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How to Develop a Therapeutic Voice

Lessons for New Clinicians & Their Supervisors

   All artists, whether they are writers, musicians, or actors, must develop a voice, that hard-to-define yet distinctive style which runs like an invisible thread through all their work, opening up a space of creative possibility between their art and audience. How is this done and is it even relevant to us as therapists and supervisors?

   As a supervisor of early-career clinicians, I view this as essential and pivotal, playfully likening it to the process we see on television each week on the show “The Voice.” Just as Alicia Keys, Blake Shelton, Gwen Stefani, and Adam Levine compassionately and thoughtfully mold, mentor, and inspire young talent, so too must we as supervisors help our beginning clinicians. Like them, we do so best by listening to the emerging voice with our eyes closed and our hearts open.

    Each clinician has their own music and style that they come in playing, and supervisors are there to help them draw out their raw talent, experiment with new genres, and ultimately learn about how to make music that is, as Duke Ellington said, “beyond category.” This is therapy that transcends theoretical orientations (genres, if you will), one that becomes a unique blend of the clinician’s theoretical and empirical knowledge, their personality, and their emerging therapeutic repertoire. Through a combination of modeling and sensitively tuning in, supervisors deepen and expand their supervisee’s repertoire of therapeutic skills and enlarge their openness to curiosity, ambiguity, and ‘not-knowing’ in the service of fostering the clinical growth and transformation of their patients.

     While this is a complex and subtle task, I have developed a simple, yet powerful way of encompassing this process and the elements that comprise it. In my view, there is a yin and yang here, that when in proper balance and harmony, lead to a fully developed therapeutic voice. This voice not only serves the therapist, but also promotes the opening and expansion of the patient’s own voice and forms the groundwork for creative therapeutic work.

     The yin of the equation is therapeutic presence, loosely defined as the capacity of the therapist to be receptive, mindfully attentive, emotionally available, nonjudgemental, and resonant with the client’s unfolding experience (see Geller and Greenberg for more). Freud originated this concept in his earliest writings on advice for the practicing psychotherapist, noting the crucial value and importance of “evenly hovering attention.” Considered the foundation for tuning in to the patient’s unconscious, it also provided a potent tool for opening up one’s mind and heart to new possibilities for understanding and engaging one’s patient. Similar to the Zen buddhist notion of ‘beginner’s mind’, therapeutic presence comes from the framework of ‘not knowing’ in the service of creativity. To paraphrase the Nobel prize winning poet Wislawa Symborksa, the point is to say I don’t know and keep going!

     There is much empirical backing for the value of therapeutic presence in building a solid working alliance and in generating positive outcomes in therapy as well its benefits in supporting clients in deepening cognitive and affective exploration, interpersonal risk-taking, insight, and mindful awareness. This process provides not only safety and empathic validation for the patient, but also models for them a newfound openness to their own conflicts and difficulties. This stance also takes away the undue burden of supervisees having to be the ultimate expert, and allows them the flexibility to allow themselves to be immersed in the process and possibility that is vital to good therapeutic work.

     The yang of therapeutic voice is therapeutic authority, which I define as the command of theory and technique and a discriminating awareness of how to put these into practice. Put another way, it is the confidence to properly select, apply, time, and adjust one’s interventions in a multicultural and relationally sensitive manner (by relying on the yin of therapeutic presence, of course!). It is important for supervisors to support beginning clinicians in their developing clinical intuition and instincts, the confident application of their theoretical and empirical knowledge, and a sense for having the ‘authority’ to make therapeutic moves. Just as a singer needs to take risks with trying out moves in expanding their interpretation of a song, so to does the beginning clinician, and as supervisors, we are right behind to encourage and support it!

     Taken together, we have two complementary components, that both support and provide an valuable tension that helps to create the ‘transcendent third’ which is therapeutic voice itself. It is very common for beginning clinicians to have either one or the other component well developed. For example, often times, I have met fantastic supervisees who excel at being empathic, reflective, and thoughtful with their patients, but lack the confidence to make discriminating and thoughtful interpretations that take into account their valuable instincts and intuition regarding new creative possibilities. These supervisees, understandably, worry that if they use too much of their authority, they will overwhelm or possibly hurt their clients. On the other side, there are trainees who are very proficient at being directive, setting goals, and moving quickly towards intervention. While this is greatly beneficial, in of itself, it does not offer enough room for the patient to openly explore and steep in their feelings or draw on the relational process to entertain new possibilities. Happily, these issues are easily redressed with the proper support of a supervisor who can help bring out both of these sides and model for supervisees how they can be balanced and integrated in a unique therapeutic voice.

   A 19th century poem by Frances Cornford sums up this process best. Rather than paraphrase, I’ll include it here:  

       With what attentive courtesy he bent

       Over his instrument;  

       Not as a lordly conqueror who could

       Command both wire and wood, 

       But as a man with a loved woman might

       Inquiring with delight

       What slight essential things she had to say

       Before they started, he and she, to play.

     This is the essence of a tempered and balance therapeutic voice, one that enables new music to emerge within and between therapist and patient, and one that is essential for the supervisee to develop within the open and creative framework of a supervisory apprenticeship.

Michael Alcee, Ph.D. is a clinical psychologist in Tarrytown, NY who specializes in helping supervisees develop their therapeutic voice. As a training coordinator at a college counseling center for 8 years, he has a passion for getting to work with new talent and helping them bring new creative possibilites to their work and to the field. If you would like to know more information about supervision with Dr. Alcee, feel free to contact him at [email protected]

References

Freud, S., & Hutchins, R. M. (1952). The major works of Sigmund Freud. Chicago: William Benton.

Geller, S. M., & Greenberg, L. S. (2012). Therapeutic presence: A mindful approach to effective therapy. Washington, DC: American Psychological Association.

Geller, S. M., Pos, A. W., & Colosimo, K. (2012). Therapeutic presence: A common factor in the provision of effective psychotherapy. Society for Psychotherapy Integration, 47, 6–13.

Geller, S. M., Porges, S.W (2014). Therapeutic presence: Neurophysiological Mechanisms Mediating Feeling Safe in Therapeutic Relationships. Journal of Psychotherapy Integration, 24 (3), 178-192.

Hayes, J., & Vinca, J. (2011). Therapist presence and its relationship to empathy, session, depth, and symptom reduction. Paper presented to the Society for Psychotherapy Research, Bern, Switzerland.

McCollum, E. E., & Gehart, D. R. (2010). Using mindfulness meditation to teach beginning therapists therapeutic presence: A qualitative study. Journal of Marital and Family Therapy, 36, 347–360.

Norcross, J. C. (2011). Psychotherapy relationships that work: Evidence-based responsiveness (2nd edition). New York, NY: Oxford University Press. doi:10.1093/acprof:oso/9780199737208.001.0001

Schore, A. N. (1994). Affect regulation and the origin of the self: The neurobiology of emotional development. Hillsdale, NJ: Erlbaum, Inc.

Szymborska, Wislawa (1998). Poems: New and Collected. New York, NY: Harcourt.  

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