#121. A Masterclass in Managing Vocal Health and Well-being in Singers

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Episode Transcription

Dr Marisa Lee Naismith  00:00

Hi it’s Marissa Lee here, and I’m so excited to be sharing today’s interview round episode with you. In these episodes, our brilliant lineup of guests will include healthcare practitioners, voice educators, and other professionals who will share their stories, knowledge and experiences within their specialized fields to empower you to live your best life. Whether you’re a member of the voice, community, or beyond your voice is your unique gift. It’s time now to share your gift with others develop a positive mindset and become the best and most authentic version of yourself to create greater impact. Ultimately, you can take charge, it’s time for you to live your best life. It’s time now for a voice and beyond. So without further ado, let’s go to today’s episode. This week on a voice and beyond, I am so excited to announce that we have quite a treat for you as we replay a tease from three of my very favorite guest interviews. This throwback episode is a masterclass to help raise awareness around how we as voice teachers can manage some of the most common issues relating to the care of our students when they are most in need. I offer these to you as I believe that as a voice teaching community, it is most important to keep an open mind to the various kinds of modalities that can be of assistance for a singer who may be suffering from a voice disorder or requires help to manage their anxiety, especially around stage performance. I absolutely love and endorse the approaches and philosophies of my guests on today’s show. Our return guests include Walt Fred’s, who was featured in episode number 75. Walt is a licensed physical therapist who has been teaching myofacial release continuing education since 1995. In 2020, Walt rebranded and launched manual therapy seminars, a new training program in which he continues to teach all types of therapists including massage therapists, speech language pathologists, voice professionals, physical therapists, and occupational therapists. Internationally, Walt has been able to apply his therapies to vocal athletes, and in this episode, he describes how our second guest is David Juncus, a clinical psychologist performance coach, a voice workshop lecturer, and co author of the book act for musicians. David is the third wave therapist with additional training in Acceptance and Commitment Therapy, otherwise known as act. David describes act as an evidence based psychotherapy that aims to promote mindfulness and acceptance, and he explained how he has been able to successfully treat performance anxiety in musicians as well as singers using this treatment approach. You can check out his full interview in episode number 55. Our final guest is Lori Sonnenberg, who was our guest on episode number 60. Lori is a Chicago based licensed speech language pathologist, clinical voice specialist and singing voice specialist whose clients include professional performers, educators and speakers. In her voice clinic, Lori works exclusively with voice and breathing disorders and specializes in muscle tension dysphonia related disorders recovery from voice injuries, professional voice care and support, post operative voice recovery and problematic technical voice issues for singers This is an episode you don’t want to miss out on as our brilliant lineup of guests offer their insights, approaches and philosophies relating to the health and care for singers in our voice studios. So, without further ado, let’s go to today’s episode

Dr Marisa Lee Naismith  05:32

Walt Fritz, you’re an interesting person, and the work that you do is highly interesting as well. So you are a licensed physical therapist, and you’ve been teaching myofacial release. So let’s start with what is your training background? And how did you stumble upon this modality?

Walt Fritz  05:53

Okay, so first of all, I’m going to have to make a couple of corrections. Because in 2020, during COVID, when nobody was working, and we had all kinds of time on our hands, I rebranded my, my work, I rebranded my seminar line, and I kind of rebranded my brain to move on from the words myofascial release into manual therapy, which is a much more sterile, call it a generic way of touching versus manual therapy, which has a lot of codified beliefs within it. Okay, so now I use manual therapy that even my brand is foundations and manual therapy seminars. But let’s get to your question. So now that I feel better, because my brand is clear, okay, I started this work back in 1992. You know, I’ve been a physical therapist since 1985. And I did a lot of things during those those first couple years. But then in 1992, I took a first seminar and myofascial release from a physical therapist in the United States, who teaches a lot of physical and massage therapist by the name of John Barnes, and, you know, popular continuing educator in the States. And I took one of his classes, and I kind of fell right in the rabbit hole, I really, I liked his approach, I liked the work, I liked the exclusivity of the model of the ability to access the person, and their fascia, their connective tissue, and everything else that was entwined with that. And I, like I said, I fell down the rabbit hole. And I took everything that that Barnes had to offer in the next couple of years. And then I started working for him as a teaching assistant in 1995, which was the beginning of that, that teaching education career that you mentioned a few minutes ago. And I spent about 10 years on the road with him assisting. And then like many things in life, they come to an end, and I needed to find a new path and start my own journey. So in 2005, i 2006. Somewhere around in there, I broke free from that model. And I started teaching in a very small way small classes, small number, my version of myofascial release, which probably wasn’t a whole lot different from his version, except for a couple, a couple of differences. But over the next 10 years, I saw thing the need to change I really did, I started training with other people, I started listening to other people’s beliefs and ideas and their way of presenting touch based intervention, not just how they did it, but how they explain what it was impacting, and how those changes are manifested in the patient client. And the more I learned, the more I realized, I probably didn’t know very much when I thought everything was about the connective tissue. Because in a way, myofascial release and a lot of manual therapies, massage, manual, circum laryngeal treatment, which is popular in the in the voice community, a lot of them almost view tissues as accessible from the outside. When it comes to muscle tension. It’s as if the clinician can reach into the throat and literally bypass everything in the way to get to that muscle tension, which I mean, it’s a lovely simple story. That’s really it’s a crap story. Okay, it really is a garbage story, because I learned it was all about the passion. No, it’s not the muscle. It’s the passion, it’s connective tissue. And we were sort of taught that when we do certain things that we’re biasing for fashion, and I bought it, I taught it, I believed it, and then I stopped believing it. Now, I don’t think we can touch anything. I don’t think you can treat a diaphragm without a scalpel. Okay. I think we can work with people’s problems that are associated, for instance, with the diaphragm with the inferior constructors of the larynx. I think we can do things that are seem to be related, but it is impossible to select an isolate the inferior constrictors for treatment unless you’re working with a scalpel, and it’s just not happening, hopefully in our fields. So

Dr Marisa Lee Naismith  09:53

this is great, but can I just ask one question, because let’s not take for granted that people know what Fe SRIs and let’s break down what myofacial release actually does and got

Walt Fritz  10:06

it. Okay, so mio is muscle fascia is connected tissue. It’s the stuff that covers a muscle, it connects muscles, but it also connects a lot of other structures in the body. In the myofascial release narrative, its fascia, which is just that that covering of the muscle on the connector is somehow viewed as the missing link in healthcare. And that’s literally the words that are used the missing link that nobody else knows about, except for us, okay, which is kind of weird. But it said that it gets bound down in terms of in response to injury in terms of trauma, surgery, and that that then creates dysfunction. People were taught various ways to treat a person, stretch a person, poke a person, do things with a person via touch and pressure to quote unquote, and I’m using air quotes here released the fascia Yes, in that it said that the fascia is now back to its original state. All of those are lovely concepts that have been totally unproven by outside research, but yet people get better when we do myofascial release. So what do you do in that conundrum? Research doesn’t prove it. But here, we get all these lovely results when we use the work. I think the concept of common denominators needs to come into play. When I do manufacture, release, I think I’m affecting passion, and I help people when somebody doesn’t arrange a massage, they think they’re affecting the muscle specifically, and they help people, they help people. But they both have totally different stories. Can both of those people in those stories be right? Or are their underlying factors, the common denominators that play and that’s kind of where I’ve gone in the last five years or so is to stop worrying about issues in the tissues and worry about working with the human being in front of me, not their tissue. And unfortunately, in the manual therapy community, which includes physiotherapist, massage therapist, voice, local massage therapists, speech language pathologist, there’s still a lot of tissue worshipping, when it comes to the specific tissue as well as the pathologies that are said to lie in those tissues. And I just think it’s time that we start evolving beyond those historical narratives really catch up with the rest of the healthcare community when it comes to seeing any problem. It’s multifactorial, and not just one tissue as being pathologic.

