any particular structure or setting.

As far as to whether NLP can be effectively used in clinical voice disorders, the answer is wholeheartedly YES. However whilst it is widely accepted that NLP is about the structure and not the content and that it can be used in any setting and with any person, I feel that the NLP community needs to learn from it’s past. The content of the structure is in fact very important and should be made clear in order for it’s use to be replicated and developed in different contexts.

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Introduction.

I am a Speech and Language Therapist (SLT) who works in the specialism of voice disorders and am also a Master Practitioner of Neuro-Linguistic Programming (NLP). When I started my NLP training three years ago I was working for the NHS in a large teaching hospital in the outpatient department of Ear Nose and Throat (ENT). I became interested in the use of NLP in voice and started investigating what had been written about work in this area. Through extensive searches, I discovered that whilst there were a few UK based SLTs using NLP in their area of interest, including stammering, voice and lecturing there was minimal literature (a few small articles) on it and no formal collaboration between the individuals. The idea for the title and location of this project was born from my wish to investigate this further and knowing that America was the ‘birthplace’ of NLP and was frequently ahead of us British SLTs in terms of new approaches.

Aims.

My aims were as follows:

I. To investigate if/how American and Canadian Speech and Language Therapists are using NLP, particularly in relation to clinical voice disorders

II. To meet internationally leading professionals in the field of NLP and Speech and Language Therapy to share ideas and experience

III. To increase my understanding of how NLP techniques can be used in the healthcare setting

IV. To explore whether there are any barriers in using NLP techniques in the healthcare setting

V. To raise the profile of Speech and Language Therapy

VI. To keep a detailed diary of my time away with daily learnings and reflections8

VII. To write an article for the bulletin of The Royal College of Speech and Language Therapists on NLP in SLT

VIII. To produce an educational document for Speech and Language Therapists outlining how NLP can be used in the field of clinical voice disorders with examples of effective questions and therapy tools

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Neuro-Linguistic Programming.

Neuro-Linguistic Programming (NLP) was founded in America in the early 1970s by Richard Bandler (a computer programmer in modelling human tasks) and Dr John Grinder (a linguist who modelled the structuring of language). They were interested to explore how certain therapists were getting results with clients when others in their field had been unsuccessful. They observed Vaginia Satir (the ‘Mother’ of Family Therapy), Fritz Perls (the developer of Gestalt Therapy) and Milton Erickson (a Psychiatrist specialising in hypnotherapy) and found patterns between their work despite their background differences in schools of theory. From this they were able to share models, skills and techniques for thinking and acting effectively in the world. Bandler and Grinder called their discovery Neuro-Linguistic programming to refer to the three related concepts of Neuro - how we experience the world through our five senses, Linguistic - how we use language to order our thoughts and behaviour and Programming - how we choose to organize our ideas and actions to produce results. O’Connor and Seymour (1990) describe the purpose of NLP ‘to be useful, to increase choice and to enhance the quality of life’. Since the 1970s NLP has been used in a wide variety of settings including sport, health, professional development and leadership. Discussing the applications of NLP in medical practice, Walker (2004) describes is as “a behavioural technology which can really help patients to change quickly...It involves getting curious about the structure of their internal world and how it manifests in behaviours - some of which may lead to problems, other lead to solutions” (cited in Wake 2010, p14).

One of the differences in NLP from many other psychological approaches is that the focus is very much on the intended positive result rather than analysing the cause of the problem. For example if someone was to present with a problem of anxiety, the focus is more on the desired feeling of calmness rather than an in-depth exploration of where the anxiety stemmed from and reliving past memories of anxiety. In this case, past experiences of calmness could be elicited and explored so that they may be ‘modelled’ and used by the person when they need to.

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Clinical Voice Disorders.

Clinical voice disorders are disorders of the larynx (voice box) and typically they are thought of falling into two distinct categories 1 - structural and 2 - non structural. Whatever the underlying cause the result is that a person experiences a change in their voice which does not resolve spontaneously e.g. the typical rough voice experienced during a cold that disappears when a cold improves. Voices may be described as sounding ‘breathy’, ‘rough’, ‘croaky’, ‘whispery’, that the problem may have started suddenly or gradually and that it is affecting their ability to ‘sustain voice during the day’, ‘make themselves heard in noisy environments’ or ‘be heard on the telephone’. People may suffer with voice problems from all occupations and lifestyles but typically those with higher vocal demands e.g. teachers and call centre workers tend to suffer with voice problems. Speech and Language Therapists who specialise in voice are the professionals that see these patients. Typically these patients present to their GP initially with reported voice changes and are then referred to ENT (Ear Nose Throat Doctors) who objectively view and assess the larynx. As voice disturbance (dysphonia) can be a sign of throat cancer, this needs to be ruled out before referring to the SLT.

The diagram on the left shows a cross section through our head and neck. It shows the location of our larynx and of the two vocal folds (sometimes referred to as cords) (as seen from above). During voicing, these two vocal folds vibrate together, approximately 150 times per second for men and 200 times per second for women, to produce a buzz. This buzz travels up into our mouth where we shape it into sounds and speech.

