The Stakeholder Model of voice research: Acknowledging barriers to human rights of all stakeholders in a communicative exchange

Abstract

The act of communication is a complex, transient and often abstract phenomenon that involves many stakeholders, each of whom has their own perspective: the speaker, the listener, the observer and the researcher. Current research practices in voice disorder are frequently framed through a single lens – that of the researcher/clinician or their participant/patient. This single lens approach risks overlooking significant barriers to the basic human right of freedom of expression for those with a voice disorder as it omits consideration of the impact of voice disorder on the listener, and consideration of the wider impact of the voice in the occupational context. Recent research in the area of voice has developed a multiple lens and subsequent Stakeholder Model that acknowledges the experience and reality of multiple stakeholders viewing the same phenomenon, the voice. This research paradigm is built on Article 19 of the Universal Declaration of Human Rights as it considers the realities of all stakeholders in forming a deeper understanding of the causality, impact and aspects of communication disorder. The Stakeholder Model will be presented as a suggestion for future investigations of communication disorders more widely.

Keywords:

• Voice disorder
• dysphonia
• human rights
• Universal Declaration of Human Rights
• Article 19
• United Nations
• communication
• speech-language pathology

The voice conveys human experience

On the 70th anniversary of the Universal Declaration of Human Rights (United Nations, 1948), we celebrate what it is to be human. Voicing is the most fundamental element of human verbal expression – without it there can be no vocal expression of emotion, no singing, no spoken words and therefore, no verbal expression of complex meaning. It lies at the heart of the human right to verbal expression and it is the most common media through which we communicate. It is an implied component of Article 19 of the Universal Declaration of Human Rights as people can express meaning not only through “verbal” features such as syntax and lexicon but also via non-verbal or suprasegmental features such as accent, voice quality, speech rate and pitch (Brown & Lambert, 1976). Our earliest vocal communicative acts occur as infants via crying and gurgling (Oller, Oller, & Badon, 2006). This most basic non-verbal, vocal act is highly efficient in conveying meaning regarding the needs and state of the infant (Scherer, 1984). Thus, suprasegmental elements of communication may be our earliest developed and possibly most fundamental communication channels (Gleason, 2005). Even after the development of language, tone of voice can change the meaning explicit in language to convey meaning beyond the literal interpretation of the words themselves.

The human voice is elegant in its functionality, consisting of three neurological subsystems that control the function of the laryngeal anatomy for (1) airway protection, (2) vocal expression of emotion and (3) vocal control for speech and singing (Simonyan, Ackermann, Chang, & Greenlee, 2016). These subsystems allow the voice to convey both the words and the feelings or arousal state of the speaker including if they are energised or tired, sick or in good health, happy or sad. The healthy, highly trained voice of a professional performer is expected to convey the greatest range and complexity of linguistic and emotional expression. This use of the voice is often considered to be the ultimate in human communication, and it is the foundation of vast music, live entertainment and radio/television industries worldwide. Importantly, each listener may perceive the message with different nuances depending on their own experience and internal expectations. This individual interpretation applies to both the affective and linguistic content of the message and may not match the intent of the voice user.

The voice is experienced differently depending on the lens through which you view it

Understanding how the voice and the vocal signal are experienced in daily expression of thoughts and feelings therefore requires consideration of not only how the voice is experienced by the speaker, but also by the listener. The Brunswik “lens” model of attribution (Brunswik, 1955), describes how objects or behaviours can never be directly perceived by an individual, as what is perceived by an observer depends on many factors. These can include the attributes of the object or behaviour, the manner in which it is perceived, the context within which it is perceived and the characteristics of the individual perceiving it. Scherer (1978) extrapolated Brunswik’s model when considering the phenomena of voice quality where specific, measurable behaviours (such as habitual voice quality or vocal pitch) are cues used by listeners to attribute personality characteristics to speakers. This model acknowledges that the impact of listener attribution cannot be ignored when considering the voice and its role in expression. How it is heard is, for many, the ultimate record of the speaker’s intent and the measure of success or not, of their communication.

