We return! To discuss the effects of trauma on the voice. An unexpected detour this month, since so many papers have been written on it and yours truly has had a troubled relationship with the voice during times of troubled relationships. A podcaster’s nightmare.
And also. A singer’s nightmare.
Today, we cover the paper:
What’s in a singer’s voice: The effect of attachment, emotions and trauma
Elisa Monti, David C. Kidd, Linda M. Carroll & Emanuele Castano
Logopedics Phoniatrics Vocology
2016
Intro:
The field of vocology and vocal care isn’t a stranger to ways psychology can upset the voice. Divorces, personal losses, natural disasters… Distress in life comes through in the way we express ourselves. When duress is great enough, we might even fall mute – unable to utter – without a single, clear, physiological cause. This makes it challenging, of course, as is always the case, for anyone afflicted to get effective care. A holistic, system-thinking, approach is necessary to pinpoint the mental hangup causing vocal disorder…. Which isn’t what western medicine deals with. It can leave vocal professionals – such as singers or podcasters – shit out of luck, in further distress, and at risk of losing career traction.
Among professionals of voice care, the relationship between the mind and the voice is well known. For instance, psychological conflicts (e.g. spouse or parent relationships) and traumatic experiences are thought to be at the origin of psychogenic voice disorders, such as conversion aphonia (1)—a crippling condition which makes a person unable to speak. It is possible that psychological factors may also affect the voice more broadly, affecting it in systematic ways that do not necessarily result in a clinical diagnosis. Furthermore, to the extent that the voice takes on a different role and thus meaning for different individuals, it could be expected that psychological factors are particularly at play for those individuals whose voice is a more central part of their identity, such as singers.
Emotional states have been implicated in vocalization challenges and changes. Anger makes the voice punchy. Sweetness and care are associated with slow and agile mouth movements. Let down is expressed with gradual softening. And “As vocal psychotherapist Diane Austin observes, if one’s needs and feelings remain unmet, the voice can become inaudible, tense, breathy, or simply ‘untrue.’” One might say it becomes “inauthentic.”
Emotions have also been related to different mechanical processes of phonation. Anger has been found to be associated with ‘violent movements between extreme articulatory positions’; tenderness has been associated with ‘slow, more supple movements’; and disappointment has been associated with ‘progressive relaxation of the tongue and soft palate’ (3).
While it is evident that distinct emotional states can affect the voice, it is also reasonable to hypothesize that the physiological subsystems that underlie voice functioning are affected by psychological experiences that may have occurred in a recent or distal past.
Such an impact, we suggest, is particularly likely to emerge among singers, whose sense of self is directly linked to their voice. Study 1 focuses on the relationship between attachment style and the voice, while Study 2 also looks into the effect of childhood trauma on the voice. Study 2, additionally, examines the relation between specific self-conscious affects (e.g. shame) and vocal characteristics.
So, while feelings unquestionably affect voice… we have to wonder if there’s a traceable pathway from one to the next. Is physiology affected by psychology, which then changes vocal output?
This would be highly applicable and potentially beneficial to study in professional vocalizers – singers – whose identity and often livelihood is linked to vocal control and capacity, as their awareness of voice is internally heightened and externally mediated. Therefore, the authors of this paper conducted two studies using singers. First, asking how attachment and voice are related. Secondly, looking at psychological characteristics of those attachment styles as they affect voice (i.e. shame and guilt).
We start by providing a brief review of the attachment and childhood trauma literature.
Let’s talk background information on attachment, trauma, shame, and physiology.
Attachment
Attachment style begins in infancy, as the relationship with parents establishes the relational expectations of the individual. Parental figures are supposed to offer protection and security – a barrier from stress and fear – that teaches the child how safe relationships function. Attachment is thought to be shaped by 1) proximity of the caregiver to the child 2) need fulfillment from the parent to the child and 3) sense of safety provided by the adult to the kiddo.