Examples of a structural dysphonia are vocal nodules (symmetrical swellings on the vocal folds which the singers Julie Andrews and Adele have suffered from), vocal cord palsys (sometimes occurring after nerve damage) or vocal polyps (a unilateral swelling in the mucus membrane covering one of the vocal cords). Non-structural dysphonias are typically seen as ‘muscle tension’ i.e. that laryngeal muscles are being overused or misused and are causing a disruption in how the vocal folds vibrate.

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In voice therapy the initial session is usually comprised of a thorough case history including details around the presenting voice problem, past medical history, occupation and social history. Most therapists then provide an explanation of how voice is produced and the results of the ENT examination. Advice is given on vocal hygiene such as being adequately hydrated, and voice care such as not shouting or talking for sustained periods of time over loud noise (see The Voice & It’s Disorders - 2002 for more information). Most people want to know what specifically has caused their particular voice problem and sometimes this is more obvious than others, for instance if their voice changed suddenly after shouting loudly at a football game. Future sessions aim to explore different aspects that can contribute to voice difficulties and provide the patient with appropriate vocal exercises to help improve and then maintain normal voice. The Pacific Voice Clinic in Vancouver uses the following useful diagram to summarise these aspects:

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It is regularly noted in patients with non-structural dysphonias that there have been significant emotional events that can be attributed with or contribute towards voice change. Imagine a time when you have experienced a very sad event and your voice changes for a short period of time as you feel a ‘lump’ in your throat or think of when you are feeling stressed and you notice the muscular tension in your shoulders or neck. This is similar to how the muscles used for speaking can be affected when there has been acute or chronic emotional stressors. Therapists differ in their approaches but I always explain the link between emotions and voice in the first session. Often this elicits details about past events that patients may not have previously thought relevant to mention during the initial case history e.g. long standing stress at work or caring for a sick relative. It is this subset of patients with largely emotional causes to their voice problems that I am particularly interested in and which my project has aimed to explore the use of NLP with.

Current issues within the NLP community.

The NLP community is at a crossroads - is it a passing fad or does it want to be more accepted, for instance like Cognitive Behavioural Therapy (CBT)? One of the issues is that whilst there is an accredited body that aims to govern the practice of NLP in the UK (The Association for NLP - ANLP) there remains many training organisations and individuals that work outside of it. These unregulated bodies and individuals have and will continue to damage the area until the community works together to come up with models of best practice. The ANLP is currently looking at professional values in NLP, at what makes a NLP Professional e.g. hours of training before charging, regular supervision and of actively promoting research. There is a recognised lack of an established evidence base and at the first international NLP research conference in 2008 the dominant theme was how more research activity is needed to contribute towards credibility, recognition and respectability. Within the last five years, research is becoming part of of the identity of NLP globally, to mention just a few studies in progress; NLP in Chronic Fatigue Syndrome at Southampton University that has funding from the National Institute of Health, NLP in Post Traumatic Stress Disorder in the USA and Wales with support from the MOD (Ministry of Defence) and an interest from NICE (National Institute of Clinical Excellence). Wake et al. (2012) have recently written an excellent book that examines the current evidence of the clinical efficacy of NLP techniques.

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Current issues within the SLT community.

As the NHS is undergoing huge changes in it’s structure and how it runs it’s service, so do Speech and Language Therapy Departments find themselves in the firing line. In the face of ever growing financial cuts and the constant need to justify one’s input and time with patients, the need for evidence based practice has never been stronger. SLTs need to be able to show that they they are getting better results, long lasting changes and in as quick a time as possible. At the same time that financial cuts are leading to posts being cut or positions frozen, budgets for external training are minimal. This results in SLTs having to rely on in-house training, self-funding courses and informal learnings such as reading to continue their professional development. All of this can have a detrimental effect on staff morale and lead to feelings of job frustration and dissatisfaction. Clearly this will have knock on effects to the various people we are trying to serve.

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Findings.

To help present a structured, cohesive section on my findings and to avoid duplication I have picked out and grouped the most relevant learning points under the sections:

- Mindfulness- NLP- Voice

Mindfulness.

Investigating and Integrating Mindfulness in Medicine, Health Care and Society : The 11th Annual International Scientific Conference.

My wish to attend this conference was two fold; firstly to familiarise myself with the current applications of mindfulness in health care and secondly to learn how research is being carried out in this area. A copy of the agenda is in the appendix.

Having been on a short course of Mindfulness for Speech and Language Therapists in the UK in 2010 and completed a 10 day Vipasanna meditation course in India in 2008, I was already interested personally and professionally in the use of mindfulness / meditation in everyday life. Mindfulness can be described as an open or receptive attention and awareness of one’s present moment experience. I use aspects of mindfulness (the body scan and a three minute breathing exercise) with voice patients to give them the experience of ‘quietening’ the conscious mind with it’s racing thoughts and to notice their body in the present moment. A frequent issue for my caseload of patients is muscular tension in the laryngeal area (where the voice box is) and the first step in being able to reduce this tension is to first acknowledge its presence.

