Music Performance Anxiety in Opera Singer

Logopedics Phoniatrics Vocology, 2010; 35: 175–182

ORIGINAL ARTICLE

Music performance anxiety in opera singers

CLAUDIA SPAHN1, MATTHIAS ECHTERNACH1, MARK F. ZANDER1, EDGAR VOLTMER2 & BERNHARD RICHTER1 1Freiburg

University Medical Center, Institute of Musicians’ Medicine, Breisacher Str. 60, Freiburg, 79106 Germany, and Friedensau, Department of Health and Behavioural Sciences, Friedensau, Germany

2University

Abstract Music performance anxiety (MPA) represents a high challenge every vocal performer has to meet. MPA can be defined on a continuum going from a low to a high level. MPA and its phenomena can be considered in terms of four levels: affect, cognition, behaviour, and physiology. A study carried out on seven opera singers and two instrumentalists during performance situations showed highly elevated values for the performers’ heart rate and blood pressure. This study, as several others, yielded no clear evidence pointing to a correspondence between the level of anxiety and of physiological arousal. At the end of the article a multimodal approach to the treatment of MPA is illustrated consisting of different psychotherapeutical and body-oriented methods. Key words: Blood pressure, heart rate, instrumentalists, music performance anxiety, opera singers, psychological aspects

Introduction The emotional expressiveness of voice is fundamental in all human communication. In fact, we sometimes call our voice ‘the door to our soul’. People whose profession involves using their voice consciously employ the voice’s expressive possibilities. Clearly emotions, feelings, and affects are paramount issues to musicians in communicating and understanding music. The famed singer Janet Baker, in an interview published in The Observer, stated of singers in general that ‘… our business is emotion and sensitivity—to be the sensors of the human race’ (1). Emotions are of fundamental importance from several perspectives: the perception of a voice and of its expression, as well as the emotions induced in the listener, does not coincide with the point of view of the performer inducing these emotions. The craft of professional singers consists in consciously generating the emotions a theatre piece or opera requires. The requirements a vocal performer has to meet are high: ‘artificial’ feelings are to be presented with absolute technical mastery and perfection. But how

does the performer deal with his own feelings, his present mood, his fears of not fulfilling certain expectations? As individual feelings and small insecurities have a direct repercussion on the vocal performance, a successful handling of his own emotions is of decisive importance for a professional singer. Handling one’s own voice represents a particularly big challenge, as the voice is part of one’s identity—both the artistic and private: ‘A violin is played by a person, a piano is played by a person, but a voice is a person’ (2). Exercising control over one’s own voice is not possible alone by the singer him or herself. Singers are therefore dependent on other people’s feedback. This interrelation may create a tension between dependency and self-confidence necessary on stage. All this demonstrates how a performer’s capacity to deal with his or her emotional factors has a decisive influence on his or her own performance. Competence in this particular field, next to vocal education, is a fundamental factor for a singer’s career development. In this context, music performance anxiety is an important issue, especially for singers, as of course

Correspondence: Prof. Dr. med. Claudia Spahn, Freiburg University Medical Center, Institute of Musicians’ Medicine, Breisacher Str. 60, Freiburg, 79106 Germany. E-mail: [email protected] (Received 22 December 2009; accepted 21 February 2010) ISSN 1401-5439 print/ISSN 1651-2022 online © 2010 Informa UK, Ltd. DOI: 10.3109/14015431003720600

C. Spahn et al.

Phenomenology of MPA Musical performance induces extraordinarily positive feelings in many players and singers. Participation in a successful and exciting performance often leads to feelings of euphoria. The baritone Thomas Allen is describing his feelings at the end of a performance of Don Giovanni in Japan: ‘I could have walked over the house-tops I was so high’ (interviewed in The Independent on Sunday in 1990). A study involving singers demonstrated how the action of singing causes an increased release of betaendorphin, commonly known for inducing feelings of happiness (3). Unfortunately, musical performance may also induce negative emotions, including distress and anxiety, which in some individuals can approach extreme levels of terror, impair quality of performance, and have debilitating effects on professional careers (4). Berghs (5) even described a loss of contact with reality in singers, associated with types of increased or decreased muscle tonus. MPA can be considered on a continuum from low to high (Figure 1). The low to middle range of MPA—for which also the term stage fright is used—is a normal and positive phenomenon for performance on stage. High levels of MPA belong to pathological forms of MPA and do need treatment. In 1983, Steptoe carried out an interview study with young professional opera singers (6). First, participants were asked to evaluate the quality of their performance in five different settings: lesson, private practice, audition, dress rehearsal, and public performance. The second step consisted in assessing the singers’ emotional tension in these five situations. Emotional tension values were represented on a nine-point scale. The study showed that the best singing was produced at an intermediate level of tension (in public performances). In contrast to this, the situations associated with greater tension (dress rehearsal and

