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Working SLPs, ASHA, and... Spiderman?

Writer's picture: Tobias KrollTobias Kroll

A tale of power, disconnect, and the duty to care


A moment of great truth. (c) Sony, 2002 (via TopMovieClips)


Full disclosure: I am not a working SLP. I’m a working professor. I’m an SLP, for sure, but my day-to-day consists of teaching and grading, of reading and writing, of collecting data and analyzing it. Not of managing a caseload of 80 kids or scrambling to reach 110% productivity before lunch.


As a professor, my main obligations are towards my students, my colleagues, and the few patients I see. But I do not serve my narrow circle alone. I also have obligations to the wider profession. Including, first and foremost, the working clinicians who were students once. They were told, by professors like me, that they were in for a meaningful and rewarding career. When I see that promise jeopardized, it is my duty to speak up.


How is the promise jeopardized? Well, it seems that being an SLP, in too many cases, is no longer meaningful or rewarding. (I can’t speak to AuDs’ situation. If you have comments on that, feel free to leave them below.) Patient needs are not met. SLPs cannot meet their clinical responsibilities. Some can't even pay their bills - which can lead to disastrous tragedies.


There is currently an outpouring of anger at ASHA on social media. It began when they announced a dues raise earlier this year. Normally, that kind of thing is met with a low-grade bickering that subsides soon. Not this time. The backlash is ferocious, has only gained strength over the year, and has brought to my attention (and, I assume, to that of many others) an organization called Fix SLP, whose sole purpose is to weaken ASHA’s role in the professions. All of which tells me something is profoundly wrong. Working clinicians are suffering. The promise is no longer true. And ASHA, for all practical purposes the face and the representative organization of the professions, seems to be oblivious to all this at best – or actively dismissive of it at worst.


This post is my attempt at grappling with these issues. I will try to wrap my mind around what is going on, what the data says, what kind of relationship ASHA and working clinicians are enacting – and, crucially, what ASHA’s duties are in this situation. And yes, there will be a Spiderman reference.


 

The issue: suffering ignored


There are quite a few things I like about ASHA. It’s nice to have an organizational umbrella for the professions. Relevant conversations are found in one place, so most of us are at least vaguely familiar with them. There are journals to publish in and conventions to go to. Every now and then, some policies improve somewhere thanks to ASHA’s advocacy. On the rare occasion that the wider world wants to know about speech, language, and hearing, they know whom to approach. The CE Registry is convenient.


There are also quite a few things I dislike about ASHA. It is too wedded to a rigidly narrow view of scholarly inquiry, and of our professional practice. We exist at the intersection of the sciences and the humanities, of physiology and culture. We should be drawing deeply from those rich wells. Instead, ASHA tries to make us forge our own, separate profile as “a science”. The result is rather drab, and lacking in scholarship. (The only source of interdisciplinary thought I can make out is an unreflective progressivism, which is even drabber.)


I guess we all tend to have mixed feelings about the institutions we are beholden to out of necessity or convenience. What didn’t even occur to me, until recently, is that it is possible to view ASHA as a racket. Then I started hearing what actual SLPs on the ground think. And now I’m flustered.


Check out these comments by Preston Lewis, fellow SLP, on Facebook earlier this year (and he gave me permission to use them; highlights are mine). They’re quite representative of about a gazillion of comments I’ve seen since I’ve started paying attention to all this.



There are a few things to unpack here. First, the cost of the CCC (ASHA dues and related costs). Earlier this year, ASHA announced they’d raise dues by $25, to $250 a year. Which would be annoying under normal circumstances. Especially since certification and ASHA membership are quasi-required to get a job. To be sure, legally the Cs are not mandatory to work as an SLP. But thanks to ASHA’s outsized influence in the field, they are so in practice. Rare is the employer who will hire an un-C’d SLP (and nonexistent the academic department that will). For most clinicians, saying “thanks, bye” to ASHA is not an option.


All of which would be fine, I guess, if circumstances were normal - if working clinicians were largely happy and satisfied with their jobs. This is clearly not the case. As hinted at in Preston’s post, they have serious concerns – and when they bring those to ASHA’s attention, they are told it’s not ASHA’s job to deal with those, since ASHA is not a union.


