Paralinguistic Communication in the Therapeutic Relationship

Archives of Psychiatry and Psychotherapy, 2012; 1 : 49–54

Paralinguistic communication in the therapeutic relationship

Wiesław Sikorski

Summary The author, on the basis of literature and his professional therapeutic experience, describes the meaning of vocal signals in diagnosing patients’ problems and improving communication during a therapeutic dialogue. In the article the author also shows the influence of voice vocal features on evoking many nonspecific therapeutic factors as well as accelerating the insight and overworking process. The great importance of metasignals, i.e. information concerning emotions hidden in patient’s utterance has been no- ticed. A therapist is able to recognize them by careful listening to all vocal signals, particularly to: speech rhythm, voice height and verbal intensifiers. The author indicates that vocal signals themselves may often influence the content of transmission and give a lot of reliable information about patients. Patients’ reactions on a therapist’s behaviour are high- ly influenced by the reception and evaluation of his/her vocal signals. Therefore, a therapist should more thoroughly analyse voice features present at a therapeutic interaction and become their conscious sender and recipient.

voice signals / therapeutic relation

INTRODUCTION el; the way in which the words can be uttered, acts on these two planes. Therefore, the paralin- Paralinguistic communication – also called guistic messages may provide additional infor- paraverbal or proto-language communication mation about how much the extra-verbal mes- – includes vocal, but extra-verbal aspects of sage is honest, and to what extent it is distort- communication properties, such as voice pow- ed. The therapist, when interpreting parallel fea- er (volume), the rate of speaking, variations, er- tures of voice, accompanying the speech content rors and other distortions of speech fluency, set- of a patient, with his „body language”, can better ting or level of voice, and its quality. „Paralan- predict the consistency or its lack in the simul- guage”, which is not fully a verbal or extra-ver- taneously transmitted content, in both – verbal bal message, at the same time, tries to „register” and non-verbal channels. It can also determine communication on various levels, and therefore which of these two channels is currently leading, seems to complement well the signals at the sub- and thus which is the one, you can rely on more. ject (verbal) and the emotional (non-verbal) lev- Since, for example, when a patient in his uttered words, more strongly emphasizes the issues that Wiesław Sikorski: Institute of Pedagogical Sciences, Depart- are important for him, he manifests a high atten- ment of Social Communication, Opole University, 48 Oleska Str., 45-052 Opole, Poland. Correspondence address: Wiesław Sikor- tion to the tone of voice, its volume, speed and ski, Institute of Pedagogical Sciences, Department of Social Com- clarity of speech, then it must be assumed that munication, Opole University, 48 Oleska Str., 45-052 Opole, Poland. the information transferred by the subject plane E-mail: [email protected] (content) are quite reliable. In a situation, how- This article has not been aided by any grant. ever, when the verbal utterance is dominated by 50 Wiesław Sikorski different non-language sounds (without verbal know, or at the beginning of a psychothera- content), such as sighs, groans, munching and peutic session); grunting, it is more reliable connected in terms – non-verbally (for instance, when the sentence: of communication that the signals may be sent at „You have lost your mind” is accompanied by an emotional (relational) plane. In the first case, vocal signals in the form of a friendly smile or the patient is focusing heavily on the fact that his a humorous tone [2]. words were the most expressive; somehow he is not able to a similar extent to take care of his Meta-communication contained in vocal sig- „body language”. In the second case, however, nals is the main subject of analyses and discus- the occurring sounds which characterize some sions included in this paper. difficulty in expressing something in words, ac- tivate other media channels, including the ones which cover the relational plane (facial expres- META-COMMUNICATION AND THE PROCESS OF sions, gestures, posture) most [1]. THERAPY