audition) were those in which the performance level was lower. The results of this study are consistent with the inverted U-pattern, the Yerkes-Dodson curve (7) (Figure 2). Therefore it can be stated that any kind of stage appearance training, and any kind of treatment for MPA, ought to aim at allowing the person on stage to reach the individual optimal zone during his performance (Figure 2). In this regard MPA can be understood in terms of something continuous (see Figure 1). The change from normal to pathological and clinically relevant MPA occurs when the singer is personally suffering a lot, and/or when he cannot deliver his optimal performance on stage.

Epidemiology There are various examples of well known opera singers who suffered from stage fright. One of the most famous is Enrico Caruso. His impresario wrote in the memoirs: ‘With him, stage fright took on indescribable dimensions, robbed him of all reason, whipped his nerves and led everyone surrounding him into despair. On performance days there had to be deathly silence in all rooms. Every word spoken aloud distressed him. Breakfast, lunch, food absolutely easy to digest and consumed in tiny quantities—nothing of it he could keep to himself, and after drinking two cups of chamomile tea he drove to the theatre.’ (8) The impresario’s memoirs also reveal what means Caruso would use to cope better with his stage fright. He had applied inner pockets to his tail-coat, in which he would keep small bottles out of which he

optimal functioning zone

high

for all musicians. This article discusses the specific requirements placed upon professional opera singers, and focuses on the issue of music performance anxiety (MPA).

MPA

performance

176

low

Music Performance Anxiety low low

high stage fright

pathological form

Figure 1. The continuum of music performance anxiety (MPA).

high arousal

Figure 2. Correlation between performance and arousal. The optimal functioning zone of music performance anxiety (MPA) is at a middle level of arousal (7).

Music performance anxiety in opera singers Table I. The four components of music performance anxiety (MPA). Affect: Cognition: Behaviour: Physiology:

Feelings of anxiety, tension, apprehension, dread, or panic Loss of concentration, heightened distractibility, memory failure, catastrophizing Tremor, difficulty in maintaining posture and moving naturally Disturbances in breathing pattern, dry mouth, cardiovascular changes, gastrointestinal disturbances

drank on stage, with his back to the audience. The liquid in the bottles was a made up of distilled water, orange drops, and a pinch of salt. All performing artists experience MPA in different states across their professional lifetime. We have no epidemiological data on how many professional solo singers suffer from a pathological form of MPA and therefore would need treatment. A study by Kenny et al. (9) carried out on 32 opera chorus artists revealed a high state anxiety for 18.8% of the singers. As a measure of comparison, only approximately 15% of a sample of normal working adults are expected to score comparatively high values (9).

177

stimulus (10). Stanley Schachter (1922–1997) defined emotion as an experiencing state, which results from the interaction of stimulating perceptions and certain cognitions (11). Joseph E. Ledoux analysed fear in terms of neurophysiological reaction (12). He was able to ascertain that situational fear is learned in relation to corresponding stimuli. This can be applied to MPA and the way it develops. Nowadays we assume that there are two signal paths for performance anxiety (13) (Figure 3): The first one is fast and is an unconscious process. This path leads through the thalamus and the amygdala and activates the so-called periaqueductal grey (PAG) and the hypothalamus. Here, the reaction chain of the vegetative, autonomous nervous system is put into motion, with its hormones adrenaline and noradrenaline. The second signal path is considerably slower and represents a conscious reaction. This path involves higher cortical areas and offers a more detailed analysis of the situation. From the hippocampus, brain information is provided concerning emotional significance.