Occupational voice users are defined as people whose occupations are dependent on their voice to meet their occupational demands and are estimated to comprise up to 45% of the population (Titze, Lemke, & Montequin, 1997). For the occupational voice user, the listener response often defines effectiveness of the voice and indeed the professional outcome. For example, the success of a radio broadcaster is determined not by his or her vocal health but by the listener ratings of the broadcast. Similarly, the teacher, is judged as successful by the learning and engagement of their student, not by their vocal skill or stamina. Yet in the vast majority of voice research the lens through which the voice is assessed is that or a clinician or researcher, with a predominant focus on the phenomena of voice disorder.

Voice disorder: Common, under-treated and sometimes misunderstood

Voice disorder is a common human condition occurring across all age groups, in women more frequently than men (Roy, Merrill, Gray, & Smith, 2005) and in occupational voice populations more often than non-occupational voice populations (Seifpanahi et al., 2016). Research on voice disorder has been predominantly from within a medical model. That is, for the most part, voice researchers and voice research examine deviation from a so-called “normal” and descriptions of symptoms both quantitatively and qualitatively have been emphasised. The impact of voice disorder in society is substantial yet often unrecognised.

The lifetime prevalence of voice disorder has been reported to be as high as 30% (Roy et al., 2005). Voice disorders are estimated to cost society billions of dollars (Verdolini & Ramig, 2001) and have significant impacts on quality of life (Marmor, Horvath, Lim, & Misono, 2016; Siupsinskiene et al., 2011). Voice disorder is generally under recognised and under treated. For example, in a large epidemiologic study of voice disorders in the United States, of the approximately 43% of adults surveyed who experienced voice problems at some point during their life, only one quarter had seen a doctor or speech-language pathologist for treatment of their dysphonia (Roy et al., 2004).

In addition, voice disorder in some cases reflects emotional barriers to the expression of the self. The work of Baker (2010) and House and Andrews (1988) suggests that traumatic life events and situation can precede the onset of so-called functional dysphonias. For these people, their inability to communicate may reflect an underlying lack of freedom or safety in verbally expressing their ideas, opinions and experiences.

The hidden impact of voice disorder: Hearing the voice through the ears of the listener

There are however hidden costs of voice disorder, infrequently acknowledged in current voice and speech research. Firstly, the impact of voice disorder on the comprehension of the listener has been documented (Morton & Watson, 2001; Rogerson & Dodd, 2005). Speakers with dysphonic voices were understood less easily with listeners, largely children, comprehending less than when they listened to non-dysphonic speakers

Secondly, there is the impact of the attribution of the listener. Beyond the implied meaning of the language itself is also the listener’s perception of the characteristics of the speaker’s voice (Laver & Trudgill, 1979). Listeners may form opinions about a person’s personality based on one or more specific vocal features (e.g. voice quality, speech rate or intonation) and according to a range of variables such as their experience and knowledge of that speaker, the listener’s state of mind and the context of the conversation (Knapp, 1984). Personality attributions involve a listener making judgements about the causes or nature of a speaker’s behaviour (Kelley, 1972). They may include not only judgements of a speaker’s personality traits and attitudes (Pittam, 1994), but also judgements about age (Hamsberger, Shrivastav, Brown, Rothman, & Hollien, 2008;), physical attractiveness (Hill & Puts, 2016) or social status (Brown & Lambert, 1976).

There are many lenses through which the voice can be experienced and understood. Using data collected across three experiments, (Madill, 2008) explored the relationship between specific laryngeal movements and how the speaker was perceived. For example, constriction of the false vocal folds (as occurs in commonly occurring voice disorders such as muscle tension dysphonia) were strongly correlated not only with auditory perceptual judgements of voice quality (glottal fry, roughness, strained voice quality and reduced loudness) (Madill, Sheard, & Heard, 2017) but also with listener attributions of higher levels of neuroticism and lower levels of extroversion and conscientiousness. Thus, change in speaker voice quality may have profound negative effects on the personality attribution made by listeners.

The Stakeholder Model of voice research

The Stakeholder Model of voice research has emerged in the context of occupational voice users, acknowledging even greater complexity when the voice is needed to engage the listener’s attention and clearly communicate a message (Warhurst, 2013; Warhurst, McCabe, & Madill, 2013). The Stakeholder Model acknowledges that there are many individuals involved in a communicative exchange and each individual’s perspective should be considered in investigating the nature and impact of the communicative event.