How concerning are SLPs’ issues? For an answer, I encourage you to head over to Fix SLP’s Facebook page. Take some time and peruse the comments. You might be surprised (or dismayed) at the bleakness of the picture. School-based SLPs are overwhelmed with impossible caseloads and outlandish paperwork requirements. Rehab-based and medical SLPs are squeezed by ever-increasing productivity demands and corporate greed. Both constantly have to fight insurance for reimbursement, and both see their patient care deteriorating as it is becoming subordinate to compliance and profitability. Many haven’t seen any pay increases in a long time.


“Sure,” you may argue, “but those are just complaints of individual clinicians. Why should ASHA heed anecdotal data?” Well, what if it’s more than anecdotal? I can speak to the school-based part directly: Phương Liên Palafox and I did a study on exactly that. (We are currently fighting to get it published in LSHSS - they're not liking that we put authentic human emotions in our write-up.) You can read the breakdown here. And yes, it’s pretty bad. It’s not only caseloads and paperwork. SLPs are grinding themselves down advocating, incessantly, for students whose needs are not met, in systems who neither understand nor care about what SLPs do.


“Tragic,” you may reply, “but that’s just a qualitative study with 12 participants. How do we know there are more than a dozen SLPs in trouble like that?” And you’d be correct. Our data says nothing about the prevalence of these issues, and prior research has mixed results - possibly because much of it has been done prior to the 2010s, and things have hit the fan only recently. Which is why we will follow up with a survey soon. In the meantime, I invite you to ponder this 2012 study. It found that about 60% of school-based SLPs find their caseload unmanageable. And I'd wager that's gone up over time.


(On a side note, when we sent out the initial recruitment message asking for overwhelmed clinicians, we got over four hundred (!) replies. That’s over four hundred clinicians willing to take two hours out of their busy day to talk about how they are struggling. Which tells you something.)


What about rehab-based and medical SLPs? That's not my area, so I can't really speak to it, and I don't know if this has been researched - but I do follow healthcare news in general, and the picture is similarly bleak. Physicians report burnout as a result of corporate greed impacting their practice. Half of them say their workload is unmanageable. Nurses decry how unethical business practices are depriving them of their ability to function. And I doubt things are better in the SLP world.


In a nutshell, we have reason to assume the situation is, indeed, dire across the field. And you’d think ASHA would be taking that extremely seriously. After all, it’s not “only” the wellbeing of clinicians that’s at stake (as if that weren’t bad enough). It’s also our reputation as a profession. If this dysfunction is allowed to go on over time, even just in a minority of work contexts, questions about our role ensue. Employers, insurers and legislators might well wonder if we’re needed. “If SLPs can’t do their job and no one cares enough to address that, maybe they’re dispensable”, the reasoning might go.


As ASHA keeps pointing out, they’re a professional association, not a union. The stated purpose of their existence is to advance the professions, not ensure good working conditions for clinicians. Well, as it turns out, those two are not separable. And ASHA isn’t addressing either one. And then they're wondering why clinicians are angry.


To reiterate: legally, ASHA is neither required nor set up to tackle these issues. Legally, the Cs aren't mandatory. The question is, then: are clinicians justified in their anger? Are they being reasonable when they expect ASHA to do something about their plight or else take a hike?


I will spend the remainder of this post arguing that yes, they are. Because of ASHA’s influence in the field, exemplified in the quasi-mandatory nature of the Cs. The relationship between ASHA and SLPs is one of great power on the one hand, and lack thereof on the other. And – here’s the Spiderman reference – with great power comes great responsibility.


 

The root cause: A lack of care


When my then-fiancée (now wife) and I first moved in together, we rented a beautiful old house with two Roman-style columns in the living room and a crossbeam sporting a Latin inscription: ab illo cui multum datur, multum requiritur. Which is a Bible quote that translates to: “Of him to whom much is given, much is required.” It’s one version of an ethical proscription known across many traditions and belief systems. In America, we sometimes call it the “Peter Parker principle,” based on the iconic moment where Uncle Ben tells his superhero nephew: “With great power comes great responsibility.”

My motto, and that of Spiderman.


Mulling on it in the months that we lived there, I found it expressed a vague, inchoate sense of right and wrong that I'd been harboring for years, and which has since become central to my thinking. That's because I work in healthcare, as we all do, and the Peter Parker principle is at the very core of that work. In caring, someone uses their power (in the form of knowledge and skills, time, or resources) for the benefit of another. The he to whom much is given is who we are in our professional lives.


But not only our professional lives. Caring, it turns out, may well be at the heart of what it means to be human. That's the gist of a new-ish and already quite influential ethical philosophy called, unsurprisingly, the ethics of care, which is increasingly informing how we think about clinical practice and sundry other areas of life.