Dr Marisa Lee Naismith  12:21

So did you start finding that with your own patients, or do you call them patients or clients, I call them patients, patients that you started to do different work, your work was evolving, and you started to see results within those patients. That wasn’t this heavy, or this tissue work?

Walt Fritz  12:44

Yeah. Well, in the in the narrative that I learned from the myofascial release work that I learned, it was fairly Okay, so it was on the gentle to moderate range. Very seldom did we use really aggressive work, okay, which the there’s an irony here, I still use a similar style of treatment that I did back when I started myofascial release in 1982. I don’t believe it’s about the fashio anymore, but I still find that work is helpful. What’s different about my treatments now is instead of everything being performed in quiet, where the patient can go deep into their emotional being, and I’m sort of I’m tasked with the role of the expert in knowing what to do. My Sessions now involve constant feedback. It’s an iterative approach back and forth, where I’m asking my patient what they’re feeling, and if it feels helpful, useful, irrelevant, because I realized that the more I know, the less of which I’m certain, so much so that I need their help to do the evaluation and move through treatment. And it’s really interesting. The difference is, I’m doing the same thing with my hands. But I’m not the boss anymore. Ah, therapeutic partnership truly. And in the concepts of shared decision making, which are really coming up in medicine and health care. We’re rolling into a manual therapy environment where I don’t call the shots, we call them together, so to speak. And it’s irrelevant, unless Marissa, you feel that what we’re doing is useful. That’s a big difference.

Dr Marisa Lee Naismith  14:16

Yes. So who are the clients that usually come to you? And you know, why are they usually coming to you for?

Walt Fritz  14:24

Yeah, so full disclosure I teach primarily the work that I teach live is my voice and swallowing disorders class, which is attended by speech pathologist by voice coaches by massage physical therapists, etc. Like here in upstate New York State of the United States where I have a practice in a home, I have a head to toe type of physical therapy, clientele, I might get a patient coming in for foot pain or head pain or back pain, but I now try and select patients from within the context of what I teach. I have a quote unquote closed physical therapy practice where someone can just schedule with me on As I lead them because I got a call this morning from somebody who was looking for some help. And they said, I know your practice is busy, but I have a problem with my voice in the area, the hyoid, and I said, Yeah, my practice is full and close. But I want you in my practice, so you can come in, because that’s the kind of patient I want to see. So I get referrals from speech pathologist, and in the Rochester, New York area, I get some from Ear, Nose and Throat surgeons. But I also get a lot of people finding me on my website because of this niche work that I teach to others in swallowing invoice in oral motor dysfunction in tongue related issues, breathing issues, all sorts of things. And that’s really, it’s become my passion and my love and my practice here. How do

Dr Marisa Lee Naismith  15:40

you do discover that this was useful for singers? I mean, have you sung yourself? Was this something that I have a personal passion for the singing voice, and I would like to try working with a

Walt Fritz  15:55

sad story. And we’re not going down this road at all. No, I am not a singer. I’m not a singer at all. I certainly enjoyed music. And it’s always been a part of my life. But let me back up a little bit before the singer entry into my practice into how I got teaching to speech pathologist. And that was, in my own world, I have some serious problems with attention deficit issues, okay, meaning I can’t stay on task. Okay. Now, in my practice, that kind of was a hindrance at times, but it also turned into a blessing. Because I can literally look back into the early 2000s, when I was working in the neck Creek, and in this region right here, where I was taught we work with neck pain and, and pain radiating into the arm, etc. And I was working with a patient and I was finding that doorbell, I call it an area of their neck, which was connecting with their neck pain. And we sort of sort of just got settled into treatment, and I was treating this area and my AD D kicked in and I said okay, what else can I see around this area, and I started poking around, and instead of being going anterior to posterior, which is where the nerve roots lie, I went to the midline. And I started exploring this area. And I didn’t know what the time where I was. Now I know I’m behind the thyroid garbage. But when I did that, my patients started telling me about a swallowing issue that she experienced. But she hadn’t written it on her physical therapy intake form, because that had no relevance to a physical therapist. Okay, so that was interesting. And those sorts of experiences tended to repeat themselves over swallowing, as well as voice disorders and Globus and things like that. So much so that in the in a when it was, it was in, it doesn’t matter. Many years ago, I was writing about it on the internet, I had a blog early on and somebody caught wind of it. And a speech pathologists from the University Chicago, invited myself and an EMT from New York City, Benjamin Asher to give a one of class in Chicago to speech pathologist on voice and swallowing using myofascial release the old term, that’s how I got started in your world, okay, or at least part of that world in terms of voice from that really awkward beginning, because I really didn’t know your world, I was coming from my physical therapy world and trying to translate things. Since that time, that first class in 2013. It’s been really a constant evolution and learning process for me on learning more about you, I’m learning more about who you work with both as a singer working with singers, etc. But it’s also with the primary population of the speech language therapists, the speech language pathologist, and all the various issues that they deal with, which was, you know, it’s very different from a physical therapist. So I’ve been on a constant learning curve for myself.

Dr Marisa Lee Naismith  18:39

That’s amazing. So I’m very interested to hear then, because I know first up you call singers, vocal athletes. I’m interested to know why you call us vocal athletes.

Walt Fritz  18:52

Yeah, that’s a term that I borrowed from Mercy Daniels Rosenberg in 20. The Born in terms of their book, the vocal athlete, and I think it’s really like

Dr Marisa Lee Naismith  18:59

I have behind me, there you go. Yeah.

Walt Fritz  19:03

I just think it’s a real app descriptor, because it’s a taxing profession. And I don’t need to tell you, or your listeners or watchers that at all, and, and although it’s not an athlete in the traditional sense that we might be that athlete, there’s certainly the working with a highly refined set of skills, as well as the problems that come along with those skills. And I see my work as being one slice of a much larger piece on how we can be impactful with that vocal athlete, we can be impactful with the dysfunctional voice, the muscle tension dysphonia, right? Because truly, I use and teach identical work, whether you’re suffering from primary muscle tension dysphonia, or you are an elite level singer, it’s the same work. It’s applied in the same way. It’s the same sort of experience, which is to a lot of people frustrating because they expect, okay, I’m working with a vocal athlete or a high level performer, there must be certain techniques that You’re better for that person. But I teach a fairly small range of ways to interact with someone. But it’s that as I like that word iterative, it’s back and forth. It’s a constant back and forth relationship that you build with any person, any patient no matter what their issue. And basically, it’s touching them in the area and saying, What do you feel when I touch you? Does it feel useful? Does it feel harmful? Is there anything about what I’m doing that feels like it might be helpful? Would you like me to change what I’m doing? And it’s just, it’s a fun process that I really, really enjoy. And getting back to that I think vocal athlete perfectly describes the elite level singer in in even the the amateur singer because it is about working up just like an athlete would to elite status. What are

Dr Marisa Lee Naismith  20:45

typically the types of problems that a singer would have benefit from the type of work that you do?

Walt Fritz  20:53

Sure, again, understand, Marisa, my sample size is much smaller than a lot of the people who are working day in and day out with a singer. I will get people with definite issues of tongue tension or tongue tension. It’s a pretty generic phrase, right? What does it mean?

Dr Marisa Lee Naismith  21:10

Tension is a big thing yet we all have that.

Walt Fritz  21:13

That’s exactly right. But definitely tongue tension, tongue fatigue, a lot of times there’s the vocal tension, vocal fatigue, vocal pain that ensues, when you know somebody’s is working too hard training too hard touring too long, that sort of thing that will work with it as well, a lot of it is I actually see a fair amount of maybe you might call it an amateur singers, or maybe not singers in general, but people who like to sing, but find they can’t do what they once did. Now, vocal range diminishes as we age, etc. But it’s still fun taking that vocal non athlete and helping them as well with really what ended up being similar problems, you know, and then I get to live vicariously through speech pathologist and vocal coaches who I’ve trained. And then I see them going out there working with elite level performers, and using this work on a, sometimes a daily basis in the warm up and the cool down, etc, mixed in with all the other good things that this person that this national does with the singer. And it’s, I tell you, it’s a pretty gratifying life to be able to see your work, translate it to that elite level, but then equally translated to the person with post head neck cancer, and a lot of issues with basic swallowing, to see your work being used to help that person in to me, that’s equally gratifying.

