A Clear Voice

Conversation First: Reflections on Jackie Gartner-Schmidt’s Keynote and Conversation Training Therapy

• BLA Connections • Season 1 • Episode 40

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This episode of BLA Connections A Clear Voice, hosted by Natalie Watson, features a follow-up conversation with Jackie Gartner-Schmidt after her keynote presentation at the British Laryngological Association (BLA) Conference 2025. Dr Gartner-Schmidt discusses Conversation Training Therapy (CTT), an approach that begins with everyday conversation rather than traditional vocal drills. The focus is on addressing the vocal behaviours patients experience in daily life, such as hoarseness or vocal fatigue, rather than treating diagnoses in isolation.

During the discussion, Dr Gartner-Schmidt explains the research origins of CTT, its links to clear speech and audiology, and why it can lead to faster and more meaningful carryover into real-world communication. She outlines who is most suitable for the approach, when alternative therapies are more appropriate, and highlights the importance of sensory awareness and negative practice in helping patients maintain efficient voice use over time.

Three main takeaways

  1. Voice therapy targets behaviours, not labels
    CTT focuses on changing inefficient vocal behaviours that can occur across different diagnoses.
  2. Starting with conversation supports carryover
    Using real speech from the outset helps patients apply changes more quickly and consistently in daily life.
  3. Negative practice strengthens self-management
    Learning to move between inefficient and efficient voice use improves awareness, confidence, and long-term outcomes.

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Jackie Gartner-Schmidt :

We don't treat diagnoses, we treat vocal behaviours. Patients don't come in to you and say, I just can't feel those interior vibrations when I hum. They come in and they say, you know, I get hoarse or I get tired talking.

Natalie Watson :

Welcome to BLA Connections A Clear Voice. As we continue our seventh series, I am your host, Natalie Watson, and I'm delighted to bring you discussions and insights from experts from across the globe on all things laryngology. In today's episode, we have one of our keynote international speakers from our annual conference, Jackie Gartner-Schmidt, joining from Pittsburgh, USA, where she is a professor of Carla University in the Department of Speech Language Pathology. Before her position at Carla University, she was the co-director of the University of Pittsburgh Voice Centre and Director of the Speech Language Pathology Voice Division at the University of Pittsburgh Medical Centre for 20 years. Dr. Gartner Schmidt's 25-year clinical and research focus specialises in assessing and treating patients with voice and upper area disorders. Dr. Gartner Schmidt has over a decade of NIH-funded clinical research, experience as a co-investigator focusing on the development and efficacy of different voice therapy programs, and has developed and validated seven patient-reported outcome measures. She's published over 60 peer-reviewed papers, multiple book chapters and online courses, and presented over 500 lectures nationally and internationally. She's a TEDx speaker, is known podcaster, and today is talking about conversation training therapy. Thank you so much for joining us today. Hi, I am so happy to be here. This is awesome. Yeah, sure.

Jackie Gartner-Schmidt :

So it's been about a decade now since we first presented and did research on it. And it's uh it it it really flips the traditional voice therapy model on its head by using conversation as the stimuli. And so it's not so much uh drills and based on a hierarchical approach, which I'll explain a little later. But the the driving force for change, if you will, is having patients lock into sensory discrimination while they're actually talking.

Natalie Watson :

Great. So how did it all start? How did you come about this conversation training therapy as an approach?

Jackie Gartner-Schmidt :

Yeah, no, great question. Um, it actually the genesis of it started back when I was doing my um doctorate. So I did my doctorate, uh thesis, if you will, dissertation, with tracheoesophage of voice speakers looking at phonatory offset and onset. And I had an audiologist on my committee, and she said, you know, Jackie, you ought to look into the literature on clear speech, which was very much in the audiology literature, makes sense, um, intelligibility. So I was like, oh, all right, cool. And I came across these two um actually three seminal research. This is back in the 1980s, on clear speech. And the first was, you know, basically they had people speak to people who were hard of hearing and asked them to speak clearly. And lo and behold, the people who spoke clearly versus just normally had higher intelligibility for the hard of hearing. But the really cool thing was they did acoustics on clear speech. And it turned out that clear speech, just with that one directive, boosted intensity, boosted vowel space. And through the years, there's been tons of research showing that it increases photoy airflow, it increases or decreases speaking rate, causes more pauses. Um, all these really amazing things that we as voice therapists kind of have as our end goal when we generalise everything that we do into conversational speech. So I so back then, you know, I thought about it and that was really cool. And then you went on to uh in 2003, started the University of Pittsburgh, and promptly forgot all that cool stuff. And then as life is going on, we're starting looking into the literature. And although we've got amazing techniques and I use them all the time, and there's research on them, and they're great. Our adherence rate for voice therapy is really terrible. Um, like up to 64% of people either don't do what we say, or the worst case scenario is they drop out. Yeah. And then we did a little research asking our patients what they thought was the hardest part of voice therapy. This was back in 2000, I can't remember, 13, 14. And they said transfer to conversational speech. And we weren't the only ones. Other people started saying that. So, Dr. uh Amanda Gletsby, she was actually my student. She's like a flipping rock star, she's at Emory University. We got together, we hired her, and it was like, well, why don't we start at conversation? And this is, you know, you're you're a laryngologist. Patients don't come in to you and say, I just can't feel those interior vibrations when I hum. They come in and they say, you know, I I get hoarse or I I get tired talking. So that was a genesis is let's give them what they want. So it's it's relevant to them. And yeah.