The consideration of the voice as a phenomena consumed by many stakeholders was explored by Warhurst and colleagues (Warhurst, 2013) in a series of studies investigating the voices of radio broadcasters. In pursuit of a definition of a “good voice for radio”, multiple stakeholders were consulted, including radio industry professionals, clinicians and listeners. For radio broadcasters, communicating a life-saving safety message, moving the listener to an emotional state, or selling a product all require a voice that is perceived positively by the listener. The listener here is thus also seen as a vital stakeholder as they are a consumer of ideas and emotions that only the voice can convey.

Different language was used by each stakeholder group to describe phenomena associated with the voice. For example, employers considered the voice in terms of their expectations and those of their listeners (Warhurst et al., 2013). By contrast, radio listener judgements of what makes a voice good for radio relied on a series of direct comparisons between voices (Warhurst et al., 2017) with implicit comparative ratings of goodness used to determine listener judgements ranking of voices. A more traditional acoustic description approach was then used to examine the properties of the “good” and “not good” voices and provide insight into how voice measurements may relate to the listener’s judgement in a specific context. Application of the Stakeholder Model provided comprehensive evaluation of the broadcasters’ voices and showed that many commonly accepted clinical tools for measurement of voice (e.g. acoustics, clinician perceptual voice evaluation) are likely to be inadequate in reflecting the complex needs of radio broadcasters and other professional voice users. The Stakeholder Model enriches our current understanding of the impact of voice disorders because it expands the communicative context beyond the speaker and listener. This comprehensive approach has not been explicitly acknowledged in research on communication disorders to date, although research in speech pathology often investigates the perspective of dual stakeholders such as patient and carer (e.g. Worrall et al., 2016), patient and employer (e.g. Logan & O’Connor, 2012), patient and clinician (e.g. Tschiesner, Becker, & Cieza, 2010). Neither research nor clinical practice have historically acknowledged the impact of the heterogeneity of stakeholder perceptions and the impact this may have on communication disorder for both professional and non-professional speakers.

In summary, describing or defining the state of the voice can be viewed through multiple lenses by multiple stakeholders. Auditory features such as pitch and loudness are acoustic phenomena that can be measured objectively, but may be experienced and evaluated differently by the speaker and the listener. Whether the pitch of a voice, for example, is too high or too low is dependent on age, gender, or situational expectations. Therefore, the ability of a voice to impart a message is determined by the extent to which it matches the expectations of its listening stakeholders.

Article 19: Consideration of all stakeholder realities in forming a deeper understanding of the causality and impact of communication disorder

Article 19 of the Universal Declaration of Human Rights (United Nations, 1948) is specific in its wording, that “everyone” has the right to freedom of expression and opinion. Every communicator has a range of social determinants of their health. For example their race, gender, early development, work, stress, housing standards, exposure to conflict/war and social supports (World Health Organization, 2003). Therefore, for every person with a communication disorder, there will be different stakeholders at play, who reflect their individual social determinants of health. The Stakeholder Model, as applied to occupational voice users, allows us to consider the wider effects and implications of communication disorder on a person’s ability to fulfil their occupational requirements. For example, a man in Australia whose stuttering impairs his corporate work will have very different social barriers to communication when compared to a child in rural South-East Asia with voice disorder. Similarly, these individuals will have differing stakeholders (e.g. boss, colleagues, teachers, friends) with whom they communicate. These stakeholders will ultimately affect the causality and impact of the communication disorder. Acknowledging and supporting the human right to express feelings and thoughts begins with hearing every individual’s voice. To ensure that everyone has the right to freedom of expression and opinion, without impairment or interference, it is crucial that clinicians and researchers widen their lens to consider all stakeholders in describing, remediating and accommodating an individual’s communication disorder.

Declaration of interest

No potential conflict of interest was reported by the author(s).

Acknowledgment

The authors would like to acknowledge the support of the Dr Liang Voice Program at the University of Sydney.