An individual’s attachment style is largely a reflection of her or his patterns of relating with their primary caregiver (often the mother) during childhood (5). Theorists, beginning with pioneer of attachment theory John Bowlby, argue that the caregiver–child relationship has an evolutionary purpose of protecting young children from hazards, giving them a secure basis for development (6,7). In human societies, adults protect children from both physical and psychological dangers. As a result, the three fundamental elements of attachment are:
(1) the level of proximity of the caregiver to the child, including the behavior a child displays during caregiver’s absence; (2) the caregiver’s role as ‘secure base’ for the child to feel safe and secure during play and exploration of the environment, knowing the parent will be there in case of need; (3) nurturing by the caregiver, which affirms a sense of safety in the child, who will be more inclined to believe that the environment is generally benign (8).
Psychology commonly focuses on three forms of attachment; Secure, insecure anxious, and insecure avoidant. Secure attachment corresponds with a child’s ability to function separately while realizing they can return to the parent when needed. Anxious attachment is marked by duress when the adult is not in proximity and continued discomfort when they are around. Avoidant attachment is linked with disinterest in the caregiver when proximal. And surprise category four: disorganized attachment can feature a combination of the above. These patterns are established young and often carried through life.
researchers developed a taxonomy of three basic attachment styles: secure attachment, indicated by activity during the caregiver’s absence and pleasure at their return; insecure anxious attachment, indicated by distress during absence and upon return; and insecure avoidant attachment, indicated by a failure to respond to the returning caregiver. In later studies a further category, that of insecure disorganized attachment, was developed (12,13). Disorganized attachment is associated with traumatic experiences in childhood, such as abuse or neglect (12,13). Patterns of attachment in childhood have been shown to persist into adulthood (8–10).
They not only affect how adults feel about others – but also themselves. If gifted secure attachment, resilience and relational responsiveness are often seen. If insecure attachment is built, sense of incompetence and relational unreliability are more common. These are generally stable attachment and self-assessment patterns because they’re recreated from childhood into the grown individual, consistently confirming previously established beliefs about whether the person is worthy or valuable.
Models of self and other can be based on positive expectations (resilient self, responsive other) for secure attachment or on negative expectations (incompetent self, unreliable other) for insecure attachment. Adult attachment is directly dependent on infant attachment because of ‘internalized’ representations of the internal working model (11). These attachment dynamics that from childhood are reenacted into adulthood directly influence one’s perception of the environment as safe or unsafe and—crucially—directly influence the self-concept and other-concept as ‘good enough’ or not.
We discuss attachment because it doesn’t exist in a vacuum:
Attachment and physiology
As explained by Maunder and Hunter, insecure attachment can have an impact on physiological responses and on adults’ health conditions (14); this has been shown in several studies that hint at the fact that attachment impacts self-regulation and stress responses. Previous studies also showed that insecure attachment affects a variety of physiological factors such as brain activity, heart rate, and skin conductance response.
Insecure attachment, in general, might have destructive health effects. Because it corresponds with sensing a lack of safety in relationship and in isolation, it can increase chronic stress load. Stress load can then impact all biological systems. Insecure attachment is known to impact the brain, heart, and skin.
In particular, insecure anxious attachment is not correlated with positive personal health outcomes. But insecure avoidant attachment doesn’t seem to feature the same critically negative results, suggesting that anxious attachment may interplay with physiology in a deleterious manner.
Importantly, anxious attachment has been associated with worse health outcomes in adulthood compared to avoidant attachment (18,19), therefore suggesting that its effects on physiology are more damaging than those of avoidant attachment.
Here we intend to look at the relationship between attachment and voice.
With all of these long-term health effects connected to attachment style, it’s unlikely that the voice isn’t affected as well. And since both forms of insecure attachment herald back to childhood relationships, we also need to talk about:
Childhood trauma and physiology
You’ve heard – the body keeps the score. Physiology isn’t immune to negative effects of trauma, and the longer the duration, the greater the change. Our bodies can be thrown off systemically, leading to things like chronic inflammation and immune disorder that open the door to myriad illnesses and ailments. Trauma also changes the structures of the brain, impacting the functionality of the entire meat suit. High ACE scores are correlated with disease and early fatality for a reason.
