Beyond Competency: The Value And Challenge Of Obtaining Advanced Clinical Skills In Voice

Gaining basic competencies brings a foundation level of knowledge to our practice. However, in voice work, even gaining basic competency prior to a clinician securing their first voice job has always been a challenge, not least because the majority of voice posts start at a point higher than newly qualified level.   The same is even more true for transgender voice roles where there is no clear defined way of obtaining experience post qualification.   It often relies on the input of more experienced clinicians. 

For the last 20 years of my career, my clinical work has included supporting SLTs to obtain knowledge, skills and confidence to practice in voice. This has been based mainly on the amount of queries I received/receive directly from therapists and from recognising the gap between qualification and gaining specialist clinical skills in voice. In highly specialist small fields, it is generally clinicians on the ground, faced with all facets of the work who recognize skill and service gaps first rather than service managers or professional bodies.  This was especially true in trans voice services where specialist trans voice specialists were few on the ground.  

 Trans voice work queries and requests for guidance started in 2001, soon after I was appointed as voice specialist at the Charing Cross Gender Identity Clinic. Apart from NHS clinicians directly trained by myself in post and the associate clinicians who work within my private practice, a large volume of clinicians have now attended the Working with Transgender & Gender Diverse Voice course which has run almost every year in a live format.  It was a course I tried to gain RCSLT quality assurance for (on more than one occasion) but was informed that there was no U.K clinician then who would be able to peer review it for them. I forged ahead, secure in the knowledge of what could help SLTs and ran the first course in 2002.  Necessity with motivation leads to invention and innovation. Often what we really need to get ahead is a reliance on ourselves and our abilities.  In 2020 – that year of 3 national lockdowns, the course did not run live but the online version – level 1 was launched. (It had been in the making for about a year beforehand). For reasons unknown to me, other that it has always felt important to share and assist, system improvements and practical solutions seem to be a constant journey for me.   

Post graduate training courses are essential not only for knowledge and skills training in specialist fields, but at their best, they provide a safe and supportive space for clinicians to share, practice, connect and develop.  At their very best, they are nurturing learning spaces. When I hear accounts of clinicians feeling uncomfortable in professional clinical gatherings, or feeling that the same themes are explored repeatedly or in just mildly altered forms, I am always disappointed – true inspiration and confidence building cannot occur in unsupportive  or unrefreshed environments.   

In transgender and gender diverse voice work, basic competencies and skills include the cultural awareness aspects fundamental for gender identity awareness. This includes knowledge regarding appropriate and non-pathologizing terminology.  These streams of awareness are vital for culturally competent practise in the field but without extended voice skills to accompany cultural awareness, outcomes for clients are likely to remain limited.   Achieving a voice that approaches or falls withing the gender-neutral range is perhaps an outcome that is most easily reached.  This may well be sufficient for the client and in accordance with their own personal goals. However, based on subjective assessments made over the last 20 years, the majority of trans women seeking voice therapy services, are seeking a female perceived voice outcome.  This requires more advanced skills on the part of the clinician and in the vast majority of cases, longer duration of treatment – an issue that will be picked up in a future article.  This may well change over time and similar service user monitoring by other services can only add to our knowledge.

Stepping Up: Launching Working with Transgender and Gender Diverse Voice – Level 2 

On a general level, the lack of opportunity for gaining more advanced clinical skill still remains for the majority of SLTs.  One of the questions I’m asked most frequently by therapists is “How do I progress clients beyond the initial exercises?” It’s a question that cannot be answered in a short form. Apart from all the nuanced aspects of individualised voice work, it involves, at least, a more advanced training with enhanced knowledge and guidance provided in a structured and accessible format. Very often, the SLT is focussed on the types of exercises but recognizing stages of treatment and how to support clients through these is often a missing link.

The Working with Transgender & Gender Diverse Voice- level 2 course will be newly launched on 1st June, 2021; this follows on from the online level 1 courselaunched in December 2020.   For those of you have contacted me about how to gain more advanced clinical skills, I’ve let you know that the next level is coming!! Completing the course has been a challenge at a time when referrals to my practice – both for standard voice and for trans voice have continued to increase.  It was hoped that level 2 online version would be available just after Easter but June 1st launch date has, I think, worked out for the best – it coincides with the start of Pride month so for the 30 days of June 2021, level 1 is available with a 30% discount to all clinicians. Level 2 is available to any clinician who has completed level 1.  Level 1 completers are automatically enrolled on our loyalty discount scheme for future courses but this discount is increased to 30% for the 30 days of June 2021. To redeem a 30% discount off of either course, simply enter the coupon code PRIDE2021 at checkout. Level 2 completers will also be eligible to attend future group supervision sessions.  This will provide an opportunity for case discussion and management.  I am a fan of group supervision for the following reasons: 

  • Supervisees can learn from queries and cases that others bring to the meeting
  • SLTs come together in a supportive environment of targeted learning 
  • It is cost effective for supervisees
  • It is time efficient for the supervisor

As for the previous course, level 2 includes clients discussing their voice goals and challenges as well as video observation of direct therapy. Feedback forms from the live courses over 19 years evidence this aspect as one of the most highly valued by clinicians. As for level 1, presentations have been enhanced and updated. The course also provides: 

  • Key learning points summary
  • Downloadable therapy resources
  • Video observations of therapy with clients.
  • Client audio recordings 
  • Reflective learning guidance questions

The main presentations in the level 2 course are listed below: 

  • Introduction featuring ‘The pitch lift debate’
  • Advancing practitioner skills
  • Lightening the vocal tone
  • Therapy hierarchy & generalisation
  • Language use and non-verbal communication
  • Counselling & navigating through progress barriers
  • Phone and volume therapy
  • Voice feminisation surgeries

One of the most enhanced of the newly updated presentations is the voice feminisation surgery talk. The rapid rise in clients seeking glottoplasty and the lack of specialist knowledge currently within the NHS necessitated this.  It is one example of where specialist SLT knowledge is now concentrated within private practice, an inevitable consequence of voice feminisation surgeries having not being routinely available in the NHS for approximately 10 years.  (In some case corrective voice surgeries have taken place but these are few and far between). The theme of glottoplasty surgery is closely linked to the theme of advanced clinical skills and will be a subject discussed in my series of articles this month.           

My closing lines centre on a comment made to me recently by a supervisee that reflects the revolving circle of training and clinical practice.  The therapist commented on how attending a live Working with Transgender Voice course 12 years ago totally altered her work life practice. She decided on that course that trans voice work was what she wanted to do from that point forward and now successfully works almost exclusively in this field.  It reminded me of the value and potential that structured and focussed training courses can have in changing the lives of therapists and in this case, increase service to minority client populations.   The course had lived up to the intention I set for all my courses: Educate. Encourage. Empower.