Dr Marisa Lee Naismith  22:34

Okay, so let’s just start, let’s just go back a little bit. So I’ve come to you, because I’m having vocal problems of some description, whether it’s loss of range, you know, or I’m becoming very fatigued very quickly. So I come to you. Let’s talk about that diagnostic process. What happens from the moment I walk in the door, like this kinds of questions that

Walt Fritz  23:01

write and I’m a very medical, medically based practice, as a physical therapist, that’s basically some of my legal requirements. So we’re going to take history, we’re going to take all those things, we’re going to do objective measurements, if it’s appropriate, we’re going to check out your medication history and past and present all of those good things that a medical clinician should do. But then when I’m going to do Mercy’s, okay, let’s pick something you talked about what?

Dr Marisa Lee Naismith  23:25

Oh, let’s just say vocal fatigue. Okay, I become fatigued really quickly. The voice seems to tie Ah, got it within 10 minutes of singing.

Walt Fritz  23:37

Yeah. What does it feel like to you? What does it feel like?

Dr Marisa Lee Naismith  23:40

It just feels like when when you run and you feel that you can’t run any further, it’s just that the voice is tired, it doesn’t want to work. I feel like it takes a lot more energy to try to sing I have to work a little harder to find eight

Walt Fritz  23:56

and what is it what yeah, what does it feel like? What does it feel like? Is there discomfort? Is there pain? Is there a Ching is there, give me that what is feel like

Dr Marisa Lee Naismith  24:04

okay, it feels like I have to push to make a sound.

Walt Fritz  24:09

Got it? And you came up here with your hand where is that pushing meeting to take place around this

Dr Marisa Lee Naismith  24:15

area here?

Walt Fritz  24:16

Got it. So, what you just did was you started the process by by doing two things, you took a more general problem, and you better defined it in terms of a feeling not you know, you said it wasn’t pain, etcetera, etcetera. But you came closer to talking about that feeling because in my work, if you don’t, if you can connect with the feeling I have, I struggled to help people. If it’s abstract, it’s more difficult. That’s why the concept of what does it feel like is so important to me, as well as where do you feel it? Because where I start is literally where you say it’s right here. This is where the tickets and I’ll ask you questions like Marisa right now at rest.

Walt Fritz  24:58

Do you feel fatigue No,

Walt Fritz  25:01

not at all, nothing, there’s no thought that I have a problem down the road. And that’s fine, right? So what I might might need to have you do is I may need to have you go ahead and go to a place in your range go to a place in your whatever that is to see if you can start, like connecting with that feeling, even if it’s not as bad as it is after 15 minutes. Can you do something right now so you can feel even right now, you don’t have to do this for the sake of I don’t want to put you on the spot. But I’m showing that the process it’s like, okay, if it’s not there at rest, can you bring yourself in contact with it. So you have a really not just a memory of it. But the felt sense within your body, because what we’re going to be doing is when I start to do a stretch, burn input, or whatever it is we’re doing to this area, I’m looking to maybe replicate that feeling. Or if it’s there all the time, like some people have a constant, I’m gonna use the word pain, right? They have a constant pain, if we do something, it may heighten it just a little bit. So you know, we’re doing something where it may comment, right? I call this the continuum of relevance, I want to do something to this area of you, Marissa, that you recognize how whatever you just did, while that’s relevant, that’s familiar, you calmed it, you brought it to my awareness, not just this abstract thing where I’m going to work by magic on you, and then you’ll be be better down the road. Because the iterative processes, if you’re not connecting with it, we can’t work back and forth from it. I also like to teach homework, I like to teach homework all the time. But you know, one of my favorite things to teach is, can we be hypothetical again, for a moment, you’ve had, you’ve had, you’ve had this problem for months, or years, right? And we get done, and everything you’ve tried, nothing really creates a chain. Okay? We’re done with our session, you say, Boy, well, this is really weird. I feel different. Your homework might be to allow yourself to realize that you can feel different. And that change is possible. Because up until this point, you’ve not felt changed. But in this moment, you do feel change. You might ask me, well, will it last and say, well, that’s our job. But can you just allow yourself to see yourself as a singer, who is not destined for this always to be there? Because in this moment, you feel different. And I tell you, that is such harder homework than me giving you a list of 10 things to do or stretches or exercise, sometimes just re envisioning ourselves in a different way. We’re, yeah, and I think it’s really useful work

Dr Marisa Lee Naismith  27:31

well, so well, then you’re kind of working with their psyche a little bit, too. So it’s not just because I know as soon as we do get in our heads a lot. We are constantly in our heads, we worry about everything that’s going on with our voices all the time. So you’re trying to create a shift in mindset as well.

Walt Fritz  27:53

It really is. Yeah, it’s an embodiment of the biopsychosocial concepts, realizing that every problem has, it’s it’s the three legged stool. And so our changes every every change that we want to institute, it’s more than just creating different muscle tension. It’s everything that goes along with that, and what brought you here and where you’re going from here, which truly is the psychosocial aspect of the biologic?

Dr Marisa Lee Naismith  28:19

Well, the thing is that we can’t separate the mind body emotions, all those sorts of things.

Walt Fritz  28:26

Yeah, life is wonky, humans are weird, but yet we simplify it to the simple sama. Get your posture better, get your tongue where it belongs, all these simple means that we’re taught, and then we regurgitate to our patients and sometimes to our students. And you know what, I don’t want to be totally dismissive, that stuff worked. But why it works is exceedingly complex.

Dr Marisa Lee Naismith  28:50

Do you teach this to teachers? And can teachers use this in the boy studio, as, as long as we’re within the law, of course of what we

Walt Fritz  28:59

want to speak for Australia, because I know when I taught, I taught in 2019, the Australian voice Association, and they limited enrollment in the class to speech language therapists, only one voice, one voice coach was allowed in, under an agreement that she wouldn’t use any of it. I don’t know how that worked. But anyway, in the United States, there’s a similar line. But I know voice coaches who do some touch base work. I’m not saying they’re doing it legally or illegally. They’re figuring out a way to make it work on their own. I know a couple of voice coaches in the United States who have gone back to massage school to get their certificate so they can, quote unquote, legally do this work in the United States. But you go over to the UK, and the rules are so blurry. So blended. Voice coaches can do do this work, because the regulation bodies, it’s very different than in the United States, and I’m guessing in Australia, and I’ve taught in other countries too, and then the lines get really big Very different than the scope of practice boundaries, professional personnel very different in other countries as well. So can a voice coach take this work? They do. And sometimes they’ll take it just to say, I want to learn more about it for my own benefit, as well as how I might refer out to others that sort of work. And are they doing some of it on their own when they get back to their studio, possibly, but I ask people to work within this their own professional boundaries. But what they do when they when they leave any continuing ed seminar or training is really hard to police. So,

Dr Marisa Lee Naismith  30:33

yes. And well tell us about your own.

Walt Fritz  30:37

The name of the book is manual therapy for voice and swallowing a person centered approach.

Dr Marisa Lee Naismith  30:42

And in that book, do you discuss basically the some of the things that we’ve talked about? Is it a book that will help teachers within their studios? Or is it describing the work that you do?

Walt Fritz  30:55

I think it describes a lot of different things I don’t I don’t go into outside of my lane when it comes to other voice coaching type of techniques, but I talk about it within the context of, okay, here’s, here’s a tool, if you will, here’s a tool that can be used, I go deep into the background, because I love to talk and I love to write, I talk about the things we talked about here. But I also talk about a lot of other behavioral aspects of the work, etc. And I go deep into a lot of the different types of sequences, whether it’s techniques that a clinician would do to a patient or a client. But it’s also a lot of it can be self applied as well. So I do think it’s relevant for the voice coach for the, for the vocal teacher as well. Yes. Yeah.