When traumatic experiences occur, they affect one’s psyche as well as one’s body. Research suggests physiological responses are generally altered by traumatic experiences, especially if the latter are prolonged (20,21)… prolonged trauma exposure has been associated with risky physiological and health outcomes such as immunosuppression (26). Furthermore, trauma during childhood can lead to changes in structural and functional properties of the brain that can contribute to psychosocial disorders in adulthood (22). Adverse childhood experiences have been identified as some of the strongest predictors of fatal health conditions in adults (27).
The relationship between attachment and vocalization, however, hadn’t been explored prior to this study.
While, to our knowledge, there is no empirical research on the relationship between attachment and the voice, the effects of trauma on the voice have been investigated in several studies—albeit only from a perspective of vocal pathology.
What had been previously revealed through research was the impact of trauma on respiration, which can be severe enough to cause vocal impairment without physiological pathology – even to extreme lengths such as aphonia (loss of capacity to speak). Major psychological events like losses and accidents can cause these constrictive disorders without a clear biological source.
For instance, research has shown that traumatic events can affect one’s respiration and also one’s voice, in some cases contributing to a clinical voice disorder (28–30), such as conversion or functional dysphonia (vocal impairment in the absence of laryngeal pathology) (31). Other studies on psychogenic voice disorders reveal the impact of traumatic or stressful experiences (e.g. loss of a loved one, unhappiness, conflicts, and accidents) on the voice, showing that symptoms associated with a vocal disorder can occur without a biological cause. When this happens, the cause is often found to be psychological. Instances of emotional trauma associated with cases of aphonia (inability to speak) stem from psychological factors that contribute to muscle tightness in the vocal folds (30).
When we’re talking about constriction and self-shutdown? It’s also a good idea to discuss:
Anxiety and shame
It’s no mystery: anxiety affects the body. It can lead to changes in breathing, which changes the voice. Research suggests that higher anxiety levels could correspond with greater voice pathology, higher frequency range, and reduction in silent (intentional) pauses.
A bit on silent pauses: they’re used to determine next words without using fillers (um, like, ya know), and they’re also instrumental in allowing the listener to absorb, calibrate, and respond. After a sentence or question, we might use a silent pause to open room for the other voice to chime in. During a sentence, we might use one to carefully choose what direction we’ll continue our speech in. When we’re anxious, the mind doesn’t allow for this quiet, calm, collected feature of speech. Instead, language is more rushed, jumbled, and impulsively expressed.
Research has investigated how anxiety can impact physiological functions leading, for instance, to deep and irregular breathing (29). By affecting one’s breath, anxiety can affect one’s voice; individuals with high anxiety levels seem to be more prone to developing benign voice disorders (28), and a decrease in anxiety matches decreases in Fo, frequency range, and frequency of silent pauses (32).
Self-conscious affect might also be related to voice. Feelings of shame have been associated with negative conceptions of the self and a sense of humiliation in front of others (which for singers could be related to stage fright) (34). Importantly, shame is associated with feelings of being ‘small’, a sense of shrinking and worthlessness (35). Also, shame proneness is about feeling ‘exposed’ (35). For this reason, we expect shame to relate to vocal intensity and perhaps perturbation.
Shame may also play a role in voice, making it smaller and less exposing. Vocalizing draws attention, so self-conscious feelings can cause obstacles to expressing oneself or doing it confidently. In the case of singers, stage fright is a sizable challenge when humiliation or self-unworthiness are feared. That means shame, like anxiety, is another potential connection between childhood trauma, wonky attachment, and voice pathology.
And, luckily, we have voice professionals to learn from:
More evidence from performance and implications for singers
Because singers centralize identity around voice, it is heavily psychologically impacted. Traumatic events are known to impact performances. Conflict and family health are particularly implicated in spawning anxiety and affecting vocalization.