Investigation of opera singers on stage Models of MPA If we observe the phenomena of MPA more closely, we can distinguish between four levels: affect, cognition, behaviour, and physiology (Table I). Our understanding of how these levels interact and of how emotions can be conceptualized has undergone considerable change. William James (1842–1910) defined emotion as a purely physical phenomenon, namely as an experience of bodily reactions, following the perception of an exciting

In order to gather information about the physiological parameters of singers during their stage appearance, we carried out a study on opera singers at the Freiburg theatre, Germany.

Sample and methods In this study we analysed nine musicians, seven singers and two wind players, during performance situations as well as during rehearsal and the

Stimulus Sensory Cortex Consciousness

MEMORY

Thalamus

First pathway

Associative Cortex Hippocampus

Amygdala Hypothalamus

PAG

Second pathway hormone Sympathetic nervous system

Figure 3. Central pathways of music performance anxiety (MPA) (13).

C. Spahn et al.

daily routine situations of the regular theatre business. There were missing data in different singers and situations (see Figures 5, 6, and 7). The nine subjects were four women and five men, and all except one young singer had a several years of stage or orchestra experience. The youngest singer was 26 years old, the oldest 58, and the rest of the musicians were aged between 20 and 37 years. The study was conducted in collaboration with the local theatre. We drew important information about experiences on stage from individual interviews with the musicians, as well as from the artistic direction of the theatre. None of the musicians who participated in our study met the criteria for a pathological form of MPA in regard to both their self-evaluation and the judgement of the theatre’s artistic direction. Heart rate and blood pressure were measured with the Somnoscreen (Fa. Somnomedics, Würzburg, Germany), a standardized device which was originally conceived for application in sleep medicine and which was adapted for the use on stage. The Somnoscreen consists of a small box, which is wired around the waist of the musician, and of a measuring electrode and cable, which are fitted on to the little finger of the proband. Heart rate and blood pressure were generated by the pulse transition time (PTT) (14). At the same time the subjects completed the questionnaire on state anxiety (15) before and after their stage appearance. The Spielberger State-Trait Anxiety Inventory (15) comprises a 20-item self-report, assessing state anxiety (i.e. feelings of apprehension, tension, nervousness, and worry). It is a standardized and internationally established instrument.

220 200

heart rate mean before performance

180

heart rate mean during performance

160 mean heart rate bpm

178

heart rate mean after performance

140 120 100 80 60 40 20 0 1

2

3

4

5

6

7

8

9

subjects

Figure 4. Mean heart rates before, during, and after performance in a sample of nine musicians (subjects 1–7 opera singers; subjects 8 and 9 orchestra musicians).

The systolic blood pressure could only be measured correctly in six singers. These subjects show similarly high values before and during the performance, and lower values after the performance (Figure 6). Only subject 4 has a higher rate before the performance compared to during the performance. They lie between 110 and 190 mmHg and thus mostly lie above the medical normal range of 90–120 mmHg (16). Evaluating the questionnaire on state anxiety, we found that all five singers (only five singers 220 200

Results

160 max heart rate bpm

Figure 4 shows the average heart rate before, during, and after the performance. In all musicians the heart rate was at its highest during the performance and reached average values of between 110 and 140 beats per minute (bpm) (except for subject 9). Before the performance, most heart rates were slightly or significantly higher as compared to normal values for people of the same age. The subjects also showed a higher heart rate during the performance in comparison to their own heart rate in a state of rest. After the performance, some musicians’ heart rate sank to values lower than before the performance, in other musicians it remained higher or went down to the same level as before the performance. As can be seen in Figure 5, the subjects showed the highest peak values during the performance. These values go up to 200 bpm.

180

140 120 100 80

heart rate max before performance heart rate max during performance

60 40

heart rate max after performance

20 0 1

2

3

4

5

6

7

8

9

subjects

Figure 5. Maximum heart rates before, during, and after performance (subjects 1–7 opera singers; subjects 8 and 9 orchestra musicians).

Music performance anxiety in opera singers

anxiety values but almost normal blood pressure values (Figure 8).