The following two hidden layers of meaning META-COMMUNICATION IN PSYCHOTHERAPY can be found in the messages formulated by the therapist and patient: it is the transfer of specif- The starting point for the discussion about the ic words, and the second - meta-communication importance of diagnostic and vocal communica- - which is a message referring to emotions. Ac- tion signals must be undoubtedly the reference cording to P. Watzlawick, J.H. Weakland and R. to the studies of a famous group of researchers Fish [3] the therapeutic interactions without me- and therapists of Palo Alto. The people gath- ta-communication would create a chain of mu- ered in it, of a stature as P. Watzlawick, G. Bate- tual misunderstandings and conflicts. Any com- son and V. Satir, were one of the first to recog- ments, any discussion of the contentious state nize that the decisive role in the reading of the of affairs, any additional question about wheth- communicated content by a patient plays „me- er the words that had been heard were under- ta-communication framework”. According to stood correctly, comprise meta-communication. this assumption, the framework contains guid- The ability to invoke meta-communication in a ance on how the message can be interpreted. A situation of overt conflicts and disturbances of therapist is provided with clues, that allow him relations with patients belongs to the profession- systematize his perception and understand the al competence of the therapists. It is the base of meaning of words spoken by the patient. These all successful compromise. researchers have taken the trouble to determine Meta-announcements can cause difficulties at how these frames are clearly communicated. It any stage of therapy, starting from conclusion of was obvious that this must occur in some form a therapeutic contract, through the use of certain of „meta-communication.” In other words, they procedures (e.g., therapeutic interventions) and assumed that any information at the same time ending with the completion of therapy. Some- includes tips on how to understand it. In the times a seemingly clear and logical statement case of communication in the therapeutic rela- with a positive tinge, can, through an improper tionship (and also interpersonal) it suggests that meta-announcement, express a negative attitude. such clues can be expressed: For example, if a therapist at the time of the conclusion of the „therapeutic contract” first utters – verbally (for example, by saying the sentence: the sentence, „I’m going to help you”, and then „I think you are crazy, but this is obviously s/he adds the verbal modifier „only”, at the same just a joke”); time stressing and uttering it with rising into- – contexts (for example the question: „How are nation, then an entirely different message aris- you?” may be understood differently if by the es. Now the words „I’m only going to help you” application of the same non-verbal means the take the form of a signal expressing an attack expression is uttered during a chance encoun- or a defensive attitude or a grudge. Moreover, ter in the street when meeting somebody you the use of such meta-announcements – especial-

Archives of Psychiatry and Psychotherapy, 2012; 1: 49–54 Paralinguistic communication in the therapeutic relationship 51 ly demonstrating disapproval and anger – is not Pause and silence easy to neutralize. If the addressee of the meta- announcements formulated this way is a patient, According to the first pragmatic axiom of then the defence harmful, negative content, in- communication P. Watzlawick [4], which states cluded in them, can be even more difficult. An that „it is impossible not to communicate”, even additional problem is the fact that on the one short interruptions and moments of silence also hand the creation of such meta-announcements may communicate something. Many junior re- easily gets out of control, and on the other, the searchers of psychotherapy are so much afraid attack that is hidden in them is usually so subtle of silence that they begin to speak before they that often the sender (here: the therapist) is not can understand why the patient remains silent. aware of the harm caused to the recipient (here: Meanwhile, the cause of this silence may be that: the patient). Similarly, the addressee (here: the a) the patient is thinking intensely, b) s/he expe- patient) may often be unaware of this, how s/ riences strong emotions, c) s/he does not want he has been hurt. For example: a patient admits to talk or talk about what s/he is thinking, d) is that s/he often changes his/her therapists which concerned about the reaction of the therapist, e) are commented by the current clinician as fol- the patient is trying to get a grip, f) s/he is not lows: „Presumably, I’m not your last therapist”. able to choose the right words, g) s/he is con- The modifier „presumably” and the accent on cerned that the conversation will be overheard, the word „last” make that the message means: h) s/he is wondering whether to reveal what was „You are a psychotherapy addict” or „You lack up to that moment carefully hidden, kept in se- motivation to overcome the problems,” or even cret, etc. [5]. „The complaints are so serious that no therapist is able to help you”. A therapist, in formulating such a statement with good intentions, in order Voice characteristics and mental disorder to encourage the patient to work intensively on him/herself, obtained the opposite effect. As a A strong connection between the character- consequence, to the end of the session, the pa- istics of voice and certain psychopathological tient may feel discomfort and anxiety, yet having states has been documented. For example, de- no idea how it came to the deterioration of his pression is accompanied by speaking in a slow frame of mind. Consequently, this may trigger a and long manner, full of pauses; schizophre- „resistance” in therapy, and even pose a risk of nia, however, is characterized by flat and mo- its premature failure („drop-out”). notonous voice. The voice of patients suffering For this reason, every therapist should make from these symptoms usually sounds very sad, an effort to learn the skills of control over their especially when faced with the necessity to re- own meta-announcements and to cope with neg- fer events from their own past, both kinder and ative meta-announcements created by patients depressing, or overwhelming. In addition, pa- and by those people who are „implicated” in tients with depression and schizophrenia show therapy (e.g. family members). According to P. a noticeable lack of ability to express emotions Watzlawick [4] taking into account the fact that in their tone of voice. This applies, in particu- communication is an aspect of content, and the lar, to the former: because it is much more diffi- aspect of the relationship (the second out of the cult to recognize the emotional tinge in paralan- five axioms of pragmatic communication) can guage communications emitted by patients with be very helpful in this respect. The interpreta- depression [6] you can see, therefore, that the tion of what was essentially told by the patient, acoustic characteristics of voice can be a source in a decisive extent, depends on how it was said. of discrete monitoring of the patient. However, I would like to add here that the ability to read Ellgring and Scherer [7], Ostwald [8], Heaton [5] correctly the meta-announcements contained and many others, basing their assumptions on in the paralanguage is to increase awareness of the measuring procedures of the vocal proper- how they are constructed, while paying more at- ties, gathered a reliable material to confirm the tention to rhythm and pitch of voice. fact that the voice characteristics significantly af-