This is unique to singers, whereas other performers might be able to separate mental and emotional conditions from their ability to play another instrument. Because in the case of vocalists the body contains the software and hardware necessary to do the job, they have no separation point between mind and output. The nerves controlling the throat, lungs, and vocal cords can’t be tuned up separate from changing the emotional or nervous system state of the performer. Spasms, constriction, and relaxation of the laryngeal muscles are correlated with systemic wellness or distress.
As noted above, the effects of psychological factors on the voice are even more likely to be present among singers, for whom the voice is a more central part of their identity. While we are aware of no psychological study specifically targeting this population, there is some evidence that traumatic events affect the performance of musicians (38,39). Specifically, parental conflict and dysfunctional family environments affect musicians’ level of anxiety and their relationship with their instrument (40–42).
In the case of singers, their instrument is the voice, which is even more likely to be affected by psychological states, compared to other musical instruments, since it can be directly affected by somatization processes. The laryngeal nerve, for instance, is sensitive to emotional changes (2). Emotional distress affects laryngeal muscles in the same way that a factor as damaging as smoke affects the throat of a non-smoker, causing muscular twitches in the larynx. By contrast, in the absence of emotional distress, laryngeal muscles appear relaxed (43).
A form of distress particularly relevant for singers, stage fright, has been analyzed from a therapeutic psychological perspective by McGinnis and Milling (44). During intense stage fright, the heart races and the throat dries up. Both physiological changes have been shown to affect vocal performance (34). Moreover, McGinnis and Milling observe that stage fright symptoms are unmistakably similar to those of social phobia, which has been shown to have a relationship with attachment patterns and trauma (17,22). This raises the possibility that stage fright, and its vocal consequences, may likewise relate to attachment and trauma.
Again, we can nod easily towards stage fright as an example of the brain-body-voice connection, during which the heart and throat are often acutely affected. This connection is so weighty that researchers such as McGinnis and Milling have posited that stage fright and social anxiety are remarkably similar; once again potentially implicating insecure attachment as a cause of negative vocal health.
So how did researchers explore these connections?
METHODS
Thirty-five adult participants identifying as singers were recruited for the study. Attachment style was assessed using the ECR-R (Experiences in Close Relationships–Revised). The Childhood Trauma Questionnaire Short Form was administered to assess trauma. A revised version of the State–Trait Anxiety Inventory (STAI) was utilized to score anxiousness. The TOSCA-3 (Test of Self-Conscious Affect version 3) was used to assess shame proneness (47). They used The Singing Voice Handicap Index to record voice disability in singing. And once again the voice analysis was conducted using LingWAVES (49), a software program used for professional voice and speech analysis.
Participants
Participants (n¼25; 14 women, 11 men) (Table 1) were recruited through music programs at universities and conservatories, as well as via Craigslist, a popular online listing of classifieds. Singers self-identified regarding performance and style as either musical theatre singers (10), choral singers (6), or jazz singers (9). All had a minimum of 5 years of vocal training.
Materials
Attachment style was assessed using the ECR-R (Experiences in Close Relationships–Revised). The ECR-R is a 36-item questionnaire designed to assess individual differences in attachment-related anxiety (i.e. insecure versus secure about their partner’s availability and responsiveness) and attachment- related avoidance (i.e. comfortable versus uncomfortable being close to others).
The Childhood Trauma Questionnaire Short Form
The CTQ, a self-report measure, was administered to assess trauma. It is 28-item self-report scale constructed to assess different kinds of abuse and neglect in childhood and adolescence. Subscales estimate abuse (Emotional, Physical, and Sexual) and neglect (Emotional and Physical). Additionally, there is a three-item Minimization/Denial subscale to control for response bias, specifically the minimization of abuse.
A revised version of the State–Trait Anxiety Inventory (STAI) (58), a 40-item self-report measure of trait and state anxiety, was used. The main version of the STAI contains 20 items for trait anxiety and 20 items for state anxiety. The revised version uses six items for state anxiety. Participants are asked to report their frequency of anxiety-related experiences on scales ranging from ‘almost never’ to ‘almost always’.