The conference turned out to be an impressive and satisfying marriage of science and art. Multiple research studies using randomised control trials, many of them using neuro-imaging as their pre and post outcome measures were presented, along with countless studies of practitioners integrating mindfulness in a variety of contexts including schools,

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universities, hospitals and corporate organisations. I learnt about the challenges and obstacles that can face one when trying to integrate a ‘new’ technique into environments but of how opportunities were created and taken to overcome them. At a time when there is growing interest in using a more holistic and client centred delivery of healthcare, research studies using the ‘language’ of science serve to provide a common ground for practitioners and medical Doctors to discuss new approaches. The point was made on more than one occasion that the focus of research in this area is not to prove that mindfulness works but rather to test hypotheses. This mirrors the current discussions in NLP and one that the Research and Recognition Project is addressing.

Delegates represented a wide range of professionals including Physicians, Surgeons, GP’s, Psychologists, Nurses, Psychotherapists, School teachers, Occupational Therapists, life / personal coaches and those in research. Most were from America but others had travelled from further afield including Australia, Argentina, South Africa, Germany and Russia (and of course from Oxford, England!). There were regular opportunities to connect with people during breaks, different workshops and presentation forums which made for some inspiring and thought provoking conversations. To name just a few:

• The team from Duke Integrative Medicine who have created a ground breaking centre that combines the best of western scientific medicine with openness to proven complementary methods. Mindfulness has been placed at the centre of Duke Integrative Medicine as they believe that each individual is the single most powerful factor impacting their own health and wellbeing. This mirrors one of the presuppositions of NLP - ‘People have all the resources they need’.

• Aleeze Moss from the research department at Jefferson Hospital who has been looking at MBSR (mindfulness-based stress reduction) for elderly in long term care. Almost all participants in qualitative interviews reported increased awareness, less judgement, great acceptance of themselves and their life circumstances, aw well as greater compassion for self and others.

• Diane Abatemarco, Associate Professor Director at Nemours, who is interested in mindfulness as a way of improving self-care and enhancing job satisfaction. The benefits of this are enhanced wellbeing with less burn-out and distress while providing the best care for patients.

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•Jon Kabat-Zinn (pictured here with me) , founder and director of the Stress Reduction Clinic at the University of Massachusetts Medical Center. We had an interesting talk about his view of NLP and of integrating mindfulness into it (mentioned in the abstract). Jon has written ‘As care-givers, we have to remind ourselves of what we of course already know, namely that all human beings, including ourselves and our patients have, to varying degrees but almost always far more than we suspect, deep and life-long inner resources for learning, growing, healing and personal transformation’ (Kabat-Zinn 2000).

Mindfulness in NLP is useful both at the practitioner and client level. For the practitioner, it allows them to listen attentively and non-judgementally whilst for the client, it allows them to enter an open and calm state, one in which their internal barriers can be lowered which can allow change to happen without resistance. The additional relevance for NLP is that being able to quietly attend to your sensory and mental experiences of a situation enables us to copy and reuse helpful patterns.

NLP.

Through my meetings and discussions with the many NLP practitioners, trainers, psychotherapists and psychologists I met, the following areas were picked out by me as being particularly pertinent for using NLP in voice disorders. I will be using NLP terminology within this section that I will attempt to give brief explanations of. For those readers that are not familiar with the topic I would recommend reading any of the NLP reference books in the bibliography for further detailed explanations.

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• Goal setting.

NLP places particular importance on eliciting a client’s issue and then setting a well formed goal or outcome. As mentionned earlier, the focus is on directing the mind towards what is wanted in contrast to what is not wanted. In SLT we can get caught up in the client’s issue and spend huge amounts of time listening to their ‘story’ within the initial case history and again in future sessions. Whilst fundamental in establishing rapport it is vital that the therapist leads the client into discussion about how they want to be rather than inadvertently allowing them to re-experience the negative issue. NLP uses the acronym PESEO (O’Connor and Seymour 1990) to guide clients to set well formed outcomes. Below is an explanation of the acronym and examples of questions you could use.

P - Positive e.g. What do you want? (If negative... ‘What would you rather have?’)E - Ecology e.g. How much do you want it out of 10?S - Specific e.g. When, where and with whom do you want this?E - Evidence e.g. Imagine having achieved this goal, what do you see, hear and feel?O - Own part e.g. Is this within your own control to achieve?

This process can itself be so motivating and empowering that positive change may start to occur simply as a result of this exercise. I have co-authored an article on the use of Goal Setting in NLP and SLT (Appendix 2) and within it have illustrated the use of this with a voice patient.

• Submodalities.