Dr Marisa Lee Naismith  31:35

Just the last few questions here. What is the greatest lesson that you’ve learned about the voice since embarking on your vocal athlete journey and working with with these vocal athletes,

Walt Fritz  31:50

I think humility, humility, in not trying to fix people, humility, in trying to allow their, their path in life to guide what we do. I came into this not knowing anything about voice at all. And I still only know a tiny bit of what you and the other professionals that I teach, know. And I’m very transparent about that. I’m not an expert in voice or swallowing from a physical therapist who has good tools, that I can kind of meet you in the middle of a bridge cannon to teach them to you. And that let you go back and make it your own, both from your perspective, as well as perspective of your clients. But I think working with vocal athletes, it’s just to stay humble. And here’s what I have to offer you. Does this feel helpful? And I think it’s just to always be addressing our biases.

Dr Marisa Lee Naismith  32:49

Hi, David, and welcome to the show. It’s such a pleasure having you on our podcast of voice and beyond. So you are a clinical psychologist, you are a performance coach, a voice workshop lecturer, and you have co authored a book. And when I looked you up on the web, man, there is so much that you so much work that you do that I’m absolutely fascinated in. And I feel like a child in a candy store having you here right now. But let’s do some digging first. Talk about the psychologist. So is that what you studied out of school?

Dr David Juncos  33:36

Yeah, that’s my primary role out of all those hats that you just described there. This is the one the longest and the most expensive that but the most enjoyable. I have to I have a doctorate degree in clinical psychology from the school in Philly. I’ve been out of school for almost 10 years now since 2014 or so. And yeah, I am a generalist in private practice. I work with adults and teens, ages 14 and up, treating a garden variety of problems anxiety, depression, substance abuse, ADHD, work, stress, school stress, mental stress. I’m also a couples therapist. You name it. When you work as a generalist, you kind of treat anyone who walks through the door. For the most part, I do have some people that I specialize in, and also some people that I’m perhaps less equipped to handle. So

Dr Marisa Lee Naismith  34:23

we’re going to talk about some of those things that you work with because I’m so fascinated, and some of them are very relevant to creative performers and creative artists. But I need to ask you, what inspired you to go into psychology because I know a lot of people do psychology because of their own kind of emotional baggage to they’re trying to figure themselves.

Dr David Juncos  34:50

I always was interested in psychology from a young age. I think I’ve been blessed to be raised by two parents who We’re in helping professions and around my mom. She’s departed now, but she was a social worker. So I kind of got hit by that bug. I like working with people. My dad is a medical doctor, from Argentina, a very, you know, very socially adept and awesome person as well. So I just I love people, and I love to work with people. And that’s the general answer. The specific answer is I was an introvert growing up in a family of extroverts. So I kind of needed to have the ability to introspect and understand why my personality was a little different compared to my family. And so I spent a lot of time kind of thinking about my family and thinking about my interactions with my family, and just kind of, you know, in my head, whereas my, my family was just kind of doing their thing and just kind of extroverts rising in front of me, if you will. So I think when you feel a little bit different compared to the people around you, it, it makes psychology at the forefront of your mind more often because it becomes a lot more personally relevant kind of thing and kind of to answer your question like, you assume, yeah, you know that that was challenging.

Dr Marisa Lee Naismith  36:02

Let’s talk about the singing side of what you do to start with. And yeah, how did you come to work with singers? And have you sung yourself?

Dr David Juncos  36:16

I have a song Is that how you say, Yes, I am a singer. I’ve been the singer of a rock and original rock music band that I was also the principal songwriter. And so that’s probably where this push to work with singers has come from. But I’ve also been trained in singing to I wouldn’t say classically trained, but yeah, when I was a kid, I was a member of boys choir in high school. So I guess that would be a formal kind of version of singing training there. But But I didn’t take private lessons for singing. I took private lessons for other instruments, but not for singing. Okay, so some training, if you will. And I just, I don’t know, I gravitate towards singers, because they, they need help a lot, meaning, you know, they, they have a very unique kind of condition, if someone has performance anxiety, and they’re an instrumentalist. They can kind of hide behind the, the anxiety of hide behind instrument, I mean, whereas singers You can’t hide. And when you’re a singer, performance anxiety you want to hide, you know, that’s, that’s often the behavioral manifestation of anxiety, you’d rather just not be seen in that vulnerable state like that. But there’s, there’s no hiding that you have to do it some time. So I think there’s, there’s that reason to, I just, I, I think they need help, like I said, and it’s just, it’s fun. It’s fun working with singers, I get along well with them.

Dr Marisa Lee Naismith  37:35

So you do work, you consider yourself a third wave therapist, and you have additional training in Acceptance and Commitment Therapy. So what is that

Dr David Juncos  37:49

act is, as you rightfully pointed out, it’s a third wave behavioral therapy, meaning the third wave is the mindfulness and acceptance wave. This follows the second wave, which was the cognitive and behavioral the cognitive wave, if you will, behavioral psychotherapy. But this newer wave has been popular in like the last 15 or 20 years. And it is, it’s, it’s, in my opinion, smarter, because it aims to teach the way you relate to your thoughts teach you to relate differently to your thoughts, excuse me. So whereas CBT teaches you to change the content of your thinking. So it’s less, you know, distorted and more based on reality, which can take time to build up that skill to kind of restructure the way you think, but act and similar mindfulness and acceptance based therapies. So you don’t really need to change the content, you can just change the way or the context in which you experience these thoughts. That way you relate differently to them. And when you relate differently to them, you respond more flexibly to them. It’s intuitive, because it teaches you to put less effort into changing what you basically can’t change and just learning to kind of increase your willingness to be with anxiety, without struggle without kind of trying to get rid of it, while simultaneously putting energy into things that are really valuable for you. For example, if you’re a singer and you really value expressing yourself and value like connecting with the audience, then the idea is can you do two things at once? Can you feel anxious on the one hand, and not really struggle against that and just kind of let that be while simultaneously connecting while simultaneously expressing if you have to do that while anxious, that’s hard to do. Right? But that is an act of flexibility. So the main goal and an act specific to act not shared among the other. Third wavers is psychological flexibility. How flexible can you be while feeling uncomfortable, basically, okay, so

Dr Marisa Lee Naismith  39:34

what I get from that is you allow yourself to feel the feelings that you’re feeling, but it’s how you process them. That changes

Dr David Juncos  39:46

how you respond to them. Yeah.

Dr Marisa Lee Naismith  39:49

So what then motivated you to use that therapy? On singers? How did all that come out?

Dr David Juncos  39:58

Sure. Oh, well I started out with instrumentalist. The first work I did in the Spain was my dissertation back in the day in 2010 2011 or so, I worked with a pop and rock drummer in Philly actually. And this is, believe or not, it was not the first time to act at venues with music performance anxiety, there was a Swedish master’s thesis that had been done in like, the year prior. So, but regardless, this is a new kind of application and acceptance academic therapy. So I tried that out, it went, Well, I administered 12 sessions of that therapy to this pop and rock drummer, he got better, I was like, this is pretty cool. So after I graduated, I replicated that with a student violinist at a local university, kind of using everything that I learned in the previous project and kind of refined and tinkered as I went, that showed even better results I got that published, I then came across the opportunity to work at a elite choir College in New Jersey, perhaps you well, maybe I shouldn’t mention them. I’m not sure if they want me to mention them. But their name is in the research study. So I had a friend who was an alum at that school. And I think my, my connection to working with singers was very much because of my connection with this singer. But this friend of mine in particular, she was a graduate of the school. And I wanted to do another research study that was a little bit bigger than the previous two. And I was like, You know what, this seems like the gods are aligning nicely here. So let me try this out. And long story short, after months, and even a year of trying to get through the front door, they eventually agreed to let me do this study at this particular car club. So I did a small group intervention with a group of seven singers at that part of their school. And they all got 12x psychotherapy sessions, plus the chance to do group performances in front of each other as part of the exposure therapy part of the therapy, which is a big component of fact. And, you know, similar to the previous two studies, they got better in the same kinds of way. So it’s just been growing this kind of research that I’ve been doing is started out with small scale projects and growing a little bit incrementally with every project that I do. But yeah, the most recent study that I done was with singers, and I just was hooked. Yeah, I guess.

