Speech-language pathology (SLP) has become a well known commodity in the US human service economy. In most urban areas and many rural ones, there are speech-language pathologists serving the population from cradle to grave. Many SLP's are focused upon the needs of children, while scores more are specialists in the needs of adults. The need to communicate stays constant throughout the life span, though the aims of good communication differ with the different demands of human development - cradle to grave. The majority of SLP's are found within educational settings, though a growing number of professionals work within healthcare settings.With wholesale changes being brought to the field- through increasing demands by payors for accountability, and by the tightening of efficiency standards by employers looking to get the best return on investment, there are SLP's who have their clinical practices streamlined to keep the productivity high. When more people are served, that furthers the profession and all those who benefit from our services. More SLP's work as well.
But when quantity of service may jeopardize quality - and anecdotal reports from the field hint at such a degradation of service quality in some work settings - it is worthwhile to consider a service model that holds communication between person served and clinician uppermost; where the person served directs the care but is accountable for the outcomes achieved; where meeting the person's needs includes treating problems at the level of participation (involvement in life situations), instead of predominantly at the level of impairment (breakdown of bodily functions);and where the SLP uses all the tools available to her/him in the worksite. This participation-based approach to practicing clinical SLP we will call "organic SLP", to contrast it with impairment-based approaches to SLP that might be called "mechanistic SLP". Why is there a need for this approach to clinical treatment of communication problems?
* Mechanistic SLP makes us the 'question lady'. SLP is often known simply as answering questions from drill books, where human communication is a dynamic and versatile skill set that one does in all conditions. There is a need for skill development where persons served will use them, as early as possible. The person served should be a partner in all interventions whenever she/he has the capacity to do so, giving feedback often on the effectiveness of intervention. Communication thus becomes the game, the transaction that is demanded by real life - not the rigid stimulus-response routine of drill settings.
* Mechanistic SLP makes us too much like physical and occupational therapy. In a multidisciplinary treatment setting, most persons served identify mobility and self-care needs as the reason they are in "therapy". SLP may follow treatment sessions of the other professionals, at which time the person served may say "I'm tired from therapy!" or "I talk just fine" or "Are you going to ask me questions?". Organic SLP approaches establish a positive, affirming relationship with the person served, so that treatment time is not solely a number of repetitions completed, or a % age of trials attempted. It is building a therapeutic relationship based on cooperation, built throughout the person's day and for which the SLP will provide high levels of customer service.
* Mechanistic SLP forces us to train persons to change behaviors at the component skill level - it is not real life. Clinicians who follow the evaluation with a roster of component skill exercises (e.g. sentence completions to improve formulation of thoughts; contrastive word pronunciations to improve speech clarity) - and that is all there is - face a person served who does not know how to turn success at drill, to success in real life where that skill is desired. There need be, from the time of evaluation, time given in each session to map the person's success at use of a component behavior - onto the real life setting where the behavior will be ultimately used.
*Mechanistic SLP does rely upon the latest advances in applied behavioral science, to help persons with communication (and swallowing) disorders keep the highest quality of life. Regardless of the high degree of reliability and validity for many of these treatments. SLP clinicians must finally keep it simple when it comes to training the person served towards independence. The component skills should be stepping stones over which the person served will move, to get to a level of competence with real life. The person served should hear from the SLP, something to the effect: "You're trying to get rid of me, so you can do this on your own. We will both know when that day has come. Until that day comes come, we will review often what we are doing and why. I will need your input about what we are doing, so that we can both be confident we have achieved YOUR goal". That is the mission of a practitioner of organic SLP.
What else can we ask of clinical SLP's, such as those who work with adults, that allow the persons served to touch real life in their training?The next post will provide some answers.