This refers to the qualities of our five sensory modalities (modes) of awareness, namely:

V - Visual (picture, sights, images)A - Auditory (sounds: noises, music etc.)K - Kinaesthetic (sensations, feelings)O - Olfactory (smells)G - Gustatory (tastes)! ! ! ! ! ! ! (Hall 2008)

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Submodalities enable us to be even more precise when talking about how we experience the real and constructed world. Examples of submodalities from the three most common modalities are as follows: Visual - Colour or black and white? Still image or moving video? Auditory - Quiet or loud? To the right of you or all around you?Kinaesthetic - Hot or cold? Smooth or textured?

When talking about the laryngeal constriction that is often experienced by voice patients, using submodalities can be very helpful in eliciting how the throat feels in it’s ‘problem’ state and then comparing it to the ‘desired’ state. I have illustrated the use of this with a voice patient.

SLT: Tell me how you know that your throat is painful?Client: Well because it hurts!SLT: But how do you know it’s ‘hurting’ and not ‘comfortable’?Client: Because it feels scratchy here (stroking area of throat)SLT: Where does the scratching start and stop?Client: From here to here (pointing out places on her throat with her finger)SLT: And is there a temperature to it?Client: Yes, it feels really hotSLT: And does that feeling move around or is it constantly there?Client: It’s there constantly at the momentSLT: Are there any times when it’s not there?Client: I don’t notice it when I’m watching TVSLT: How does it feel then?Client: Well I don’t know, it doesn’t feel of anything really

The SLT may then ‘play’ around with the submodalities and notice if this changes their client’s experience, for example turning down the temperature and imagining their throat cooler or seeing if they can move the scratchy feeling up and down or even remove it completely from their body. I have previously met with Art Giser (Founder of Energetic NLP) who had suggested asking clients to imagine a magnet outside their throat drawing

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out their tension. There is no right or wrong way to play around with submodalities, the skill is in being creative and flexible in your approach and to try many different ways of changing their experience.

This could also be extended into how a voice looks like. For instance, asking a patient to draw a circle of how open their throat feels. This may elicit a small circle which the SLT can then compare to a large circle with the feedback ‘We’re aiming for a throat the size of a drainpipe rather than a straw’.

People can differ in terms of their ‘dominant’ modality and so the benefit of exploring different modalities and submodalities is that you are aiming to find ‘the difference that makes the difference’. What one person finds helpful, another person may not. I recall using this with a professional singer who had a sudden breakthrough and exclaimed ‘Oh my goodness, I’ve got it, I’ve totally got it, all I need to do is focus on how I want it to feel not how I want it to sound’. By focusing on the feeling associated with a ‘normal’ voice she was able to easily control the sound of it.

Rachel Hott commented about the importance of leading kinaesthetic change at times, like when a yoga teacher corrects you. Clients can find it very helpful to put their fingers gently on your throat to physically feel the wideness that you can achieve when demonstrating how to release laryngeal constriction. This kinaesthetic feedback gives a client something to aim for and enables them to model (copy) how you do it. Rachel also made the suggestion of buying a toy bull frog with a large, wide throat to give client’s a clear picture of how their throat should look and therefore feel.

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• Logical Levels

Robert Dilts’ Logical Levels model shows the various different levels that change can occur at and is a useful framework for organising and gathering information. The benefit of this is that is enables you to identify the best point to intervene to make the desired change. The model (below) is hopefully self-explanatory but to help understand the relevance of this in relation to treating adults with dysphonia I will use the following scenario: A teacher who is experiencing voice problems that are affecting her ability to use her voice throughout the day.

I will first give examples of what may be causing or contributing to her dysphonia and then suggest how voice therapy may aim to correct this.

1 - Environment. A noisy classroom due to students, poor acoustics or outside noise.Intervention: reducing noise where possible, e.g. closing doors and windows or turning off unnecessary electrical equipment that may be causing noise.

2 - Behaviour. Regularly having to discipline students through shouting. Regular throat clearing. Sub-optimal hydration.

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Intervention: advice on vocal hygiene and care e.g. keeping hydrated, not shouting and avoiding throat clearing.

3 - Capabilities. Unable to raise voice volume safely or use effective breathing.Intervention: teaching vocal warm up exercises, strategies for increasing voice volume safely and breathing exercises.

‘Traditional’ voice therapy tends to look at these three bottom levels. They are clearly important and useful areas to address but do not touch the ‘deeper’ levels of emotions / layers that can be affecting the voice. Here are examples of what may be happening at the top two levels.

4 - Beliefs and Values. A belief that her voice is never going to improve or that she is not worth hearing anymore.Intervention: New belief generation that her voice can improve and that it is worth hearing.

5 - Identity. Conflict about speaking out or asking for help (if an experienced teacher)Intervention: Identify and resolve conflict.