250

systolic blood pressure mean mmHg

179

200

Discussion 150

systolic blood pressure before performance

100

systolic blood pressure during performance

50

systolic blood pressure after performance 0 1

2

3

4

6

8

subjects

Figure 6. Values of systolic blood pressure before, during, and after performance (subjects 1–4, 6, and 8).

filled out the questionnaire) showed higher anxiety values before the performance as compared to after the performance, with one exception. In comparison to a reference sample of students before an exam, the subjects showed altogether relatively low state anxiety values (Figure 7). After comparing psychological and physiological parameters we found that individual anxiety values and systolic blood pressure show different characteristics and a different development in the analysed subjects. For example, subject 2 has high 50

subject 2

The physiological parameters measured in the context of this study do not of course depict exclusively the cardiovascular sympathetic arousal caused by stage fright. The singers move a lot on stage during the performance. In addition, their heart rate and blood pressure rise during singing alone. The instrumentalists (subjects 8 and 9, respectively) do not move a lot while playing in the orchestra pit but still show a higher heart rate and blood pressure while playing. This is due partly to the intensity of the playing and blowing act for brass instruments. Referring to the literature on the field of MPA, there are—to our knowledge—only very few studies on singers, and till now there are no studies in which singers were monitored and analysed during their stage appearance with reference to physiological and psychological parameters. Haider and Groll-Knapp (17) investigated instrumentalists and determined a mean heart rate among members of the Vienna Symphony Orchestra of 93.9 bpm during concerts, which means an increase of heart rate of 27.7 bpm on average. In comparison to a reference sample of students before an exam, our singers showed altogether relatively low state anxiety values. A possible explanation could be that we had a very small sample of singers

49 students exam

45 42 STAI-State-Score

40

35

subject 9

40

subject 8

36

subject 6

34

subject 3

32

30

35

31 29

25

24

20 before performance

after performance

Figure 7. State anxiety scores in the State-Trait Anxiety Inventory (STAI) questionnaire (15) before and after performance (subjects 2, 3, 6, 8, and 9).

180

C. Spahn et al. systolic blood pressure mmHg

200 180 160 140 120

systolic blood pressure before performance

100

systolic blood pressure during performance

55

systolic blood pressure after performance

STAI-State Score

50 45 40

State anxiety before performance

35 30

1

234

1

2

5

25

State anxiety after performance

20 3

6

8

subjects Figure 8. Values for state anxiety and blood pressure (subjects 1, 2, 3, 6, and 8).

who—with the exception of one female singer— declared they could cope well with the requirements of a stage appearance and declared they already had ample stage experience.

Several other studies present much less evidence that MPA is associated with excessive physiological arousal. Abel and Larkin (18) showed that blood pressure and heart rate increased prior to playing

Model of learning theory

Succesful Performing Test performances Video-feedback

Performance Imagination exercices Mental techniques

perception

+

+ Psychoanalytic approach

Relaxation techniques Pharmacotherapy

thoughts and feelings

somatic reactions

+ Physiological reactions

FFF sympathetic nervous system

+ anxiety

Avoidance Flight

Exposition training Training plans

Individual conscious and unconscious motives and conflicts

Self-reflexion Psychoanalytic oriented Psychotherapy

Figure 9. Freiburg treatment model of MPA (27). Inside the bounding-box MPA is visualized as a learning spiral of fear of performance. Outside the bounding-box there are different therapeutic elements integrating psychoanalytic, behavioural, and body-oriented approaches.

Music performance anxiety in opera singers in public, but that responses were not significantly correlated with MPA. Craske and Craig (19) as well as Fredrikson and Gunnarsson (20) came to similar results. In our study with opera singers we also compared systolic blood pressure with anxiety values. Altogether, these findings suggest the following: physiological arousal may be a necessary condition for MPA, but it is not a sufficient explanation. Other factors are involved which relate to perceptions of physiological arousal as well as to the cognitive responses to performing. The most parsimonious explanation could be that performers experience the same feelings of physiological arousal, but while one finds these feelings energizing, another perceives them as signs of impending disaster. These results would be consistent with the two signal paths of MPA described earlier. Pedagogical and treatment approaches on MPA All previous clinical trials on MPA therapy demonstrated how cognitive therapies, as well as training and exposing oneself to the performance situation, are more effective than pharmaceuticals or placebo (21–24). Until now, however, there are no study results on the effectiveness of a particular psychotherapeutical approach or of a combined therapy (25). Interventional studies on specific treatment for singers are not yet available. Nevertheless, there is an upcoming interest in the psychological side of pedagogical and treatment approaches for singers. Barr recently stated in an article published in the LPV Forum that the ideal warm-up is built upon sound physiological foundations and also uses a psychological approach to prepare the singer on the emotional side (26). In accordance with the complex aetiological model of MPA, we propose at our Freiburg Institute for Musician Medicine a multimodal approach to treatment, consisting of different psychotherapeutical and body-oriented treatment approaches (27). Figure 9 gives an overview of our Freiburg treatment model of MPA. It can be visualized as a learning spiral integrating elements of a psychoanalytic approach and different other body-oriented techniques. In the area of thoughts and feelings, there are possible cognitive approaches. These approaches use imagination exercises to train positive thoughts and feelings during the imagined performance. Of similar importance is the psychoanalytic approach with psychotherapeutical refurbishment of deeplying fears, unconscious conflicts and motives, which

