Specialisms in Clinical Voice Disorders & Singing Voice Rehabilitation.
Carrie Garrett is a passionate and highly skilled practitioner working in the field of vocal health, vocal rehabilitation and singing. She has over two decades experience as a professional singer and singing teacher, adding to her skillset when she became a certified Speech & Language Therapist.
She is now a Highly Specialist SLT (Voice) working for Herefordshire and Worcestershire Health and Care NHS Trust, with skills in numerous diagnostic and therapeutic interventions related to her specialist field.
Tell us about your current job role?
In my NHS role, I work across Worcestershire serving a community caseload of adult patients experiencing difficulties with speech, voice or swallowing.
What does a Speech & Language Therapist (SLT) do?
There are many different types of SLT roles in healthcare, just as there are many types of ‘teaching’ roles in education. My job is different every day! SLTs work to support a multitude of patients with a wide variety of needs. As a community therapist, my voice patients may include professional voice users, transgender clients, and post-surgical patients alongside patients experiencing progressive neurological problems (eg. Multiple Sclerosis, Motor Neurone Disease, and Parkinson’s Disease), all of which can result in changes to speech and swallowing also. I work on community hospital wards, nursing homes, in private homes and in out-patient clinics across North Worcestershire.
Because I am Voice Lead within my service, my job role involves managing the training and the voice caseload that comes in and ensuring the quality of care for patients in that field is as good as it can be across our whole speech and language therapy team.
We work closely with the acute teams in hospitals, with voice clinics and we get referrals from ENT, GPs and from other consultants when their patients leave the acute setting. The community SLT role is more long-term and focused on rehabilitation in order to help patients achieve their goals and reach their “new normal”, maintaining and achieving what they are best able to, taking into consideration their condition.
What does a typical day look like for you ?
Within the NHS, it would involve quite a bit of admin, looking at case-loads, following up on referrals into and out of the service, with GP’s, Consultants (such as ENT), other allied health professionals (eg: Physiotherapy, Occupational therapy, Specialist Nursing teams) and, of course, working with patients.
Pre-Covid I had outpatient clinics on certain days and due to my voice specialism I might work with transgender patients who are transitioning, usually male to female or I could be working with patients having difficulty with their voice and speech because of progressive neurological conditions such as Parkinsons. I also work with people who have been referred to us with various pathologies such as nodules, or may be rehabilitating after being intubated, or working on their voice post-stroke or post-cancer.
Post-Covid we have seen quite a few people who are suffering with “Long Covid”. This has manifested as respiratory and fatigue-related problems impacting people’s voices, alongside a multitude of other symptoms including difficulty thinking (cognitive changes), changes to speech and fluency, and mental health and mood changes.
During the pandemic our service has been focused on trying to manage and support our patients in the community with swallowing problems so that they don’t develop pneumonia or chest infections, aiming to reduce the number of hospitalisations. We’ve also been supporting the early discharges from hospitals. These have occurred as a result of acute hospitals trying to clear beds quickly to prevent unnecessary infections and also in preparation for patients experiencing the ill-effects of Covid.
When did you decide this was the career for you and why?
I started off as a singer and singing teacher and I then moved into teaching and lecturing in a college, which I loved. I also taught private singing students and led various choirs alongside teaching for youth theatre organisations such as Stagecoach and at universities. This covered the first 10 years of my career after university and throughout this period, whenever singers had problems with their voice, I was frustrated that I didn’t really understand what was going wrong and how best to help them.
This led to me taking a Vocal Process course led by Gillyanne Kayes and Jeremy Fisher - which is where Ruth and I met for the first time - and here I learnt all about the anatomy and physiology of the voice. I found it fascinating and, looking back, it was life changing. It made me want to find out more and it became apparent that Speech and Language therapy was the clinical way to get into voice therapy and rehabilitation.