Whilst in some situations change may be elicited easily by changing something simple at a low level, in other situations change may be harder because there is something at a higher level that needs to be addressed. Often helping a person change at a higher level can result in a cascade of change running down through the levels. For example, helping a teacher shift a belief that her voice is not worth hearing could result in reduced emotional anxiety / tension which in turns reduces physical tension which reduces the level of throat clearing which leads to healthier vocal folds which maintains healthy voice production. Seymour and O’Connor (p.81 1990) comment that ‘change on a lower level will not necessarily cause any change on higher levels...change at a high level will always affect the lower levels’.

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• Metaprogrammes.

Metaprogrammes are our individual perceptual filters of how we see and react to the world. Being aware of a client’s own set of metaprogrammes enables you to tailor your own language to match theirs to increase rapport, understanding and motivation. Not only is it helpful to be aware of our client’s dominant metaprogrammes for these reasons but if we can encourage them to reflect on the opposing preference we are enabling them to benefit from a wider vision of the world. Some examples of the more common metaprogrammes are described below with examples of how they may relate to voice clients.

- Toward / Away from.Whilst some people are motivated to move towards the goal, others may be motivated to avoid the problem.e.g. Wanting to be able to present at the next work conference ‘v’ wanting to avoid having to ask a colleague to present instead of them.

- External / Internal.An external person needs others to supply feedback or direction whilst an internal person has their own internalised standards. External people need and enjoy supervision whereas internal people have little need for supervision.e.g. a teacher needing to hear positive feedback from others that she has taught well ‘v’ a teacher that ‘just knows’ that she has taught well.

- Sameness / Difference.‘Sameness’ people look for the similarities between things and don’t like change whilst ‘difference’ people look for the differences and enjoy change (Steinhouse 2010).e.g. a singer who has been working for the same company for a long time who is anxious now that several key choir members and the conductor have changed ‘v’ a singer who has been working for the same company for a long time and is feeling unsatisfied with the daily routine.

Rachel Hott highly recommends listening for and working with metaprogrammes. She suggested a useful phrase to elicit them as “How do you know when you’ve done a good job?’ If they are externally referenced then you know to give them praise, however if they

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are internally referenced, then you must use reflective language. She also loves contrast frames of which she gave the example “Tell me about a time when you were able to make a change when you weren’t expecting to” and “How did you manage that?’. Listen to the metaprogrammes they use here and then tailor your language to match this.

• All behaviour has a positive intention.

One of the presuppositions in NLP is that every human behaviour is at some level supported by a positive intention. In relation to voice clients, a belief that one’s voice is not worth hearing may serve a protective purpose in that a quieter voice is less likely to be heard and therefore challenged. A clue that this is happening is when a client is improving as expected until a point where they appear to stall and despite the voice therapist’s experience and skills, no further improvement occurs. Clearly the ability to acknowledge and identify this with clients is essential if improvement is to continue and frustration for both therapist and client to be avoided. NLP is a very useful framework in which to work when wanting to explore these issues further and give additional, empowering options to clients. In my conversations with Hillel Zeitlin, he offered many fantastic and insightful questions to elicit these positive intents and much of his work with ‘Core Transformation’ is built on this. As an example, I had been seeing a lady with a moderate dysphonia for four sessions and her initial voice improvement had appeared to stop. Whilst it was better than at the start it was not yet back to her ‘normal’. I used the following question to explore whether there was any benefit to her having a voice that sounded as loud and as harsh as it currently sounded ‘Now strange though this question may seem, if this part (unwanted voice) was trying to help you in some way, what do you think it would be trying to do for you?’. Whilst her initial reaction was along the lines of ‘Nothing! There’s no benefit, that’s why I’m here having voice therapy!’ (a typical initial reaction) as we discussed this further, it transpired that as she was seven months pregnant, she was unable to pick up her misbehaving toddler and was instead using her voice to discipline him. As soon as she realised that she had some control over her voice, it gave her choice as to how to proceed: did she want to continue as she was or to consider other ways of discipling her son and let her voice continue back to normal.

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One last thing to note - NLP is about the process not the content.

The processes used in NLP are not designed to be matched to a specific content. One process may work for one individual and not for another. For instance in the case of improving someone’s confidence one person may respond well to ‘Anchoring’ (setting up a process by which a stimulus triggers a response) whilst another may respond to a ‘six-step reframe’ (a process to stop unwanted behaviour by providing better alternatives). The flexibility afforded by this allows therapists to be creative and respond to their clients on an individual basis rather than adopting a ‘one-size fits all’ approach.

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Voice.

Ironically, I developed a chest infection during my last week overseas and as a result had a very rough, weak voice that made talking very effortful! I found myself opting out of conversations I would otherwise have started, apologising about the quality of my voice before talking and worrying about how I would be perceived. I was having to repeat myself in noisier environments which was very frustrating and underneath everything I was slightly worried that maybe this was a sign of something worse than a temporary cold. I’ve never experienced so many consecutive days with altered voice and it certainly gave me a taste for what my clients must go through.