181

come to the surface in a performance situation. Avoidance behaviour is a consequence of such fears, but it can be tackled by structuring, in the form of training plans and training diaries. This comprises also the real experience of exposing oneself to a performance situation. The level of bodily reactions can be positively influenced by means of autogenous training, mental techniques, and breathing exercises. This includes also body fitness and a positive body perception. Body-oriented approaches such as the Feldenkrais method, Alexander technique, and breathing therapy improve the body perception experienced when singing and the control of body language during the stage appearance, and also have a positive effect on self-esteem. A good cooperation with singing pedagogics is of decisive importance here. Also medicaments can lead to positive effects on body and psyche. From our point of view, pharmaceutical therapy is only recommended in cases of a diagnosis with unambiguous indication. The range of medicaments is very limited due to their sideeffects that are damaging for the voice. In our experience, singers themselves are very cautious about taking pharmaceuticals. An important factor is to train the stage appearance under convenient circumstances. Test performances with video feedback allow singers to perceive themselves from the outside, work at their performance, and thus gain some self-confidence. The acquired techniques are applied on stage with therapeutical assistance during training sessions for stage presence. Afterwards, the musicians can put the acquired techniques into practice on their own. The therapeutical approaches shown are supposed to be carried out in different phases. We distinguish between three phases: the preparation phase, the stage appearance itself, and the wrap-up phase. The psychological, mental, and basal body-oriented preparation should take place in the weeks prior to the performance itself. The hours and minutes leading up to the performance are discussed and planned in every detail. In this connection, factors such as nutrition, movement, and clothing play an important role. Ideally, during the performance there should be total and exclusive focus on the singing and the performance itself. So-called ‘emergency measures’ are prepared individually for any kind of trouble: these measures include the ‘thought stop’ in case of catastrophizing, calling up a positive body feeling in case of a lacking presence, own inner imagination pictures, contact with the audience, etc. The wrap-up phase is extremely important, as the pre-conditions for the next performance are created during this phase. The singer learns that heightened adrenaline concentration has to be metabolized. This can lead

182

C. Spahn et al.

to feeling ‘high’ or suddenly exhausted. Sometimes, mildly depressive reactions can occur after a performance. In opera everyday life, the three phases are drastically shortened and often overlap. The singer thus needs a considerable amount of discipline and attention in order to adapt positively to these routines and requirements. An assessment of the performance should ideally take place only 1 or 2 days after the performance itself. In this context, it is particularly important to become conscious of the performance’s positive aspects, as from these grow the resources for further positive development. Conclusions In all its different forms MPA represents a professional challenge for singers and instrumentalists. There are a number of different pedagogical and therapeutical measures used to optimize stage fright which focus on physiological or psychological factors of MPA. As expected, a first analysis of singers during a performance on stage revealed an increase of heart rate and blood pressure values before and after the performance. However, it is still difficult to assess the clinical relevance of these heightened parameters. Physiological and psychological values of MPA did not point in the same direction. This possibly suggests that performers experience the same feelings of physiological arousal, but while one finds these feelings energizing, another perceives them as signs of impending disaster. Further research is necessary in order to gain more knowledge on MPA and its treatment especially in singers. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. References 1. Crofton I, Fraser D. A dictionary of musical quotations. London: Routledge; 1985. p. 112. 2. Piers P. A voice is a person. BBC Radio 4 Programme (first broadcast on 4 October 1978). 3. Biegl T. Glücklich singen—singend glücklich? Gesang als Beitrag zum Wohlbefinden. Diplomarbeit im Fach Psychologie. Universität Wien; 2004. 4. Steptoe A. Negative emotions in music making: the problem of performance anxiety. In: Juslin PN, Sloboda JA, editors. Music and emotion: theory and research. Oxford: Oxford University Press; 2005. p. 291. 5. Berghs G. Stage fright in singers: Three reaction types. Folia Phoniatr Logop. 2008;60:294–7. 6. Steptoe A. The relationship between tension and the quality of musical performance. Journal of the International Society for the Study of Tension in Performance. 1983;1:12–22.