The TOSCA-3 (Test of Self-Conscious Affect version 3) (60,61) was used to assess shame proneness (47). It contains 16 scenarios, and participants are asked to indicate their likelihood of responding (‘1 ¼ not likely’ to ‘5 ¼ very likely’) in ways indicative of shame and other self-conscious emotions (including guilt, pride, detachment, and externalization).
The Singing Voice Handicap Index consists of 36 items (each scored from ‘0 ¼ never’ to ‘always ¼4’) on singing voice-related dysfunction and assesses the level of physical and emotional voice disability in singing mode. It was created to measure the psychological consequences of voice disorders (48).
The voice analysis was conducted using LingWAVES (49), a software program used for professional voice and speech analysis
Procedure
The study consisted of two phases: subjects first completed questionnaires online (ECR-R and the Singing Voice Handicap Index mentioned in Materials) using Qualtrics research software and, in the second phase, came to the laboratory (a vocal room, sound pressure level (SPL) 40 dB sound floor, at the New School University) to have their singing voices recorded. They were instructed to come in only if they were well rested and had avoided smoking, caffeine, and alcohol the day of the recording. They were given 5 minutes to warm up before data recording.
While the purpose of the present research was not to evaluate vocal health or potential dysphonia, we used LingWAVES’s Dysphonia Severity Index (DSI) to obtain continuous measures of jitter, shimmer, irregularity/roughness, and noise/breathiness.
Participants first completed the questionnaires on the internet and later had their singing voices recorded in-person. Researchers later analyzed the results of both.
Discussion
In study one attachment style and voice were examined. Anxious attachment diminished the intensity of the singers’ voices, while contributing to greater jitter and irregularity. However, avoidant attachment was also shown to increase jitter and shimmer (variation in pitch and volume).
Study 1 explored the relationship between attachment style and the voice among singers. Anxious attachment significantly negatively correlated with maximum intensity. It positively correlated with jitter and irregularity. Also, avoidant attachment positively correlated with jitter and shimmer. The findings are… meaningful given the known relation to attachment and physiology, defensiveness, and self-doubt.
It seems that both insecure attachment styles may impact singing – but the question remains… what mediates these changes?
In study two this was examined. Somewhat unsurprisingly, shame is the answer! It explains how unstable attachment can suppress or damage a voice. The authors suggest that a destructive self-image may correlate with keeping oneself protectively hidden – something that an intense voice would not permit. So, the voice becomes diminished due to the psychology of the subject.
The results of Study 2 replicate the relationship between anxious attachment and intensity. Furthermore, Study 2 reveals that this relationship is mediated by shame. This is consistent with our conjecture that this relationship is due to a negative self-image leading one to feeling ‘small’.
Interestingly, this result didn’t carry through with guilt. Guilt reflects an action or behavior that one feels negatively about. Shame indicates that the personality or personhood of the individual is the source of negative emotion. In which case, it makes sense that shame negatively controls the voice while guilt isn’t implicated in the same way.
While we did not plan to examine the relationship with other variables measured by the TOSCA, for exploratory purposes we looked at correlation between guilt and voice characteristics and found that guilt did not exhibit significant correlations. This is consistent with literature that describes guilt and shame as distinct emotional experiences. Research that looks at shame and guilt as distinct emotional experiences suggests that guilt is a moral and adaptive emotion; it is about an actual behavior rather than about the self specifically. Shame, on the contrary, is a more dispositional attribution and may thus represent ‘the darker side of moral effect’ (33).
And what about anxiety?
Of interest, while shame mediated the impact of anxious attachment on intensity, anxiety (which is not associated particularly with ‘feeling small’) was not a reliable mediator.
They’re saying anxiety doesn’t necessarily make us withdraw into ourselves the way that shame does. So, it doesn’t affect the voice in the same quieting way.
But childhood emotional neglect might.