Archives of Psychiatry and Psychotherapy, 2012; 1 : 49–54 52 Wiesław Sikorski fect the formation and development of a thera- vocal emotional states, but on the other hand, peutic relationship. their purpose may also be to communicate attitudes towards certain people. In addition, you need to be aware that emotions are communi- Communication of emotions cated sporadically through a single trait of voice. Therefore, in order the therapist was able to as- The need for knowledge of the principles sess what kind of emotions are communicated guiding the proper use of the paralinguistic el- by a patient with the application of the „paralan- ements also arises from the fact that they are an guage”, s/he must perform a combined interpre- important means of communicating emotions. tation of as many parameters of his/her voice as Already in young children it manifests itself possible. Otherwise, it may turn out that there through whistling, screaming or babbling; be- is a large discrepancy between what is actually ing at this early stage of pre-verbal development, communicated by the patient paraverbally, and they can thus communicate their emotions. Lat- how it is perceived by the therapist. Similar dif- er, over the years, in the juvenile and adult life, ferences can occur when paraverbal signals ex- it serves the manner in which we pronounce press emotions much related to each other such words. J.R. Davitz [9] showed that, based on vo- as „jealousy” and „pride” or „satisfaction” and cal signals, we can accurately identify emotional „joy”, which in turn makes it difficult to clearly states such as anger, frustration, sadness, happi- determine which are the ones that are actually ness, sympathy, satisfaction, fear and love, jeal- communicated paralinguistically. It must not be ousy and pride. The provided sequence shows at forgotten that there are large individual differ- the same time, which of these states are the eas- ences in the ability to encode and recognize emo- iest to read (the first four items), which are a bit tions expressed with „paralanguage”. The ther- harder (the next two items), and those that may apist must strive to be able to accurately identi- cause the most problems (the last four items). fy the emotions expressed by the patient vocal- The research by M. Argyle [1], J. Burgoon ly, and also that s/he could become an effective [10] and many others, seem to positively verify communicator who can use „paralanguage” to the popularly-sounding thesis that the voice is express his/her own emotions. With this ability, „more leaky” than the face. This should be un- it will be much easier for him/her to create the derstood that the true emotions, the most deep- right atmosphere during therapeutic meetings, ly hidden, can be explored by „paralanguage”. interactions with patients. For example, people with depressive tendencies, or the ones who already suffer from depression, usually speak slowly, with low and declining Non-specific therapeutic factors tone of voice. Talking fast, rough, with excited and breathy tone of voice, with plenty of slips Paralinguistic signals may become an impor- of the tongue, in turn is a „paralanguage” that tant element actuating „nonspecific therapeu- is characteristic for frightened people, who are tic factors”; positive expectations and hope for afraid of some people or situations. But the ten- achieving effective assistance [12]. Paraverbal dency for frequent use of independent vocal ex- messages characterizing the competence of the pressions („gap fillers”) such as „uu”, „ahh” or clinician can significantly increase the patient’s „uuh” is seen as a sign of irritability and nerv- confidence in the effectiveness of the therapist’s ousness. The indicator of emotional state can treatments. The vocal signals, aptly chosen, ad- also be the „speech range”: for instance, the lack equately to the information transferred by a ver- of harmonization of voice might suggest anger, bal and nonverbal channel (facial expressions, and purity of tone contentment [11]. gestures or proxemics), can make that the faith It is noticeable, therefore, that messages can of the patient in the therapist and his „heal- be used at simultaneous paraverbal communi- ing” process will strengthen. The therapist who cation of emotions and attitudes towards a per- speaks with the standard, general and literary son or situation. For example, anger and con- (metaphoric) dialect at the time of informing the tentment can on the one hand be transmitted by patient about the cause and type of the disorder