7. Yerkes RM, Dodson JD. The relation of strength of stimulus to rapidity of habit-formation. Journal of Comparative Neurology and Psychology. 1908;18:459–82. 8. Ledner E. Erinnerungen an Caruso. Hannover and Leipzig: Paul Steegmann Verlag; 1922. p. 73–6. 9. Kenny TD, Davis P, Oates J. Music performance anxiety and occupational stress amongst opera chorus artists and their relationship with state and trait anxiety and perfectionism. J Anxiety Disord. 2004;18:757–77. 10. James W. What is an emotion? Mind. 1884;9:188–205. 11. Schachter S, Singer JE. Cognitive, social, and physiological determinants of emotional state. Psychol Rev. 1962;69: 379–99. 12. Ledoux JE, William H, editors. Mind and brain: dialogues in cognitive neuroscience. Cambridge: Cambridge University Press; 1986. 13. Altenmüller E. Wenn unser Gehirn Angst empfindet. Zur Neurobiologie der Angst. In: Vom Lampenfieber zur Auftrittsangst. Schriftenreihe XIII der Psychosomatischen Klinik Bad Neustadt. 2009. p. 25–44. 14. Gesche H, Grosskurth D, Patzak A. Neue Methode für nicht-invasive Blutdruckmessungen durch die Verwendung der Pulse Transition Time (PTT). International Congress ‘Hypertension and the kidney’; Wien, 2007. 15. Spielberger C. Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists; 1983. 16. Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Bethesda, USA: National Institutes of Health, National Heart, Lung, and Blood Institute; 2004. p. 1–86. 17. Haider M, Groll-Knapp E. Psychophysiological investigation into the stress experienced by musicians in a symphony orchestra. In: Stress and music: Medical, sociological, and legal strain factors in a symphony orchestra Musicians’ profession. Vienna: Wilhelm Braumüller; 1981. p. 15–34. 18. Abel JL, Larkin KT. Anticipation of performance among musicians: physiological arousal, confidence and state anxiety. Psychology of Music. 1990;18:171–82. 19. Craske MG, Craig KD. Musical performance anxiety: the three-systems model and self-efficacy theory. Behav Res Ther. 1984;22:267–80. 20. Fredrikson M, Gunnarsson R. Psychobiology of stage fright: the effect of public performance on neuroendocrine, cardiovascular and subjective reactions. Biol Psychol. 1992;33: 51–61. 21. Appel SS. Modifying solo performance anxiety in adult pianists. J Music Ther. 1976;13:2–16. 22. Kendrick MJ, Craig KD, Lawson DM, Davidson PO. Cognitive and behaviour therapy for musical performance anxiety. J Consult Clin Psychol. 1982;50:353–62. 23. Sweeney GA, Horan JJ. Separate and combined effects of cue-controlled relaxation and cognitive restructuring in the treatment of musical performance anxiety. J Couns Psychol. 1982;29:486–97. 24. Clark DB, Agras WS. The assessment and treatment of performance anxiety in musicians. Am J Psychiatry. 1991; 148:598–605. 25. Kenny DT. A systematic review of treatments for music performance anxiety. Anxiety Stress Coping. 2005;18:183–208. 26. Barr S. Singing warm-ups: physiology, psychology, or placebo? Logoped Phoniatr Vocol. 2009;34:142–4. 27. Spahn C. Stage fright and performance anxiety among musicians—basic considerations and therapy. Med Welt. 2006;57:599–63.

Copyright of Logopedics Phoniatrics Vocology is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

Copyright of Logopedics Phoniatrics Vocology is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.