At the time, undergraduate degrees in Speech and Language therapy were fully funded, so I didn’t have to pay to go back to Uni. So I took a step back from full-time work and moved to part time teaching and singing alongside studying to be a Speech and Language therapist. I did a 3 year Speech and Language Undergraduate degree. When I came out I was so lucky to get a job in what I consider to be one of the best voice departments in the country - it was then known as University Hospital South Manchester, now known as Manchester University Foundation Trust. Here I gained lots of clinical experience, had lots of opportunities and great mentoring. Up until the pandemic I was still visiting there once a month to carry out my role as a vocal rehabilitation coach to performers, funded by BAPAM (British Association for Performing Arts Medicine).
What is your favourite aspect of your job?
Helping people. Being able to be part of someone’s journey towards achieving their goals; whether it’s voice, general communication or swallowing, is my favourite aspect of the job. Also I love using my skills and knowledge to solve problems. It’s like detective work. You aim to unpick why something is happening and then you are trying to offer people solutions and potential ways of getting through that, making things better and helping them to achieve their goals.
What is the hardest part of this career?
There are so many aspects to Speech and Language Therapy. The hardest part of my current role, yet most exciting part at the same time, is that any health condition or problem could be referred to our service. We could get referrals for any condition at all and you have to know how to deal with it. It is vital to be able to self-manage and to understand your professional boundaries which are based on your own experience and knowledge. It is also important to know when to refer on to someone with different experience and knowledge if that is in the best interest of the patient.
In your previous job role as an SLT in the Performer’s Clinic at Manchester University Foundation Trust (Wythenshawe) working with injured singers and professional voice users, what were the most common issues you would come across when seeing these patients?
Often something has changed in their life and it has had an effect on their voice. It might be that something stressful has happened like a job change, divorce, new baby, house move, increase in workload, a cold or illness, pregnancy; or it could be that they have had surgery for something else unrelated and it has had a knock-on effect on the body. Sometimes when things happen with the voice it can often be as a result of a psychological or physiological knock-back which has sent things out of balance and voice problems have resulted. Inevitably, we would often get people with muscle tension difficulties.
So in the diagnostic clinic you would go about unpicking possible causes to find out why and how things have gone out of balance for this particular performer?
Yes. Typically we would take into consideration any recent changes from the norm, for example have repertoire, style/genre, or vocal demand (skill level) changed?
Have costumes or staging changed?
Do they have to dance AND sing?
Are they warming up? Are they cooling down? Do they have time for vocal rest and recuperation?
Have they started taking supplements recently?
What have they been eating? Could they be experiencing symptoms of reflux or allergies?
Are they sleeping ok?
Are they having to use their voice differently in their non-performing life?
These are some areas typically looked at when assessing a patient and discussing vocal management for improvement with them.
How would I know if I had a voice problem? What are the key symptoms?
Key voice symptoms are anything where you don’t feel your voice is normal. It might feel tired and strained. It might be a little more raspy, breathy or tight pressed. It might be that you are missing a chunk of notes from the middle of your range, or it may crack as you are trying to speak or sing. You might have lost the top end of your range or find that the movement through the ‘passaggio’ has become tricker.
Professional singers and people who sing regularly tend to know quite quickly when they’ve got something wrong. Whereas normally they are able to work their way through a vocal problem, If they are not able to do that with their usual exercises and voice care routines and if the problem has lasted for two weeks or more, it’s worth being checked out properly by an Ear, Nose and Throat doctor (ENT or Laryngologist). Only when we have seen the vocal tract and vocal folds can we begin to know what may be causing the voice problem. Nobody can ‘guess’ what has caused a voice problem. We can hypothesise, but until we’ve seen what’s going on it is unwise to begin a course of treatment in case of causing further damage or simply wasting time and money heading off down an incorrect ‘rehabilitation’ route.
Could you outline some methods used to rehabilitate these conditions or injuries?
We use many different methods for vocal rehabilitation. The foundations of all voice work are in vocal health, release of tension, improving respiratory support for the specific vocal tasks of the individual, improving resonance, articulatory and projection techniques. Techniques I use time and again include exercises based upon the Accent Method, a wide variety of semi-occluded vocal tract techniques, stretches, physical manipulation, vocal function exercises, flow and resonance techniques, vocal hygiene advice and talking therapies. Management is always completely specific to the individual.