I spent time with Sarah Schneider and her Speech and Language Therapy team at UCSF (University of California in San Franciso) where there is very close working of the SLTs and the ENT team with four morning voice clinics each week. Typically, 11-13 patients are booked into a clinic. In some cases the SLT will start the consultation with a new patient including using a rigid laryngoscope (their preferred choice over a flexible nasendoscope) to get objective images of the larynx. The ENT Consultant then joins them to look at the images and make clinical decisions with the consultation of the SLT. Although I do not have any official figures, anecdotally it would appear that surgery as part of a patient’s voice therapy journey is much more common than in the UK. I do not know whether this is a consequence of the different models of health care delivery between the two countries. As an example, typically in the UK in patients with a vocal fold palsy, ENT Doctors allow up to 18 months for spontaneous recovery before considering surgery. In the USA this is much lower at 4 - 6 months. I saw a lady who had initially been seen by an ENT Doctor 3 years earlier who had been diagnosed with spasmodic dysphonia. She had been treated with botox injections every 6 months for a period of 18 months until moving states and being seen by a different ENT Doctor. The new Doctor advised and carried out more drastic surgery that included sectionning the Recurrent Laryngeal Nerve and arytenoid abduction. As her airway patency reduced, she was given vocal fold stripping and then tragically needed a permanent tracheostomy sited. Having moved states again due to needing increased support from her daughter, she presented to the UCSF clinic as a new patient. By this stage, she had developed granuloma around the tracheostomy, was finding it harder to breathe and was struggling to talk. This tragic situation was compounded when on more detailed questioning it transpired that her initial voice

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difficulties had started when she was going through a painful divorce with her husband, and had other large emotional stresses. Whilst I am not saying that this is a typical occurrence (certainly the SLT was as shocked as I was) or that the diagnosis was definitely incorrect, I am merely highlighting the importance of detailed case history taking, accurate diagnosis at onset of voice change and of the significance of taking the most non-invasive route as possible when appropriate.

I also observed sessions of voice therapy with new and repeat patients. This consisted of similar therapy to that which is offered in the UK, including laryngeal deconstriction, flow phonation and resonant voice therapy. Typically patients are seen for an average of four sessions. I had various conversations with SLTs in the team about the use of psychological approaches in voice therapy. There was not a typical or unified approach within the department or within the wider voice community. Whilst they acknowledged that voice patients often presented with emotional problems, other than briefly identifying them, it tended not to be an area that was focused on in any great depth. If they were referred a patient with what they called a true conversion disorder they referred to a psychotherapist before starting voice therapy with them. They felt that mindfulness in voice therapy was perhaps being more used but that it tended to have come from individual therapist’s personal training rather than a set teaching method within SLT. Whilst one of the SLTs had heard of NLP she wasn’t familiar enough with it to use it with patients. I discussed the possible applications of NLP with this caseload and they were particularly interested in how to identify self-limiting beliefs and how to overcome points in therapy when patient’s progress appeared to have stalled. They agreed that in the USA, the approach was more medical based with focus on traditional voice therapy exercises.

Sarah Schnieder reported that SLT students received little training in voice therapy and even less in ‘counselling’ skills. As a result, SLTs working in voice then had to rely on picking up skills and techniques from colleagues and additional courses. There is much in the literature to support her views about adequate and appropriate training being given to SLT students in the areas of interpersonal skills and coaching (Janet Baker and Christina Shewell have written much on this). Henwood and Lister (2007) have written an entire book on ‘NLP and Coaching for Healthcare Professionals’ which offers ways of improving problems with inter-personal conflict, inability to recognise or deal with stress effectively, lack of confidence in self and inability to manage negative responses to difficult situations.

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During my time with Dr Linda Rammage - Principal Speech and Language Therapist at Vancouver General Hospital, I spent time in the Pacific Voice Clinic. The Pacific Voice Clinic and the Provincial Voice Care Resource Program were established by Dr Morrison (Laryngologist) and Dr Rammage to serve the needs of British Columbians affected by voice disorders and to provide an educational resource for professional practitioners involved in voice care. Dr Rammage is the only voice specialist in the hospital and surrounding community which along with Canada’s health care policy of offering free initial assessments but subsequent fee-based therapy means that the emphasis of the clinic is on assessment not therapy. Perhaps unsurprisingly therefore, when I sat in on sessions with clients, whilst questions were asked about psychological factors these were not explored. Whether it was down to my own particular interest in the psychological aspect of voice disorders or the fact that I had spent much time discussing this aspect of voice disorders with the NLP practitioners I had met, I noticed questions and phrases used by the clients that appeared to offer clues to their own circumstances. Sometimes these questions were overt ‘Is my voice related to stress?’ whilst others were more subtle ‘I’m worried my voice is a bit better because people will be able to hear me’.

