If you ask a patient: “Where do you feel your voice?” 99% point out to his throat, 1% on his chest.
Good afternoon,I’m Michel de Kort, musician, choir conductor, singing teacher, and also voice speech therapist, in Hospital Bernhoven in Uden Holland, with 2 voice experts, prof. Felix de Jong en Ties van Deurzen.
By being a musician, I listen to a patient with voice problems in a sound way, in a singing way. In many cases I choose singing technique as starting point, as therapeutic entrance. If I make contact to a patient, give her of him a hand, I do a little game:I feel in myself the place of the voice of the patient.I ask myself: where do I feel and hear the voice of the patient?And in general:I feel the voice of the patient here, in my throat.I feel ánd hear a constriction, a narrowness.It’s a very mechanical, an instrumental way of feeling, listening and thinking.That constriction, that narrowness is the central point, the starting point of my actions, and the main subject of this lecture.I think: In some way everyone tends to narrow the throat; I don’t know why; I always compare it with the tendency to bend, to bow in your posture.Sometimes that narrowing the throatis the result of stress, of grief, of pain, more often it is general human behaviour. And then there is a factor ‘language’: the Dutch language tends to a narrowed throat.And there is factor ‘dialect’: in the northern part of Holland one speaks as: In the southern part, where we work, there is the pattern: loud and narrowed throat, and floppy lips. That’s ‘normal’.
Some people say: "O, you talk about muscle tension dystonia! Yes, I do, absolutely. No, I don't; I think it's a broader concept, because in every voice problem there are elements of hyper- & hypofunction of muscles.
In singing lessons there are a few goals in which students are systematically trained. The words for it change, the promotion subjects change. But in general it is about:
1. – In a way - enough opening of the mouth and throat (opening of the tube).
2. Forwards positioning of the voice, as far as possible away from the throat.
So, if normal pattern is:
· Narrowed throat
· Floppy lips
· Restricted pitch/restricted intonation range
Result is inaudibility: one can hear my voice, my sound, but cannot understand and hear my words. To be audible the average human being does 2 things:
. Raising loudness (the ‘turbo’ on)
. Using neck muscles, a lot of neck movement parallel to speaking or singing
There are 2 solutions, 2 ways of thinking:
1. Narrowed space of mouth&throat needs enlarging.
2. In case of a narrowed space of mouth&throat the voice feels in the throat. And it has to be away there!
I show this pattern on the basis of a mixer with buds or valves, and in general there is a lot of recognition of the patient. And that’s fantastic, and an important basis to be motivated for voice behaviour change.
Beautiful words, beautiful promotion!But for the average patient: for more motivation is proof needed: proof that a voice instruction has a positive effect. So before explaining I do voice experiments, the essential part of my investigation. No explaining, just feeling and hearing. An invitation to get aware.
Derived from singing, from teaching singing I use the so-called 3-Zones Voice Model, in the form of 3 simple instructions to a patient, standard in my voice investigation:
1. Think on your nose
2. Use your lips a bit more (than you normal do)
3. Enlarge the space in mouth&throat
4. Turn in a bit more 'high' in your speaking.
Let’s give an example.
Instruction no. 1
Th: Will you please read the text for me?
Patient reads, I notate GRBAS etc.
Th: Thank you. Will you please read the text againand think on your nose
P: Uh, ok.
P: Uh, what?
Th: You read the text and you think on your nose
P: Ok. De koning was vreselijk boos
Th: Very good, and now in your normal way.
P: De koning was....
Th: Very good, and now ‘think on your nose’.
P: De koning.....
Th: Is there a difference?
P: Yes, more easy, lighter, higher.
Th: Ok, will you read in your normal way and ask yourself:
Where do I feel my voice?
P: De koning…….Uh, here.
Th: Very good, I’ll explain further on, I let you first feel.
Instruction no. 2
Th: Now I park the nose. Your lips are a muscle. You can activate a muscle.
Will you please read and activate your lips a bit more than you normally do.
P: De koning.....
Th: Very good. Now again in your normal way.
P: De koning....
Th: Do you feel that your voice is going back to your throat?
And that’s often the point that even a patient who doesn’t feel or hear in the beginning starts to understand, is going be aware.
Th: I’ll explain something to you. This is a mixer with valves. I make an assumption: The main problem of a voice problem or globus is the narrowing of the throat. A matter of human being, country, dialect in the country, etc. Almost often in relation with floppy lips. It results in a monotone, strained voice. And that results in inaudibility. To be audible everyone tends to raise his loudness, on a party, on the soccer field, but also in Holland in Uden often standard in your family. Raising your loudness is compensation mechanism 1, a killing system. Compensation mechanism 2 is your posture, your neck position. Many people realize speaking or singing with a parallel movement of the neck. And have problems with the neck, the back, shoulders, or a headache. Do you have?
If this assumption is true, solution, remedy is:
1. If space is narrowed: enlarge the space. I teach you in a moment.
2. If your voice is in your throat: it has to be away there!
In general, the patient recognizes patterns, too much loudness, or a link with posture problems, or influence of the severe dialect, or narrowness of the throat, etc.