Natalie Watson :

Well, the rest doesn't matter, does it? It's the outcome that matters.

Jackie Gartner-Schmidt :

Right. No, you're right. And it it's the outcome, and I want to be really clear, not clear speech, but really clear here, is that clear speech, if we think of the consonants as airflow and resonance, clear speech really encapsulates flow phonation and resonant voice. And it just mushes it together in connected speech. So it's not really that we're doing anything differently other than the stimulus is conversation, and we shape and guide the patient's sensory discrimination and perception while they're talking. But the actual tenants are exactly the same. Yeah.

Natalie Watson :

And so just those few sentences that you did there, that was that was a a part of conversation training therapy, wasn't it? Yes. You gave these fantastic video examples of going through this with clients, and and it was really uh you were showing them working through just bringing down the pace, accentuating the consonant within your speech. And it's so lovely to hear that story that uh you just explained, you know, how did it all start? Because, you know, we don't work in silos, we don't work just as independent practitioners. The most important thing is to integrate with other specialties as much as we can to for that cross pollination, fertilisation, whatever you want to call it, because the ideas and the different things that we know in our own little pockets, we can share that knowledge. And this is why this podcast is great, because it's accessible to all. Um, you know, we can share everyone's knowledge together to make a better uh better life for our patients and and develop new ideas. Um so this is this is incredible that the working with audiologists and understanding um speech perception um from a from a hearing point of view, understanding then how to use that knowledge to help us deliver conversation training therapy.

Jackie Gartner-Schmidt :

Yeah.

Natalie Watson :

Brilliant. Yeah. Who who would you say conversation training therapy is suitable for?

Jackie Gartner-Schmidt :

Oh, wonderful question. So the short answer is anyone who is stimulable for it. And what I mean there is, you know, you talk about silos. This is actually now I'm talking about the silos of a diagnosis. And and we often we often hear uh this type of voice therapy is good for this diagnosis. And actually, I would dare say that many of us in the profession actually perpetuate that, right? And it's based on the cohort that they've done the research on. So Parkinson's um uh Lee Silverman voice training or speak out, Forte for Presbyphonia, et cetera. But really, I think if you had us all in a room, we would all agree that we don't treat diagnoses, we treat vocal behaviours. So said differently, if we have someone who has midmember dysvocal fold lesions, so let's say nodules, versus someone who has primary muscle tension dysphonia, versus someone who has, and I'm gonna be really specific here, has a vocal fold paralysis with the paralyzed vocal fold on the same level as the contralateral, has good closure, okay, and there's no atrophy and all that, they can all have the same faulty vocal behaviour, but there's three different diagnoses. So, so going back, anyone who is stimulable for a change using clear speech. And we will ask patients to, you know, just talk to us um as if they are leaving a really important um voicemail, or speak to me if I if if you I'll speak to you as if um I think that you know you know you are hard of hearing. And then we will also ask them to vary a little bit of their pitch inflection. And then we'll say, okay, now I want you to change your voice, maybe uh talk to me the way you came in here. Um and and if we hear a difference, and then we ask the patient, did you hear a difference? But the real clincher, and we actually did some research on this, is if the patients can feel a difference, a shift from more speaking, you know, in their throat to not having that feeling, that's a really good prognostic factor that CTT would be great for them.

Natalie Watson :

Fantastic. Why would you choose this type of therapy over other speech and language therapy techniques?

Jackie Gartner-Schmidt :

So I would choose this if the patient is stimulable for it, because our research has shown that after two to three sessions, there's both a statistical significant change and also a clinically significant change. So that's another way of saying that it's fast.

Natalie Watson :

Yeah. Two, two sessions is just extraordinary.

Jackie Gartner-Schmidt :

And and three is the kind of magic number. So that's one reason. Um, so say you have a teacher or you have a performer or a lawyer, uh, it doesn't matter. Everyone wants to make a change and be able to flip it into their conversational speech really quickly. So that's one thing. Now, I would not use this with patients that have just had um surgery, because the paradigm there is that we want to do, we want to heal that tissue. So semi-occluded vocal tract postures, yeah, um, resonant voice, oh my goodness, of course, straw fronation in submergent water, all that kind of stuff, impedance matching, blah, blah, blah. Because there, the big thing is we want the largest amplitudes to decrease pro-inflammatory markers and ostensibly heal. So would not use it there, would also not use it with functional aphonics, because the whole thing with functional aphonics is the maladaptive behaviours are in connected speech, are in their conversational speech. So, with those people, you would use stretch and flow, manual, some type of manual circumlaryngeal therapy. Um, but uh, you know, I'm a little biased and I'm not gonna lie. I will try it on usually as a as a first past. And and let me tell you the other um, that I'm I'm actually doing research now on um our transgender population, gender-affirming voice therapy. For most clients, it's really good. However, for some clients that also have um autism, they're on the autism spectrum disorder. So they're autistic people and transgender people. Sometimes this potential therapy can be too much because we are starting at a at high complexity. So think about it. We're asking the patients right away to do clear speech, and then there's a whole bunch of other component parts, but do clear speech, inflection, pauses, projection, um, amongst other things. They're cognating, right? They're thinking about what they're saying, they're reading another person and they're listening to what the other person is saying. It's like a lot. Overwhelming. And yeah. So for some people, especially if they're um and not all, but because there's high functioning autistic um people, it it might be a little much. And also for our elderly, it might be a little much. We've got to deconstruct it.

