Focus refers to the resonation of the voice in the supraglottic airways. Constriction of the airway at any point will alter the focus of the voice production. The ideal placement of the tone is forward as this placement allows the voice to resonate fully throughout the pharyngeal, nasal, and oral cavities without effort or tension. Tension at any point in the vocal tract will alter the free resonation of the tone and alter voice quality. In addition to changing the quality, less than ideal tone placement may result in a voice that fatigues easily and lacks flexibility and vibrancy.
Poor tone focus may be observed to functionally constrict the pharynx, retract the tongue, and elevate the larynx due to the habitual manner in which the voice is produced. Poor tone focus may also be the result of laryngeal pathologies which, when present, force the patient to constrict the upper airway to accommodate the presence of the pathology. This constriction often leads to what is commonly termed a back-focused tone. The voice qualities associated with several laryngeal pathologies commonly present with a backward tone focus. These pathologies include edema and mass lesions of the vocal folds which require the patient to constrict the glottic and supraglottic structures due to the presence of the increased mass; bowed vocal folds and other incomplete closures caused by laryngeal myasthenia and laryngeal fatigue, paralysis and adductor spasmodic dysphonia which forces the patient to tense the vocal mechanism as a means of pushing the voice through the spasms. As the inappropriate focus becomes habituated, it is common that direct voice therapy approaches must be utilized to reintroduce a more ideal and less tense placement of the tone.
THERAPY
A therapy approach that has been found to be useful for improving tone focus uses nasal sounds and sensory feedback to tune the patient into the nebulous concept of focus:
1. Patient Education. We begin by teaching the patient about the concept of resonation by demonstrating how one sentence may be said with various resonance characteristics. Patients are made aware of how celebrity impersonators change the resonation of the voice to sound like other people. The concept of frontal, back and mid-focus is introduced by first demonstrating a tight, constricted, back-focused phrase which the patient is asked to imitate. Since this type of tone placement is most often implicated as the problem, most patients, though somewhat embarrassed, are able to produce this voice. Second, a breathy, poorly focused tone is imitated followed by an exaggerated, almost nasal forward focus. It is explained to the patient that, while the ultimate goal was not to talk in a nasal quality, that this placement was closest to the desired focus. Practice of this exaggerated forward placement would be one step toward learning the desired placement.
2. Nasalized phrase production. The patient is instructed to slowly and softly chant the following phrases on a comfortable pitch level slightly above the fundamental frequency:
The forward resonation of each phrase is exaggerated to the extreme and the patient is instructed to feel and sense energy of the tone in the nose, on the lips, in the front of the face, and so on. Tape recordings of the phrases are made for both the clinician and the patient and ear training is accomplished as needed.
Once the phrases are produced to the satisfaction of the voice pathologist, negative practice is used. The patient is asked to alternate between forward and back focuses to demonstrate the mastery of the focus technique on the above simple phrases.
3. Introduce intensity and rate variations. Using the same phrases, patients are asked to repeat each phrase multiple times using the following routine:
very slow and very soft
Changing the rate and loudness of the chanted phrases adds a new dimension to the exercise that forces the patient to concentrate on maintaining the forward placement even as the rate and intensity are increased.
4. Introduce inflected phrase and normal speech. When the patient has succeeded in mastering the first three steps, the phrases may be modified from the single pitch chant to a more "sing-song" or inflected vocal presentation and then directly into a normally spokenphrase:
The proper focus of the tone is closely monitored during each one of these steps utilizing the phrases. Negative practice is judicially used throughout each session. Some patients move quickly through each of these steps and master a forward focus with ease. Others require many therapy sessions.