Dr Marisa Lee Naismith  42:09

And so have you worked with a one on one singer? As opposed to a group of singers?

Dr David Juncos  42:16

Yes. Yeah. So in in a different context, not in a research setting. But yeah, as a performance coach? Absolutely. I’ve worked with pretty established pop and opera stars, as a performance coach. And I, of course, I use act within my performance coaching, too. So I know this

Dr Marisa Lee Naismith  42:33

is very big to unpack the whole of everything that you do. But where do you start? Like, just say, I come into I suffer from performance anxiety? What would you do in that first session?

Dr David Juncos  42:47

Good question. And there’s so many ways to start. First thing that comes to mind is building rapport apps, you have to know that this person is going to trust you. And you know, having having research in this vein under your belt certainly is a form of credibility. So before they even come through the door that helps that you know, to know what you’re doing, and what you’re talking about certainly helps. But more clinically speaking, I like to give them a Likert scale. If you can, I have to use my hands here because I don’t have a piece of paper. That’s right. And I’d say like imagine the scale of zero to 10, right here. And on this side, you have low numbers. And right here, you have the middle over here, you have high numbers, I asked him, How willing are you to perform with your anxiety President on a scale of zero to 10. And usually, more often than not, they’re gonna say, as you can probably guess, like 101 or 2x, launch them that? Well, it’s more often the case that, yeah, when they’re struggling with problematic or debilitating anxiety, it’s usually because they have low works, but that’s the punchline. So let me set up the Joker set up the premise first here, when you’re at a low number, the way you relate to your anxiety, it’s like you’re in a negative relationship with it, and you want to get out of it, basically. So it’s marked by avoidant behavior and distress. However, when your answer is in the middle, if you’re at like a four or five out of 10, the way you relate, it’s not the same. The way you relate to it is, it’s a thing. I may not like it sometimes, but I like it other times. So it’s kind of like a more balanced perspective that you hold, and therefore you’re not going to be as highly avoidant towards them, or towards situations that trigger it. So your ability to relate and respond to it is different when you’re right here in the middle. And obviously, if you’re someone over here who loves anxiety, I don’t know who they are. But if you view anxiety provoking situations is like exhilarating and exciting. Of course, they exist. There are thrill seekers out there who wouldn’t view it as anxiety, they would view as excitement, right? Yes. They probably don’t need much of my help. But they’re not the kinds of people that come to me for help in the first place. So yeah, it’s usually the people that are over here that are struggling, and to be told that the way you relate actually can change, you can grow a more neutral relationship towards your anxiety. And that’ll enable you to respond a little more flexibly and its presence. And I can teach you how to do that one can learn how to do that. And that can be very healing and very helpful for someone here that you don’t have to stay stuck in this kind of bad romance, if you will, over here, with your anxiety, you can learn to change the way you relate and therefore respond to it.

Dr Marisa Lee Naismith  45:22

Because if if someone loves singing for it, we’ll just use singing as the example. But if someone loves singing, and they could have the opportunity of having a brilliant career in that field, to suffer that performance anxiety is such a shame for that is because they’re missing out on life, and they’re missing out on doing the very thing that they’re most passionate about.

Dr David Juncos  45:50

Yeah, they’re missing out on being really successful. Even Barbra Streisand comes to mind, I’m sure you know this story. Yes. I use her as a as a case example. And hopefully, hopefully, she’ll allow me to do this. But this is all publicly available information about her. So she forgot the lyrics to a song, you know, in front of 1000s upon 1000s of people in Central Park and the mid to late 60s or so. And she refused to go back. She refused to do public performances for like 20 or 30 years. Yes. And this is Barbra Streisand, we’re talking. This is someone who is obviously a very gifted, talented person. But imagine what she could have done had she not had that experience. And well, more importantly, imagine what she would have done if she hadn’t avoided going back,

Dr Marisa Lee Naismith  46:36

I was going to say it’s the avoidance because everyone forgets the words at some point of time.

Dr David Juncos  46:43

It doesn’t matter. Right? As long as you just accept and are willing to have that experience happened to you, then the way you relate is more neutral, then it becomes a thing rather than this dreadful, awful experience to be avoided, right? Yes. And had had I ever had the chance to talk with Barbra Streisand. I’m sure if I were to, if I were to ask her, you know, okay, where do you fall here on your willingness to do things to perform, and particularly anxiety presents, she probably at that age, that point would have said, it’s the most awful thing. Forgetting song lyrics in Central Park, when I’m in my 20s is just the worst thing ever. I never want to do that again. Okay. So that is a relationship that’s marked by low willingness, avoidance and distress, unfortunately, for yes.

Dr Marisa Lee Naismith  47:27

And so you have this 12 week program, it seems as though you keep saying it’s 12 weeks or 12 sessions, and you have a book about this. So is this something that people can also use outside of being in a clinic with you?

Dr David Juncos  47:48

Excellent question. I’m glad you asked me that. Yes, absolutely. And it doesn’t need to be done clinically, at all. Really, the beauty of the Act model is it exists in both clinical and non clinical version. So when use non clinically we call it act coaching or act training as opposed to add psychotherapy. And I’ve had the pleasure of overseeing two master’s theses at the voice Study Center piloting act coaching rather than act psychotherapy as an MPH treatment. And in both cases, these were done. The studies were done by singing teachers with zero education in psychology or psychotherapy, zero background in that, and with less than 10 hours training from me, in Act coaching, X psychotherapy, they replicated the work that I did with those seven students, as well as other students, other musicians I’ve worked with, which has great implications for now. If you’re someone who doesn’t have a lot of you know, background in psychology, fret not as long as you work with students, or if you work with, you know, coaches, if you’re a coach, if you if you have someone’s best growth potential in mind, you know, then perhaps doing some act coaching would be beneficial for you to get involved here. So, I’d love to talk further about, you know, when this is appropriate to do when it isn’t competence, etc. But I’ll just quickly share that these two particular students, they were thrilled to be able to feel helpful to feel like you know, as a singing teacher, they sure could spot the signs and symptoms of performance anxiety, but prior to getting this Training Act, they had no idea like how to intervene, they just didn’t know what to do. But there’s good research showing that music students don’t always want to talk to a psychotherapist, they’d prefer to talk to their teacher because they already had that more

Dr Marisa Lee Naismith  49:30

weight to personally so yes, as frontline workers, you are a time with students? Yes.