And then comes instruction 3.
Instruction no. 3
Enlarging the space in mouth&throat:
There are several possibilities. Most common I use:
Th: I take a small ball in your mouth&throat, diameter 2 cm. Create an open tube. I introduce it by an example with negative practice versus open tube. De koning……..And then I invite the patient to experiment with open tube. If succesfull, I invite to enlarge the diameter, 2-3-4-5-6-7 cm, in the direction of the maximum of helping the dentist.
Often the patient hears the difference, feels relief, disappearing of the constriction, more clarity in the voice, etc. For many patients it's a very important moment.
For singers with singing lessons: Use the learned technique from singing, o.a. retraction from EVT, or turn over your palate in classical singing, inhaler la voce, or……
Sometimes I use a 4th instruction:
4. Turn in a bit more ‘high’ in your speaking
Resonance (‘think on your nose’) and articulation (’use your lips a bit more’) place the voice forwards, enlarging space opens mouth&throat, turn in a bit more high gives lightness.
For singers I experiment in a song with some instructions, most common 'nose' and 'enlarging space'.
It looks simple, and it is simple, and it has to bé simple, and that is the point:instructions have to be effective in a short time; a patient has to feel or to hear in a short time that it is possible to pull on new positive voice behaviour. The difficulty is in the further training aspect, esp. the ‘thinking of’ aspect. But whát you have to do doesn’t be difficult, no, must be simple, and immediately applicable in your daily speaking and/or singing routine.
These voice experiments result inawareness, and therefore in motivation for voice behaviour change, sometimes for singing lessons, posture therapy.
Prof. Felix de Jong thinks in an holistic way and refers in several lectures to tensegrity, (tension and (structural) integrity). The structure exist by grace of the balance. If balance is disturbed, structure collapses. Voice problems have in a percentage an organic origin, but have in much bigger percentage a functional origin. It is effective - and cheaper - to do a good examination to these functional issues, and involve all tensegrity issues, for instance:
. hormonal issues,
. use of medicines,
. (for everyone with a dental brace in the past) orthodontic issues,
. posture issues,
. (for choir singers) place in the choir,
. classification problems,
. (for bandsingers) keyowner issues,
. level of voice protection or absence of voice protection,
. level of singing technique or absence of singing technique,
. (for teachers and choir conductors) class management,
. noise in the surrounding on your work,
. common loudness in daily life,
. use of amplification,
. (for bandsingers) use of an in ear system,
. lifting or sporting or weightlifting with open versus closed throat,
. (for vandrivers) using a proper carkitt in your van,
. (for everyone with varifocus glasses) link between posture and varifocus glasses, · . etc.
Felix de Jong has chosen for and configured an organisation in which the speech therapist has enough time to examine a patient, to do vocal tests, - not only clinical and scientifically liable -but also targeting two main questions:
1. What is the role of the voice technique in the voice problem of the patient?
2. What is the benefit of impróving voice technique?
It’s very motivating for patients if they feel and hear that it is possible to improve their vocal skills, that it is possible
. In a short time (2-3 minutes, 10-15 minutes)
· To have a clear course, a clear direction,
· To get grip on their voice.
· With immediate appeal to daily transfer
· With support of reminders
· With a strong appeal on consequency
· With a strong appeal on posture, relation with posture problems
· In case of singing: with a strong appeal on technique of singing, on consequency of using singing technique
· In case of doing sports with a posture issue: with appeal on posture in dancing, horse riding, other sports
Sometimes there is no benefit. That's a clear sign to the ENT-specilaisr to focus on structural deficit.
In general a patient with voice problems will be laryngoscopic examined by an Foniatric ENT-expert, and voice technically examined by a voice speech therapist. My collegue speech therapist is an expert in manual facilitation of the larynx, I’m an expert in singing, musical matters such as choir conducting. The two of us offer more variety in examination, depending on the questions of the ENT-doctor, or of the patient. I don’t think speech therapy is the solution/remedy for all voice problems.
I do think that a lot of patients with voice problems have benefit with speech therapy.I also do think that there are several routes to give form to speech therapy and that it’s efficiënt to be aware of these several routes.
The subject of this moment: the so-called 3-Zones Voice Model is such a route with roots in singing, in singing voice, in teaching singing.
One beautiful day the model was there, I wrote a book about it,And I use the model with the patients in Bernhoven, but use it also in singing lessons with amateurs and professionals, in vocal coaching of choirs, and in my work as choir conductor of a chamber choir in Utrecht, Holland (with – out of the record - a Finnish alto and recorderplayer, a Finnish pianist&organist, and very recent a program with o.a. Finnish composers).
This is the end of my lecture. Thank you for your kind interest. If you’re interested, be welcome to contact me or Felix or Ties. I’ll be delighted to tell more about the model, to show it, to train you in the model. Thank you very much!
Michel de Kort: Grip op je stem; therapie&training volgens het 3-Zones Stemmodel, Acco 2014.