Sara Harris is an experienced Speech and Language Therapist (SLT) who has worked extensively with singers. A specialist in voice disorders, Harris co-founded what is now the British Voice Association. She has also published several articles and books on the voice. She spoke to LINE HILTON.
Can you explain how an SLT can help a singer and how the role of an SLT differs from that of a singing teacher?
I always liken it to a Formula One racing team. The singer is the driver. They know the car – the voice and the performance. If something is wrong, they know immediately and go back to their singing teacher, who is like the race mechanic and does the fine-tuning. The singing teacher talks to them about tactics and does their very best to get the singer back on track. But if that doesn’t work, then you’ve got to go strip the engine down. It goes back to the original mechanics, and that’s us. An SLT goes back to the basics. We rebuild that, and then we pass the singer back to the singing teacher to go on developing them.
At what point does the SLT gets involved?
When a singing teacher is doing all the normal things, but those things are not working. They will suggest the patient seeks help by going to see their GP and then an ENT. We would get involved after the singer has seen an ENT. We wouldn’t start work until they’ve been cleared of any serious pathology.
When should a singer be referred to see an ENT?
The singing teacher should refer when what they would normally do to fix problems doesn’t work. You want to know why it’s not working – if there’s a physical problem or a technical issue.
Things to look out for are consistent difficulties, particularly if they’re clustered around one area, such as the pitch range. If the voice has an area where it consistently breaks, and nothing that the singing teacher does gets that clear, then they need to be seen.
I think it’s important to break down this awful industry bias that nobody’s allowed to have any vocal problems. A singer is like any other athlete. You would never find a marathon runner who has not had to go to physiotherapy or have x-rays. It’s the same with singers. If they’re going to do that level of work, they will sometimes get injuries. They will get tired. They will get sick. They need help, there should be no stigma at all.
What other common issues do singers come to you with?
In terms of pathologies, it’s scarring because over time sometimes people can have vocal fold bleeds. If they don’t know they’ve had them, they can be repeated, and then things generally start to stiffen up. We see those quite often. We don’t see nodules very often. We also commonly see emotional stuff. A lot of the time patients have emotional distress problems that have fed into the singing. The more they can’t sing, that feeds into the emotional problem, and round you go.
What does a typical speech therapy session entail?
In the first session we take a detailed case history and explore all around the immediate problem. Then we look at the patient’s previous medical history. Do they have allergies, asthma or a long history of tonsillitis? Have they had any injuries or operations?
Then we look at lifestyle, things like smoking, drinking habits and general voice stuff. We finish up with the social stuff. What sort of support system do they have? Do they have a partner? Do they have kids? Are they stressed? Usually by the time you’ve got to the end of a good case history, you know the likely cause of the problem.
We then make a recording. I use a laryngograph as well, which is electroglottography, which looks at the contact that the vocal folds make with one another in a speaking situation. The patient reads a passage while wearing electrodes. That picks up when the vocal folds come into contact, and it puts that down on a graph, so you can see contact by contact, what is happening in the larynx. It also aggregates the data, so that you can see how much irregularity there is in pitch or in intensity or in vocal fold closure. Unfortunately, it won’t tell you if the vocal folds are closing fully. All it will tell you is where they close, and how long they’re closed.
I then ask the singer about their aims. I ask about the issues they are most eager to resolve and the goals they want to achieve, such as to sing comfortably or build stamina. Then we go from there.
What if a singer has to have an operation on the vocal folds, when can they expect post surgery?
You’re always going to have a little bit of stiffness post surgery because the surgeon will have had to have made a small scar somewhere. But hopefully, the major problem will then be resolved. Obviously, the more complex the surgery, then the longer the recovery. We warn people that probably the first thing they’ll find is that after surgery they’re worse. That’s fine and normal. Our job is to start working that post-operative stiffness loose by gradually mobilising the mucosa again, stretching up. It’s a lot of pitch change work to lengthen and shorten, rather as if you had a stiff balloon. The first thing you do is stretch it and release it to try and loosen it up. Stretches work like that in the vocal folds, too. If it’s only a small cyst or nodules, it’s quite a quick recovery. Often, they’re doing very well by three months. But with more complex issues you’re looking at much longer, nine months to a year.
Could you give an example of an exercise that would help stretch the vocal folds?
Sirening. Just straight sirening will do it beautifully. If you’re working on stiff vocal folds, you’d need quite a high pressure, high flow one. I would always start with lip bubbles or rolled “R” to get the mucosa mobilised. It’s no good starting with a nice gentle “NG”, because all that happens is the voice will cut out. We would definitely start with a much higher air flow and air pressure, just to get things moving.
Do you use straw therapy?
Yes. That’s a good way to set up the relationship between breath pressure, resistance, and flow. The problem with it is you can advance it, but a lot of people find it difficult to get from the initial exercises into speaking or singing and maintaining that. It needs quite a lot of bridge passages, if you like, to get from the exercise into singing or speaking.
Is that something you would do with the singer? Or you would hand that onto a singing teacher?
It depends on the patient and what works with them. But yes, we would do a lot of the bridge passages into speaking and into the beginning of singing. Often, we would work concurrently with the singing teacher. I do quite a lot of collaborative working with our singing rehabilitation coach, Linda Hutchison. We love it because we both learn from one another. Also, she’s very good at taking my exercises and finding a way to translate those into singing exercises that she can then use to take the patient on into singing.
How many sessions would a singer typically need with you if they had a minor pathology that didn’t require surgery?
It depends on the client and how willing they are to do the work. Usually, we would give four to six sessions to tackle the initial aims and see how they go. Our job is to make them independent of us as quickly as possible, so that they know how to practice and progress themselves.
What common vocal health advice do you think singers should know about?
The importance of hydration is one. Mucosa needs to be damp. Otherwise, the mucus that it secretes gradually gets more like araldite, which does not do the voice any good. A simple steam can make such a difference. It doesn’t have to be complicated. I would say do it three or four times a day for ten minutes when the symptoms are bad. The other thing to get across, because so many singers earn a living by taking jobs in call centres or waiting tables, is to be aware of talking with a raised voice. Trying to keep the voice use down is important. And no smoking – obviously.
Would you advise that the singer takes their singing teacher along to the clinic?
Absolutely. It’s important that they see what happens and they see what the pathology is. If the singing teacher is with them, they can be helpful in going through things with the singer afterward.
What changes would you like to see in the singing and singing teaching world?
I’d like to see more collaborative working. If a speech therapist is going to work a lot with singers, it’s wonderful to work with the singing teachers responsible for those singers. It’s great to build relationships and often you come up with much more interesting and creative solutions working with someone.