Dr David Juncos  49:38

Believe it or not, there’s good psychotherapy research showing that it doesn’t matter the style of therapy that you do. What’s most important and most predictive of a good outcome is the relationship. So if your relationship is marked by empathy, if it’s marked by, you know, a good working report, good working relationship, then it doesn’t really matter what the content of the therapy is what you’re doing. You You’re still going to be helpful. So if you’re a music teacher who is wondering, should I get involved? When should I do this kind of work? I would say yes, if you have these kinds of qualities within your relationships with your students that’s marked by empathy and like a strong partnership, where you can agree on the kinds of problems to be solved or the problems to be worked on, then you’re already helpful, because those are good, robust predictors of therapy outcomes. So in those situations, yes, you might want to consider doing this kind of work. I also hinted at ethical issues, too. So we talked about this often voice Study Center, if you’re going to be taken on this kind of work, there’s some things you need to know. So first of all, do only what you’re trying to do. If you’ve never done any kind of performance coaching within the studio before with a private student, then don’t start doing it. You know, you want to be training? Obviously, it’s like any professional development skill here. Yes. And do do what’s in your student’s best interest to have. So if, if you’re still on the fence about whether or not to do it, and you’ve had some training, would it be in the student’s best interest for you to kind of have, you know, do it? Or should you wait until you’re a little more competent in doing this first, though, usually want to err on the side of making sure that you’re competent to deliver this kind of stuff, you’re so quickly to just kind of summarize here, when it comes to matters of competence, it really just is a matter of how much training do you have in act as a singing teacher, as any kind of non clinical practitioner, you can certainly take advantage of both clinical and non clinical training opportunities, like classes, workshops, you know, peer groups, etc, these all exist. And I highly recommend doing that plus reading on the subject. And even then, even then, if you think you’re ready to start doing this work, consult with an expert consult with a supervisor who can evaluate you for your readiness to do this kind of work. Because you really need to know what the ACT model is all about. You need to know, you know, what performance anxiety, it looks like? What are common symptoms of it, you need to know what kind of technique would be useful based on the symptoms based on the particular student in question here. And then when you can display to a supervisory person, an expert, that you actually know what you’re talking about, and you’ve had some experience on your belt in doing some performance coaching light workers, then yeah, then perhaps you’ll be ready to do this kind of work.

Dr Marisa Lee Naismith  52:11

I mean, as singing teachers, we’re not therapists, and I’ve had this discussion with other guests. When do you believe we start crossing that boundary between a therapist and singing teacher?

Dr David Juncos  52:29

Sure, it’s a very good question. And you want to make sure you stay in your lane, obviously. So if you’re addressing personal issues that are not related to music performance, or not related to practice, the practice of music to then that would fall outside of your jurisdiction, they’re so talking about, like relationship issues, talking about, you know, significant mental health problems, substance abuse, etc. Those don’t really relate directly to the practice and performance of music, whereas performance anxiety, arguably does relate to the performance and practice and music. So I see no problem and teachers getting involved in doing this kind of work. Just like there are other evidence based frameworks and training programs like mental health, first aid training, like applied behavioral analysis. These are programs that teachers can get involved with that have come originally from psychology, but they’ve been, you know, crossed over into educational settings into other non clinical settings, because they relate to the daily work of the teacher in the classroom, the teacher in the private studios. So arguably, if it’s related to performance, then yes, I think as long as you have those relationship qualities, and you have the competence, and the readiness as evaluated by someone you know, who knows what they’re doing, then give it a shot.

Dr Marisa Lee Naismith  53:40

And all those trainings that you were talking about previously to do with act? Are they things that you offer? Can people come to you for all of those, like, do you hold workshops yourself, for voice teachers,

Dr David Juncos  53:57

I am in the process of doing more and more of this work here, because as you can imagine, the demand is high for this year. So thus far, I’ve been doing trainings primarily through the voice Study Center, I do act for MPA music performance anxiety courses through the voice Study Center. I also do other acts for performance enhancement and kind of non MPA related stuff through the voice study temperatures. So yes to that, I’m growing this this training package, though, so it’s, it’s still burgeoning, if you will. But I would like for this to be at the place where Mental Health First Aid training is or where applied behavioral analysis is where it becomes like a ready, readily accessible training package for a teacher to make use of because it really informs what they do and it makes them more confident to handle these kinds of issues as they come up on the fly. So that direction I would love for this to go on here for it becomes commonplace for teachers just Yeah, sure. I’m doing the music performance anxiety training. Who doesn’t? You know what I mean? It’s really helpful, of course.

Dr Marisa Lee Naismith  54:55

What do you think we can do better as a voice teaching community to serve our students that are suffering from whether it’s anxiety, performance anxiety, what can we do to help?

Dr David Juncos  55:08

So the fastest thing you can do is to sign up for Mental Health First Aid training. Absolutely. And if you’re not sure, if it’s available within your country, then just Google it and see if it is it’s available in most countries, I don’t know if you can do it kind of like across country lines, but I see no reason why you shouldn’t be able to do something like that. That’ll help you target a garden variety and the tough problems, anxiety, depression, substance abuse, etc, and just know how to make referrals there. However, with the new new research that I’m doing in this training package that I will be offering soon, again, I want teachers to not just make referrals, I want them to actually make interventions and do coaching work with students who have performance anxiety. So I think that is a highly intuitive answer to an age old problem there. So you can check out my webpage for For more information, training opportunities, buy my book act for musicians.com. When it comes to treating students mental health related problems, or performance, anxiety, get training? Absolutely. You have to have the skill set to know what you’re doing here. Just like any kind of profession, obviously, any profession with continuous professional development courses available. So get training. And if you yourself are suffering, you know, with any kind of mental health problems and get help, because let’s face it, you know, the pandemic was brutal on singing teachers on music, musicians and large world of life. Yes, if you’re suffering with any kind of mental health problems yourself and then get help to please.

Dr Marisa Lee Naismith  56:42

Lori Sonnenberg, you are a licensed speech language pathologist, a clinical voice specialist, and singing voice specialist, and you’re based in Chicago, one of my very favorite cities in the US, and you’re also a soprano, you have you have a Bachelor of Music degree and a masters of music. There is so much to learn about you. So let’s start with what was that journey? Like? What order did all that happen in?

Lori Sonnenberg  57:17

You know, I started out like a lot of young singers who were gifted in in the classical realm. So I my voice was really well suited to classical singing. And I was a high soprano. I was also really strong musician, so I could learn and seeing very difficult music. And so I was really focused and motivated about just pursuing a big performance career in opera, right. I mean, that was what I thought I wanted to do. I would envision myself the Met and in Europe and galavanting about and singing and doing all and knowing and learning all the languages and, and that was really my focus for most of college, I was still pretty focused on that. But during college, I took my first pedagogy course, which is kind of unusual for undergraduates at that time, that was in the 90s. And we started learning about injury ran, I never had injury and not I was fortunate as a singer to never have really struggled. But I had a lot of friends who were music education majors, who were struggling and getting diagnosed with nodules and different things. And so I was sort of observing all of this as a very young singer and want to be teacher. So I tried teaching very young, I started teaching lessons when I was like 19, which I bet they would never want someone to do that now. But I look back and it was just a good fit I, I was good at teaching music to young people. And so I use my piano skills, and just my budding skills as a voice teacher to you know, start playing around in a private studio setting with other voices and realize, hey, I’m pretty good at making changes in the sound, you know, I can listen to them. And I can sort of internalize that and diagnose it by introspection, what do they need to change about what they’re doing to make it sound better or different? And so I think I started doing that sets at such a young age and, and then when I went to my master’s degree, I was recruited for that degree by a professor named Norman spy v. And it was a new program at that time, and they they there weren’t that many of them. Master’s and pedagogy were just unheard of. And they recruited me for that gave me a teaching assistantship, and I just loved teaching that I had a good instrument too. And so I was really torn. You know, I had I felt like maybe I had the chops for the performance thing, but I wasn’t sure. And I just couldn’t get the vocal injury, rehabilitation piece out of my head. And I lived really close to Philadelphia at that time when I was doing that degree and so I started observing and spending time and learning in a blaring allergy clinic. And I really wanted to be a singing voice specialist. I didn’t want to do the speech pathology piece, I just wanted to do the singing voice specialty. And I realized after talking to people that I probably would not get to really be all that involved in the medical side of things, if I didn’t do the speech pathology degree, sure. And I was in my mid to late 20s. And I said, you know, if I’m going to do this, this is the time I was envisioning this role where fingers can have very specialized support for recovering from injury.

Dr Marisa Lee Naismith  1:00:41

Okay, now, I want to ask here, and this may be a really ignorant question. What is the difference between a voice therapist and a voice pathologist? And is there a difference?