In New York I met with Patricia Angelin who is the founding instructor of the Alba Technique. This technique evolved from the work of a neuro-psychologist called Susane Bloch who arrived at the theory that there are six core human emotions: Anger, Fear, Sadness, Joy, Erotic and Tenderness. She discovered that no matter the age, gender or nationality of a person, the same physical changes would happen in each of their bodies for each core emotion. The Alba Technique aims for people to increase their emotional availability and creativity, access emotions with ease, become aware of limiting habits and move through internal blocks. She uses this technique to help professional voice users (including singers and actors) ‘Step-In’ to core emotions by adopting specific physical components. These include changes in breathing, posture and muscle. We had an interesting conversation about reversing the technique and helping people ‘Step-Out’ of ‘real-life’ emotions - rather than fabricated ones for a performance. This was something that she had not previously considered and so was interested in doing some collaborative working with me at a future stage.

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Conclusion.

Investigating the use of neuro-linguistic programming in clinical voice disorders in America and Canada has produced some surprising, insightful, reassuring and thought provoking results. Contrary to my initial hypothesis that NLP was being used in this area, I was unable to find any national or even regional connected network between NLP and SLT. Whilst there is much agreement from professionals in both areas that NLP can be effectively used in this field there remains the need for a firm evidence base to convince others of it’s worth. A major disadvantage of the healthcare systems in North America is the focus on assessment rather than therapy at the primary source of access. In contrast, one of the huge advantages for therapists working in the NHS is the permission to work at the level of therapy. This allows us ample and exciting opportunities to re-establish normal voice for our clients.

Whilst it is widely accepted that NLP is about the process and not the content, I feel that for it to be accepted both the content and the process need to be made clear in order for it’s use to be replicated and developed. Much can be learned from the field of Mindfulness and the approaches being used to raise it’s profile and credibility. As a result of an increasing evidence base it is being more widely accepted and used in both the USA and the UK in a variety of areas and settings (Rogers and Christopher 2013).

This study has been important for several key reasons. Firstly because it suggests a new way of working effectively with the psychological aspects of voice disorders to ensure a holistic, patient-centred approach to treatment. Secondly because it highlights the potential barrier to using this ‘new’ technique in healthcare setting - namely education / training and an established evidence base.

After returning from my fellowship I co-lead an ‘Introduction to NLP for SLTs’ course at Cardiff Metropolitan University. This was well attended by SLTs who worked not only in the field of voice but in other areas including stroke, care of the elderly and stammering. Since my article on NLP in SLT was published in the Royal College of Speech and Language Therapists’ bulletin, I have heard from many other therapists who are either keen to learn more about NLP or have been using it within their own caseload. These connections are being used to set up a special interest group (SIG) in this area with the aim of promoting the use of NLP, sharing ideas and developing regular training.

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References.

Dilts R, Hallbom T, Smith S. Beliefs - Pathways to Health and Well-Being. Second Edition. Crown House Publishing. 2012

Hall M. The Sourcebook of Magic. A comprehensive Guide to NLP change patterns. Crown House Publishing, 2008

Henwood S, Lister J. NLP and Coaching for Healthcare Professionals - developing expert practice. John Wiley & Sons, Ltd, 2007

Kabat-Zinn J. Participatory Medicine. Journal of the European Academy of Dermatology and Venereology. 14 (4), 239 - 240, 2000

Matheison L. The voice and It’s Disorders. Whurr Publishers Ltd, 2002

O’Connor J, Seymour J. Introducing NLP - psychological skills for understanding and influencing people. Harper Element, 1990

Steinhouse R. Now to Coach with NLP. Pearson. 2010

Wake L. NLP Principles in Practice. Herts: Ecademy Press, 2010

Wake L, Gray R, Bourke F. The Clinical Effectiveness of Neurolinguistic Programming: A Critical Appraisal. Routledge 2012

Useful Websites.

The Association for Neuro Linguistic Programming: www.anlp.co.ukThe Royal College of Speech and Language Therapists: www.rcslt.org Center for Mindfulness in Medicine, Health Care and Society: www.umassmed.edu/cfm Oxford Mindfulness Centre: www.oxfordmindfulness.org Duke Integrative Medicine: www.dukeintegrativemedicine.org

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Appendix 1: Promoting the Fellowship - Royal College of SLT Bulletin (May 2013)

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Appendix 2: Copy of Article written in Royal College of SLT Bulletin (June 2013)

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Appendix 3: Copy of Agenda for Mindfulness Conference.

Wednesday April 17, 2013A Mindfulness-Based Approach for working with High-Risk Adolescents ......................................... 7

Mindful Communication: Bringing Intention Attention, and Reflection to Clinical Practice ............... 8

How the Dharma Intersects with Mindfulness-Based Interventions: The Four Noble Truths, the Three Characteristics of Existence, and the Four Foundations of Mindfulness................................. 9

Compassion and Kindness: Enhancing Capacity to Turn Towards Difficult Emotions ....................... 10

Remembering the Body: An Introduction to Mindful Movement..................................................... 11

Once Upon a Present Moment:A Storytelling Workshop ........................................... 12

Bringing Contemplative Practice to the Bedside in Palliative Care .................................................... 13

The Expressive Mind: An Introduction to Mindfulness Based Art Therapy ...................................... 14