Particularly interesting is the result that emotional neglect in childhood predicted both average and maximum intensity in the spectrogram. One way to explain this relationship (even though possible mediators or moderators were not found in this research) could be that experiences of neglect in childhood—even more than abuse—are associated with higher behavioral withdrawal and avoidance of any stimulation that would lead to arousal (63). This is consistent with case studies in psychotherapy settings that have found an association between emotional neglect and feelings of disempowerment, loneliness, and an even greater inability to process feelings (64). These characteristics could be related to lower intensity in singers as a way of withdrawing from a vocal task that invites one to be both emotionally and physically engaged.
Childhood emotional neglect affected overall and peak voice intensity. Potentially because it correlates with withdrawal and preference for an unstimulated nervous system; methods of coping with emotional dysregulation in the absence of healthy emotional support or need fulfillment. The authors note this is unsurprising when considering the connection between emotional neglect, social isolation, self-diminishment, and lack of learned emotional regulation tools. With no options for treating unpleasant emotional conditions, individuals try to hide themselves as a form of protection against acquiring any, instead.
This conditioned instinct to self-camouflage rather than standing out may underlie diminished voice intensity and utility in singers.
And, potentially, the rest of us.
GENERAL DISCUSSION / WRAP
Study one showed a correlation between insecure attachment and diminished vocal intensity, as well as unwanted variations in pitch and volume. Study two replicated the relationship between anxious attachment and intensity while revealing that shame was the mediating factor between the two. And lastly, emotional neglect – moreso than abuse – was found to degrade vocal intensity – an indicator of contractive behavior for withdrawal-based self-protection, rather than confidently showcasing oneself.
In Study 1, results suggested a relationship between insecure attachment (anxious specifically) and voice characteristics of singers. In Study 2, the relationship between anxious attachment and maximum intensity was replicated, and it was mediated by shame proneness. Also, emotional neglect predicted lower intensity in the spectrogram, which can be interpreted as shunning expansive behaviors (i.e. being louder).
The negative relationship found between identification as a singer and both the total above-threshold trauma and anxious attachment could point to the fact that traumatic experiences in childhood and anxious attachment impair a singer’s sense of identity. As previously observed, insecure attachment can have an impact on one’s sense of identity by contributing to a negative self-image. Training and practice of singers may allow them to be more expressive of their emotions and personality, but their negative sense of self can strongly influence them.
All in all, results could suggest that sense of self is affected by trauma, which affects the voice – the tool used to proclaim ourselves as persons. Because singers can’t separate the two (self-identity and voice), the effect of trauma on vocal physiology is especially pronounced in their lives. But that doesn’t mean it doesn’t affect all of us.
While emotional and psychological elements can affect a singer’s voice, their consequences are often regarded as ‘technical issues’ or temporary emotional distress due to the immediate circumstances. These findings point to the possibility that behind a technical difficulty in the voice there might be deeply rooted emotional issues.
So, while physiological damage might be the go-to for vocal disorders, this study suggests that emotional disruption or dysregulation, low self-regard, and low sense of personal safety (alone and with others) might be the culprits behind voice pathology.
And isn’t that some shit?
Struggling to express yourself? You might want to take a look at the relationships that formed your sense of self. Improving self-esteem and relational expectations while working on need fulfillment might be the best remedies for a worn out voice. Staying silent to give it rest? Might actually be reinforcing the survival strategy of keeping small, quiet, and unassuming.
Build better relationships, foster a safe environment, and work on improving those emotional regulation skills, and perhaps you’ll be singing or speaking – professionally or for your own pleasure – with intensive and authentic abandon, soon, again.
And with that…
Don’t dismiss how emotions affect everything.
Learn about your attachment style for ways it could be reducing your living capacity.
And heed signals coming from your physiology as potential indicators of your psychological state. If you can’t speak or sound like yourself… that self might be in a reduced state and need some re-acceptance before you’re belting your heart out again.
Til we speak again next time?
Hail yourself.
And it’s effects on your voice.
Thanks for being here, sharing both.
Don’t stop humming along.
And I’ll talk to you soon.
Bye-bye.