Lori Sonnenberg  1:00:54

I think we interchange them a lot. He especially here in the States, I think everyone kind of calls themselves something just a little bit different. I use voice pathologist sometimes because I am involved a lot in the diagnostic process. And that that pathobiology diagnosis, and I don’t know it, it for me, it really feels like it gives me some credibility on the science side of things. Voice therapists, to me, it’s a little more like colloquial, the pathologist sounds a little more credible. Sometimes. I guess, my favorite, you know, title to use is clinical voice specialist. I feel like that is probably the best representation of what I do in my day is

Dr Marisa Lee Naismith  1:01:41

in your work as a clinical voice specialist. What are the most common voice pathologies? Or do you call them disorders pathologies versus disorders?

Lori Sonnenberg  1:01:53

Pathology, to me refers very specifically to a lesion on

Dr Marisa Lee Naismith  1:02:00

the local hold. All right, okay. Right. So,

Lori Sonnenberg  1:02:05

so I probably say disorders, okay, or or injury more often, but I like disorders because I feel like disorders is a little more a correct sort of categorical description, right to types of things, because so much of my practice is devoted to what we call functional voice disorders, because muscle tension dysphonia falls in that functional realm. Yes, and so so muscle tension dysphonia with or with our pathology is is the number one diagnosis in my clinic.

Dr Marisa Lee Naismith  1:02:42

So muscle tension dysphonia that is really common

Lori Sonnenberg  1:02:46

muscle tension dysphonia I, I mean, one of the things I want to make sure I say first is that it is a bit of a, it’s a bit of a wastebasket term, a lot of things go in the bin, and here and here’s what I mean by that, because when we it means that it’s a big umbrella term, rather, when a doctor doesn’t see anything wrong from an organic or physical standpoint with a larynx, which is what we want, right? We don’t want to see anything, yes. Even if they don’t really see muscle tension, it’s kind of hard to see that. They’ll that’s what we diagnosed the person with. And the voice is a little, you know, something’s not working correctly or well, about the function. Yeah. And so it encompasses so many things. It can be primary or secondary. That basically the way I like to describe it to my patients and my students is that there are very particular muscles intrinsically and the larynx that are responsible for vocal fold vibration, and closure, abduction and that process, and we don’t really want the extrinsic muscles and operators involved. All right. And so what happens in muscle tension dysphonia usually is that there are muscles that are not supposed to be involved in that process become involved, we start recruiting help from them. With compensatory strategies. Yes. And then, you know, the body learns what it learns. And it becomes habitual.

Lori Sonnenberg  1:04:19

That’s right. The brain learns it. And we’re looking and especially singers like we’re looking for, from the moment something doesn’t sound right or feel right, we start looking for a way around it.

Dr Marisa Lee Naismith  1:04:31

Yes, I call that manipulating we start to manipulate and that’s why often like when it comes to my singing students, I can tell more so in their speaking voice, if there’s a disorder, rather than their singing voice, because in there singing, we all when we see we can learn to mask it and as you said, work around it, but it’s very hard to disguise in the speaking voice.

Lori Sonnenberg  1:04:57

Yeah, you’re right. Well, because we’re not is aware of technique usually, you know, one of my mentor talks about like, how, as singers, we were really good at dressing up our voices. Like we put all the layers on we put our most beautiful gowns on and our and our coats and our hats and our scarves and we dress it up. And and we’re good at that. Yes, it can develop all by itself as the primary issue, but a lot of times muscle tension dysphonia is a secondary diagnosis to another diagnosis.

Dr Marisa Lee Naismith  1:05:32

Really, I guess there’s so many questions here. One, what causes muscle tension dysphonia? So what are those primary and secondary problems that are going on?

Lori Sonnenberg  1:05:45

So the most common example is, well, there are two I can think of one is is like nodules, or polyps, but especially nodules, very common for singers to develop the muscle tension patterns while continuing to sing and speak with injury present.

Dr Marisa Lee Naismith  1:06:04

Okay, so that’s pretty serious, right?

Lori Sonnenberg  1:06:08

And then there’s a lot of Muddy Waters sometimes in treatment, because I have to sort of suss out what’s the main issue here is this Are we dealing with an issue, because of overuse is this person truly overusing their instrument, and that’s why they can’t get better, or is muscle tension, the primary issue, and I were paired with a group of laryngologist, here in the Chicago area, who are super super savvy at diagnosing muscle tension dysphonia in the singing voice. And that’s why so much of my practice involves that, usually what we see on an exam, just to be really clear here, we usually see a gap of some sort between the vocal folds where they do not come all the way together from front to back,

Dr Marisa Lee Naismith  1:06:55

really. And that was, what I was going to ask you is when just say I’m a brand new patient, or client, and I come to you, I’ve never been to before, what is the diagnostic process that one goes through? Typically, when

Lori Sonnenberg  1:07:12

I evaluate a patient, the majority of them have already seen a laryngologist. And a diagnosis has been confirmed? Right? So I begin, there are really three major components to my my time with them in that initial visit one is a very detailed dive into their history. We’re going to talk first, yes, I’m going to learn everything I can learn about that person. And their their personal life, their professional life, the role that voice plays in their lives, what’s going well, what’s not going well, what does your voice not do that you need it and want it to do right for you. And so the history is first and that sometimes that’s not a big deal, and sometimes that’s a really long, deep dive into a lot of medical things. The second piece is the actual vocal assessment or assessment of what I call vocal capabilities. So I’m trying to find out what is this voice capable of? And then what are its limitations? I’m pretty good at just assessing things with my ears and the keyboard. So I do we do speaking samples, I try to find out like what what can this voice do all the things that it should be able to do? Yes, in in the speaking way, mean? Meaning louds and softs and highs and lows and authoritative and then we do a lot of sustained sound making so long sounds holding things out. I try to assess the way the breath is working. Are there limitations in the breath? I’m listening to tone and coming up with how do I describe this tone? Is this a clear tone? Is it is it horse? Is it husky? Is it breathy? Is it Are they straining? Are they working too hard? And then singers? If it’s a singer, which it is, yes, we go into more more subtle nuances to Kati, I want to know what can what can they do with staccato legato lines and transitioning between vowels and and what is the range like is this is this a balanced vocal range from a registration tent standpoint or is there a lot of imbalance

Dr Marisa Lee Naismith  1:09:27

and what causes muscle tension dysphonia?

Lori Sonnenberg  1:09:32

Usually the voice either there’s there’s an overuse component, or that is either one time or repetitive where they’re never quite recovering to their baseline and then they fall into those compensatory strategies show. I call it just kind of getting off track. There’s also lack of use, so you know the disuse or or too much, too much vocal rest. That happens a lot. People are scared, they rest too much for too long. And then they try to come back to singing. And then it’s not working like it’s supposed to you another circumstances getting sick.

Dr Marisa Lee Naismith  1:10:17

And people will perhaps returning to work a little too soon and not playing recovering,

Lori Sonnenberg  1:10:24

right or the body, the physical body comes back to normal, but the voice never quite comes all the way back. There’s just something a little. And the thing is though, singers like I said, we’re really good at making things work. So I think a lot of singers that just Band Aid things for a little while. Yeah. And then the muscle tension grows. The other thing I just want to make sure I mention because this you had asked about the primary versus secondary another very common sometimes under diagnosed issue that where muscle tension can be secondary to it is vocal hold per recess.

Dr Marisa Lee Naismith  1:11:02

Oh, okay.

Lori Sonnenberg  1:11:03

Which is which is a weakness in the nerve in the nerves and so that there’s weakness there’s sometimes the vocal folds get kind of flappy or one’s not vibrating and moving the way it’s supposed to. And that’s very common in the singing voice too.