Thursday April 18, 2013Neural Mechanisms of Mindfulness:Emerging Models ............................................... 15

Measured and Beautiful Motion: The Messiness and Relief of Attempting to Integrate Mindfulness into the Broader Society and the Emergence of a Global Community of Practice .......................... 17

Friday April 19, 2013Integrating Mindfulness Meditation into Leader Development Practice and Scholarship ............... 18

Integrating Mindfulness -best practices for training students and teachers K-12................................. 18

Building a Healing Community Based in Mind- fulness: Our fourteen years of experience at Duke Integrative Medicine........................................... 19

Current Concepts in Chronic Pain Neurophysiology: A Compelling Rationale for MBSR............... 19

Considering a Master’s Level Program in Mindfulness Studies ........................................................ 19

Adverse Effects and Meditation-Related Difficulties: An Empirical Analysis................................. 19

Effects of mindful-attention meditation training vs. compassion meditation training on brain responses to emotional stimuli in an ordinary, non-meditative state................. 19

A low-dose Worksite Mindfulness Intervention Investigating Levels of Inflammation.................. 19

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An integrated mindfulness program for teachers and students in educational settings ................... 20

Technology as a Vehicle of Mindfulness ............. 20

Mindfulness in Participatory Medicine............... 20

RESET: Mindfulness Training for Soldiers.......... 20

Mindfulness training induces upward spirals of positive affect and cognition............................... 20

Mindfulness Therapy for Fibromyalgia and Chronic Fatigue Syndrome: Analysis of Economic Consequences Alongside a Randomized Trial..... 20

Self-awareness, Self-regulation, and Self-transcendence: A framework for understanding the neurobiological mechanisms of mindfulness....... 20

Love 2.0: How Positivity Resonance Nourishes Health ............................................................... 21

Mindfulness, Stress Reduction, and Physical Health:

Quantitative and qualitative assessment of MBSR for elderly in long term care ............................... 30

Mindfulness-based Stress Reduction Program Can Help Caregivers to Improve Mental Health and Immunity – A Randomized Controlled Trial ...... 30

Mindfulness-based stress reduction for HIV-infect- ed urban youth: a randomized, controlled trial .. 30

Mindful Corrections: Design, Implementation & Research of Mindfulness-Based Emotional Intelli- gence (MBEI) Training for Prisoners and Corrections Professionals.............................................. 31

13 ways of looking at an MBI class: The different dynamics of mindfulness groups......................... 31

Does Meditation Modulate Brain Changes Associated with Dementia? A Pilot Randomized Trial in Adults with pre-Alzheimer’s ............................... 31

Mindfulness based training in Parkinson’s disease leads to structural changes on MRI .................... 31

Being with patients, being with self:A no-holds-barred self-suspending leap into the other’s sea .......................................................... 32

Saturday April 20, 2013Integrating Mindfulness into Nursing Education Programs .......................

So You Want a Career in Mindfulness Research?....25

Creating A Culture of Mindfulness at a University Campus .............................................................. 26

Teaching Mindfulness Meditation in Graduate Programs: Challenges and Opportunities ........... 27

The Pearls and Perils of Using Attention Control Groups in MBSR Randomized Trials ................. 27

“You call this Relaxing?” Insights from a Condensed Retreat Format MBSR Trial in Stressed Unemployed Adults............................................ 27

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Mindfulness Practice Improves Skills of Attention Regulation and Interoceptive Awareness ............ 27

A Randomized Control Trial of the Effects of a Mindful Yoga Program on High-Risk Adolescents......... 27

Ohm... Mindfulness as a way of improving self- care & enhancing job satisfaction ...................... 28

Talking about Death: An Inquiry into Imperma- nence.................................................................. 29

Innovative Approaches to Teaching Mindfulness in Higher Education ............................................... 30

Sunday April 21, 2013Bringing Mindfulness into the Acute Care Setting .. 33

Within Every Body: Teaching and Adapting Mindful Yoga ............................................................. 34

Mindfulness-Based Childbirth and Parenting: Mindfulness for Two Generations ...................... 35

Learning and Practicing Essential and Challenging Elements of the MBSR Curriculum: A Professional Development Day............................................... 36

Mindful Communication: Bringing Intention Attention, and Reflection to Clinical Practice ............. 37

Mindfulness In Schools: How a grassroots community creation came to be ..................................... 38

Lessons Learned and Novel Approaches to Teaching Mindfulness in Military and Veteran Environments .. 39

Misc.Continuing Education ........................................

New Brain-Behavior-Physiology Pathways ............

How Does Mindfulness Work – A neuroscience perspective for the MBSR Instructor/or the Non-scientist ......................................................

Mindfulness in the Workplace............................

Mindfulness Measures: Gaps in the State of the Art ..

Mindfulness-based stress reduction (MBSR) improved mental energy and processing speed after a

Mindfulness-Oriented Recovery Enhancement Reduces Pain Attentional Bias in Chronic Pain Patients

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