There have been numerous cases of famous pop singers having to cancel tours due to vocal injuries in the last 10 years. Do you think vocal injuries are becoming more common in contemporary style singers? If so, why might this be?
It’s unclear but generally there are two trains of thought. One is that vocal injuries are not more common but people are reporting them more. The other is that vocal demands from ever-increasingly demanding (and athletic!) repertoire along with busy schedules with not enough downtime, have increased incidence of vocal problems. Artists (speaking pre-pandemic) are touring more, networking more and have very different schedules to what many earlier artists and performers experienced, especially pop singers. There are possibly more radio and TV interviews along with all the flying and lifestyle changes associated with a hectic schedule.
What I have personally found to be more common is problems arising for some singers when they work across styles/genres. For example, I have found some classically trained singers moving into musical theatre or teaching students who wish to use a more contemporary sound can experience tension issues. We cannot isolate this increase in tension to style/genre changes alone, as human beings are not one-dimensional and every voice problem tends to result from multifactorial issues.
Though this might be controversial, I wonder if singing teachers and singers should acknowledge and appreciate their individual skills and stick to their strengths? The voice is an instrument where it is possible to mimic, beat box, scream, and of course explore different styles …but why do we currently strive to do everything? Why not stick to what we do well, appreciate the joy of the social and musical aspects of making music and enjoy having our own individual style? It’s ok to not be good at everything. It’s ok to be average and to do things for enjoyment and socialisation. At risk of being ‘Jack of all trades master of none’ is how my old music teacher put it to me when I was trying to do all the instrumental ensembles under the sun in my teens, and experiencing a near nervous breakdown trying to keep up with it all! Going back to the voice - The vocal set-up across styles is different and as music evolves the differences between styles/genres may be further increased.
How can you maintain a healthy voice?
Exercise voice little and often - don’t over-use or misuse it.
Manage your reflux and allergies or anything else that may cause inflammation or irritation to the vocal folds and vocal tract.
Manage your breathing and postural support.
Stay as fit and healthy as you are able to.
Learn to manage stress and anxiety and keep it in check.
Can stress affect the voice?
Yes in a number of ways. Predominantly because of reflux or physical tension patterns which are unhelpful for voice production.
If I have any vocal concerns what should I do?
Talk to a singing teacher or visit your GP if your issues have lasted at least 2 weeks. It may be an acute issue which might be illness-related or if it is something more, the GP can refer you to an ENT or voice clinic to have a look and to get you checked out thoroughly. This will ultimately save you time, money and most importantly stress because worrying about the voice problem also contributes to the voice problem.
If I was interested in pursuing a career as an SLT or VRC, what would the training involve and how long would it take?
This would depend on your specific interests. Vocal Rehabilitation is an evolving field and there are many training courses available to voice teachers to enable you to provide up-to-date advice and guidance to help you work with and support your singers. The British Voice Association is the key organisation to be involved with if you have an interest in developing these skills.
Speech and Language Therapy involves an Undergraduate or Masters degree course which is clinical. It is worth noting that the majority of Speech and Language Therapy is not actually voice-oriented. But if Speech, Language, Communication and Swallowing are areas you are particularly interested in developing clinical knowledge and skills in, then this is the route to take.
Finally if you could give one tip to professional voice users or aspiring performers, what would it be?
Sounds daft but you can’t go wrong with treating your voice as if it is a pet: feed it, water it and give it exercise. Also… LOVE IT - allow it and rest and recuperation when necessary and allow it opportunity to express!
Your voice will be variable throughout your life and lots of things will impact it but it’s about developing resilience by looking after your voice well and appreciating that it won’t always be perfect - but it will be the best it can be with care and attention.
NB: Due to Carrie’s busy NHS schedule, The Singer’s Clinic is not currently in operation but Carrie is happy to give advice and point you in the right direction with regards to any voice-related issues should you wish to get in touch. Please email email@example.com.