Dr Marisa Lee Naismith  1:11:21

Okay, so how do you treat muscle tension dysphonia,

Lori Sonnenberg  1:11:24

I am a little out of the box, as a speech pathologist in the way that I that I treat voice i i Don’t follow like the typical methods, I sort of create little blends of my own things based on what I think is going to work. And I really rely on my skills as a singing teacher. And therapy, I rely on those skills so much. Yes. And, and so usually there’s, I refer to it as kind of an unloading process. Yeah. So we begin with, let’s make sure the breath is we’re going to work with flow, we call it flow phone, we flow the breath. Yes. Usually, there’s a component of like laryngeal massage, and I do something called trigger point therapy, where we’re sort of isolating specific areas and applying pressure. And in trying to figure out, what does that do, does that change what’s happening? So then we begin with unloading, but I’m really particular in my process, because even while we’re unloading, I’m being very sneaky, about getting other things going without the person knowing. Yeah, that’s what I’m doing. Yeah. So. So while we’re unloading, I’m already choosing sounds for their therapy exercises, where I can tell that they’re getting really clean, clear, adduction, and better vocal positioning and really efficient voice thing. So really, I just use my ears in a trial and error sort of way to determine what results in really, really efficient voicing for this person. And then that’s all we do for a little while. And we get results, usually, I mean, very quickly, usually the person is feeling better when we finished the first session, and they go away, and they do it. And as the voice becomes more efficient, and we’re unloading and peeling back the layers of tension, and so forth, then we get in there and we start building, and we’re going to build and we’re going to start to work on resonance and aural shaping and vocal tract shaping. And then we move into vowels and tongue positioning. And I mean, it’s just a lot of different things.

Dr Marisa Lee Naismith  1:13:44

When we had a meeting some weeks ago, you talked about vocal folds swelling, as well, that is something that is very, very common, and many voice users who, like professional voice users don’t realize that they have it. So do you want to talk a little bit about what that’s all about? Yeah.

Lori Sonnenberg  1:14:07

Talk about oh, well, this kind of comes from my knowledge about swelling and how it comes and goes in the life of a singer or a professional voice user comes from taking people through that process of resolving swelling and injury and helping them learn the day to day week to week balance of how much voice and how much silence, right yeah, balance and be so vocal swelling, I mean, really, swelling is our body’s way of trying to protect us, you know, vocal fold vibration is a biological thing. It is not infinite there and so there is a limit. We all have a limit, your limit and my limit are different. And, and so the thing about falling and vocal fold vibration You know, did you know that there is a no other tissue in the human body that gets subjected to the kind of trauma that vocal folds do on a daily basis, I’m not surprised. So so we vibrate so much. And if we go past the limit, the vocal folds are going to, they’re going to be these little cushions that kind of pop up, you know, on the vibrating edge of the fold to protect us. But when that little cushion pops up, something’s going to change about the voice. And we have to know what the and our body or our voices are going to give us a warning signal that that spelling is present. Now, if you’re not a singer, you might not ever know.

Dr Marisa Lee Naismith  1:15:42

So how can we tell that we have something sinister going on? Or potentially sinister?

Lori Sonnenberg  1:15:49

There are some really key common signals, warning signals, I like to call them for singers especially and I, you know, I do work with non singers, but just for the purpose of our conversation, I’m Yes. Gonna use that. So And remember, the outer edge of the vocal hold is the mucosa. So we are referring to mucosal swelling in this Yes, yes. So the number one thing is loss of a high soft thing? Ah,

Dr Marisa Lee Naismith  1:16:21

that’s interesting. Because even in I mean, how many students come to me and they say, I can’t sing high, softly. The only way I can sing highs if I sing loudly.

Lori Sonnenberg  1:16:34

Yeah. So you know, we don’t know, we never know unless we look right. So but it’s one thing for someone who have never been able to do those notes that way. But it’s another thing for someone to say, I can’t sing about G five today. Like I’ve lost everything above that, what what’s going on? Okay, so but loss of five soft thing, because even the smallest of vocal folds swelling might not interfere until soft head boys or soft falsetto. And you have to get quiet to notice that. So so the loss of high soft singing, day to day variability,

Dr Marisa Lee Naismith  1:17:13

aha, so the voice behaving itself one way on one day, and the next day, the voice behaves differently. So the voice is inconsistent from day to day, it’s just random,

Lori Sonnenberg  1:17:26

right? But there’s almost always a pattern there. And that’s one of the fun things is helping people find those patterns. So the other really common things are onset delays, air escape, and the tone and increased effort. So those are probably the top five warning signals that come out. Another thing that kind of stands out just for like our listening audience, so colds and viruses and upper respiratory type things, even allergies, and reflux, and all these things that can really cause havoc in their, they cause what we refer to as more global swelling in the environment. So the whole area is going to be inflamed. And you’re

Dr Marisa Lee Naismith  1:18:08

right, right, but not just the folds, right?

Lori Sonnenberg  1:18:11

vocal folds, swelling is vocal. So if someone happens to have a little baseline swelling, that other swelling on top of it is going to really just make that voice very impaired. Okay.

Dr Marisa Lee Naismith  1:18:28

So it’s going to wreak havoc. Right, right. So

Lori Sonnenberg  1:18:31

now vocal folds swelling. Well, I get very excited about this topic, people get stressed out about it, because it’s a scary thing sometimes. But the reality is when we are busy bulk when we are a busy vocalist, we have very high expectations of our voices on a daily basis. Absolutely. Yes. And we’ll listen to the warning signals a lot of times and and we say, well, I got to teach that lesson. And I’ve got to sing that rehearsal. And, and so when you go when you ignore the signal, even if it’s the smallest little signal, but then that signal, keep showing up, then you’re moving towards something a little more chronic. So regular monitoring, knowing how to monitor mucosal swelling is important. Now, one of the things that’s confusing is the difference between, okay, I didn’t say vocal fatigue, and I should have said vocal fatigue, because that should be in the list of common complaints. Yes, vocal fatigue could mean so many different things. How do we know what it means? And so I talk a lot with my singers about the difference between is what I’m experiencing mucosal welling issue from overuse for bored isn’t really a muscular thing. How do we know the difference?

Dr Marisa Lee Naismith  1:19:53

But how many people come to you when it’s too late? Like they don’t either? Since the warning signs, they know something is up, but because if we don’t work, we don’t get paid. We keep pushing through. Do you see that a lot?

Lori Sonnenberg  1:20:10

Yeah, absolutely. And, you know, I don’t ever feel like it’s too late. I really don’t. I don’t, I’ve had too many successful experiences with singers, bringing them through the injury, experience and journey and recovery, whether that involves a surgery or not, but it for me, it’s when people just get continue to push past without that awareness. And that makes me think of how hard it is for singers to go for help to ask for help. You know, it’s a mystery to me. Yeah, it’s such a mystery. It’s why why would you not go get answers? I dream, I dream of a world of a voice world where we all understood those nuances of swelling. And and I dream of a world in academia and in private studios, and in theater in the theatrical world. And in the commercial singing world, where everyone gets education, what is it? How do I know if I’ve done too much? And what does that really mean when I feel like that? Yes, yes. If everybody knew that, and knew how to test for it, we could we could cut some of these things off at the past, you know, and, and I, and that’s how I work with my patients. I don’t let them I say, No, we’re gonna monitor this and we’re gonna test it every single day and you’re gonna write down what that is, and you know what it empowers them to make really good choices.

Dr Marisa Lee Naismith  1:21:53

Thank you so much for listening to this episode of a voice and beyond. I hope you enjoyed it, as now is an important time for you to invest in your own self care, personal growth, and education. Use every day as an opportunity to learn and to grow, so you can show up feeling empowered and ready to live your best life. If you know someone who will also be inspired by this episode, please be sure to copy and paste the link and share it with them. Or share it on social media and use the hashtag a voice and beyond. I promise you I am committed to bringing you more inspiration and conversations just like this one every week. And if you’d like to help me, please rate and review this podcast and cheer me on by clicking the subscribe button on Apple podcast right now. I would also love to know what it is that you most enjoyed about this episode. And what was your biggest takeaway? Please take care and I look forward to your company next time on the next episode of a voice and beyond.