The foundational idea is that ethical action isn't based on some abstract principles (such as virtues, or "the greatest good for the many") but rooted in concrete relationships over time. And the most formative kind of relationship for human beings is that of caring, exemplified by parental care. It's what makes growing up human possible. We are born so vulnerable and helpless that we would not survive without the presence of caregivers who hold and nourish us. Out of this basic, formative relationship come the ethical obligations that shape all other human relationships. And at the heart of it we find, again, the Peter Parker principle. There is virtually no greater power in any human relation than that of a caregiver over a newborn child. And had we not used that power responsibly over thousands of millennia, we would not be here.


(On a side note, these insights are empirically grounded in, among others, the study of child language development. See what all we’re missing out on if we don’t engage with neighboring disciplines?)


If we accept care as formative for all human relationships, it follows that all power differentials entail a duty on part of the more powerful party: the duty to care. More precisely, to use one's power responsibly for the benefit of the less powerful. If that duty isn't fulfilled, if those in power are so disconnected from those who lack it that they don't even care about their suffering, a basic principle of human togetherness is violated. The powerless are then very much in their right to be angry and to demand change - or to work towards taking power away from those who hoard it.


And here's the thing. ASHA is the one ever-present power player in the CSD field. No other entity comes even close to having so much influence. It is no wonder, then, that clinicians expect them to care. According to the ethics of care, that's just the basic ground rules of human society. And no, that doesn't mean clinicians are re-infantilizing themselves, looking for a mommy and daddy to solve their problems. At any stage and in all areas of life, it is entirely reasonable to expect those with great power to assume commensurate responsibility. Even more so when they claim (however implicitly) to represent you, e.g. by touting that they're advocating for you or how member-centric they are.


If those in power don't assume this responsibility, a severe disconnect ensues between them and those who lack power. It's the same disconnect we see between much of America and the "elites" today (where "elites" is just another way of saying "those in power"). It is roiling our nation as we're talking (I'm posting this just two weeks prior to the 2024 election). Not surprising, then, that it should roil our field.


 

Ok, so... what's next?

(c) Brian A Jackson (via iStock)


So what's my takeaway? Should we all join Fix SLP's efforts? I'd be very hesitant to endorse that idea. Remember, their main purpose is to make the Cs truly optional. Which would substantially weaken ASHA. But would it address SLPs' real-life issues? After all, dysfunctional systems, compliance and profitability burdens are all handed down to us by power players who care even less than ASHA: state legislatures, school systems, corporate interests, and so forth. If there is no one left to stand up to them, if there is no entity with enough power to take them on, how will SLPs' situation improve?


"Ok, then," you ask, "if stripping ASHA of its power isn't going to accomplish anything in and by itself, what is?" Well, maybe holding them accountable would do the trick. If ASHA, with all their influence and regulatory might, would take seriously their mandate to care about those they represent, we might see some actual change. But given their reluctance to listen to clinicians, I suspect that would require a downright revolution, one that changes ASHA all the way from the bottom to the top. Good luck with that.


"You're frustrating me," you may reply. "You're not offering any solutions." Indeed. I'm frustrated myself, in fact, as I don't quite see a way forward right now. As uncomfortable as that may be, though, it's one of my powers as an academic think through what's going on without having to rush to a solution. (Because rushing to a solution, too, would be uncaring.)


Speaking of us academics, we are also among those with power. And every now and then, someone complains about professors in those social media spaces where clinicians' anger is voiced. It's easy to see why they'd be upset with us - the system is working quite nicely for us, and we rarely if ever question it. So, here's a call to my fellow academics. Help me think this through, help working on a way forward. Live up to your duty of caring about your students, our future professionals. Voice clinicians' concerns in ASHA's spaces. And, crucially, do research. Investigate clinicians' claims and their work situations. Come up with hard and fast numbers and authentic lived experiences. That's what we can and should do right now: be squeaky wheels, poke and prod and ask questions, and be honest about what we observe.


After all, the whole system of tenure was instituted precisely so that professors have the safety and the freedom to think and speak without needing to heed the powers that be. And that’s what I’m doing here, or at least trying to.


So then, my final recommendation is for ASHA: remember your duties. I don't think you're a racket, as some out there believe - but I do think you've forgotten that you’re here to care. Yes, you're not a union - we get it. But you've amassed the power of one. And with great power comes great responsibility. Live up to the Peter Parker principle, or you may see your power taken away.

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