Natalie Watson :

Yeah. And also they as I say for the elderly, they have to hear it.

Jackie Gartner-Schmidt :

Absolutely.

Natalie Watson :

Yeah. Um so finally, I think I just want to touch on something you mentioned in your keynote lecture, which was excellent, by the way. And if anybody wants to um to hear it and listen to it, if you're a member of the BLA, you can get that all on Talking Slides as a as a member. But um, you talked about negative practice. Can you just elaborate how negative practice can help the client?

Jackie Gartner-Schmidt :

I think it is the most important part of CTT, and it's the most important part of all of our voice therapies. So Kittie Vertolini Abbott in LASAC Matson Resident Voice Therapy, her, I mean, she's amazing in all in all ways, but one of her uh most amazing things I think she brought to the profession of speech language pathology and voice is that of sensory motor learning theory. So negative practice is embedded in LASAC Madsen, and it is very much a component part. And in fact, as I said, probably the most important component part. And the reason is this um, you know, life affects our voice, uh, whether we're tired, stressed, a headless chicken, et cetera. And being able to train patients to go from their inefficient voice to their more efficient voice, okay? So let's call it their um old voice and their new voice, yeah, training them that um the it's the in-between part. We're training them to have a good voice. That's great. But really, the the most important thing, I think, is we are training them to be quick and accurate in being able to find that great voice. And I always give the analogy of riding a bike. The most important thing of riding a bike is not, and the balance is good. And the balance meaning balance of voice is good, but it's when they fall off the bike and get back on the bike. It's that falling off and getting back that is where the real learning happens. And uh it's finding, it's finding a solution space. And and uh it leads into self-efficacy, all these really good things. And we know in in motor learning theory that that's what really makes it stick.

Natalie Watson :

Oh, that's absolutely incredible. And for it to be all kind of really patient-controlled, patient-led in a way, they they really take ownership of it. So 100%. They feel that they can have they've achieved even more because they've done it themselves. That's that's what it's all about. We we just guide them. We really don't do that much. Oh, no, no, no, no. I mean, it's the it's the it's the light touch facilitation that it but the guiding in the right way. And it uh finally just I was thinking, how how do you train in this way? Are there specific courses or how how do you create how do you create this as a speech pathologist?

Jackie Gartner-Schmidt :

Yes. So we have um we do both. We just finished a um actually 10-hour webinar that we will be doing again, and it may be on a platform called Endo Education, but more uh to come for that. We do not have a website. Um you don't have to be certified in this or anything, but we do have an email, uh conversation training therapy at gmail.com. And uh yes, um we have I think now eight eight um articles, and anyone can get in touch with me. I can send them to you or at least tell you where they are. So, yes, and we're we we do some, you know, we do keynotes like uh both Amanda and I. Um so yeah. Well, brilliant. Are there any final words from you? I guess the final word is is is try it. It's gonna feel weird at first, but try it. Um and you know again, I I give an analogy of escalator, right? So the hierarchical voice therapy starting off at phonemes, words, phrases, and then conversation. Try conversation because guess what? We can always come down the stairs. We can always do the other stuff. So yeah, I guess that's my call to action.

Natalie Watson :

Oh, well, thank you so much. Thank you for delighting us on the day of the annual conference. And thank you so much for um giving your time today for the podcast. Um, really sharing your experience of conversation training therapy, how it all began in the 80s with the audiologists, and now how you're giving empowerment to the people with voice problems to try the conversation training therapy.

Jackie Gartner-Schmidt :

Well, thank you, Dr. Watson. Uh, this has been great, and I enjoyed myself so much at the BLA. So uh hope to see you there soon.

Natalie Watson :

Well, you'll be welcome anytime, anytime. So we hope you've enjoyed listening to BLA Connections A Clear Voice. I have been your host, Natalie Watson. Please do tune in this series for more laryngology topics. We would also love to hear from you. Please feel free to email with any topics you would like us to explore, any questions you have, along with any suggested experts you'd like to hear from. Also, if you'd like to contribute to these podcasts, please email inquiries at BritishLaryngological.org. Our full series can be found in the podcast provider of your choice or via our new website, British Laryngological.org. Thank you to all our listeners, and we hope you have found our podcast informative. Please remember to subscribe and do leave a review with your podcast provider. We do appreciate your likes, subscribes, and reviews.