Archives of Psychiatry and Psychotherapy, 2012; 1: 49–54 Paralinguistic communication in the therapeutic relationship 53 and, most importantly, that it is something quite guistic elements when communicating with the common and that it can be „cured”, may con- patient. What is important here is the aware- siderably increase the credibility of his message. ness that the voice plays a substantial role in Similarly, getting the patient familiarized with strengthening, creating a proper ambience dur- the therapeutic techniques and procedures that ing the course of therapy. The clinicians, who are to be used may be more convincing if the cli- do not know or ignore the rules related to the nician will do it with the proper setting of his/ „paralanguage”, may lead to an unequal distri- her voice and at appropriate volume [13]. bution into a dominant (omniscient, overly di- Paraverbal signals may also contribute to rective) therapist and a submissive and obedi- strengthening of the ritual actions of the thera- ent patient. Unnecessarily, hypercorrectly em- pist, detailed steps the aim of which is to restore phasizing uttered words, intensively chanting health. The clinician, using, e.g. modelling tech- some sentences, speaking too fast and too loud niques, such as the dual therapy (individual), can make the patient feel dominated. Numer- thus providing the patient with role models, will ous experiments seem to indicate that the voice become more credible when some content will is more important than the face in formulating be respectively distinguished (stressed) [14]. judgements about the domination of a particular No less important in the process of model- person; the face in turn is more important than ling the behaviour of the patient is the therapist’s vocal signals in forming of judgements about prestige, s/he becomes a kind of authority for the likeability [17, 18]. patient, since only then the strategies for optimal overcoming of the difficulties presented by the clinician will win plaudits of the patient; simply CONCLUSIONS with more desire and motivation s/he will pro- ceed to imitate patterns of behaviour suggested Communication is an interactive process, and by the therapist, perceived as an important and thus consists of a continuous exchange of infor- competent person. Certainly, it will not happen mation between the therapist and the patient; – at least at a greater extent it is possible – when it imposes a need for proper use of the „para- the therapist will not speak smoothly, will use language” by the clinician. Because also the pa- frequent pauses, unwarranted changes in forma- tient may negatively perceive the therapist as s/ tion of sentences, repetition of words, or stam- he is abusing the paralinguistic messages which mering and stuttering, not finishing sentences, mark the lack of credibility in communication. slips of the tongue occurring frequently, butting Certainly, the clinician who can properly intone in chaotic sounds in a kind of smacking with the important content, who can provide the pa- the lips, grunting and sighing. This can not only tient with most rapid health feedback (without greatly hinder or even completely prevent the pausing for too long), who speaks smoothly, en- process of modelling of the desired behaviour suring appropriate diversity of volume and clear patterns, but also can introduce „chaos” in the speaking, and who can speak at a relatively fast therapeutic relationship. It is a proven fact that pace, will be perceived as a much more compe- from the perceptual perspective, the lack of li- tent than a therapist who presents too monoto- quidity in the consciousness of the recipient is nous vocal signals. strongly identified with high levels of anxiety Undoubtedly, the importance of vocal sig- and fear [15, 16]. nals in the therapeutic relationship is multilat- eral: they both aimed at controlling the course of therapy, and diagnosing the patient, as well Control over the „paralanguage” as strengthening and developing the therapeutic relationship. That last statement about the dreadogenic impact of the lack of liquidity during speaking re- REFERENCES quires to some extent therapists to control their „paralanguage”; to comply with the rules re- 1. Argyle M. Psychologia stosunków międzyludzkich. Warszawa: garding the correct application of the paralin- PWN; 1999.

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Archives of Psychiatry and Psychotherapy, 2012; 1: 49–54