What Would Mrs. Doasyouwouldbedoneby Think of Speech Therapists in America?
Judith Duchan, Professor, State University of New York at Buffalo
March 25, 2000
(Article published in Royal College Speech Language Therapy Bulletin, London, UK, May, 2000)
Everywhere you look now and throughout history, you will find people evoking The Golden Rule as a guide for how to think and behave toward one another. The American version is phrased: Do unto others as you would have others do unto you. The British rendering is associated with the book character Mrs. Doasyouwouldbedoneby who has lived in the minds of hearts of all those children who have grown up on Charles Kingsley's story of The Water Babies.
Amazingly, given its omnipresence, the Golden Rule is not emphasized in the professional practices of speech therapists (known as speech-language pathologists) in the United States. There is, for example, neither a tacit or explicit expression of the Golden Rule in the statement ethical practices of the American Speech-Language-and Hearing Association . ASHA's Code of Ethics does say that "Individuals shall honor their responsibility to hold paramount the welfare of persons they serve professionally." This statement, as such, does not require the professionals to take the point of view of the client. They are permitted to treat their clients in ways that they themselves might not want to be treated so long as they think that it will promote their clients' welfare. ASHA's ethical statement is presented as given, as something to live by. There is no overarching way to help professionals make judgments about their particular actions. There is no check on whether their idea of client welfare is consistent with the client's own ideas.
But, you might be asking, what are Speech-Language Therapists in America doing that would fail the Golden Rule Test? Here are six examples of practices that clinicians might not want to have done unto them.
- When writing clinical reports, clinicians can be excessively negative and judgmental, focusing on what clients can't do rather than casting their difficulties in the context of competencies (Duchan, 1999a).
- Clinical reports leave out any depiction of the experience or voice of the person with the disability. Rather, the person is described in terms of deficits as indicated by scores, behaviors, and performance levels (Middleton, G., Pannbacker, M., Vekovius, G., Sanders, K., Puett, V. (1992).
- Clinicians are usually the ones to decide on therapy goals with little input from clients or family members about their needs or desires. This process may lead clinicians to miss opportunities to work on life-related goals of their clients (LPAA Project Group, 2000)
- When carrying out therapy, clinicians tend to select activities that emphasize their clients' problems and then focus too much on the accuracy of their clients' speech productions rather than their meanings and intents (Kagan & Gailey.1993).
- Clinicians who do focus on intended meaning tend to define intents in utilitarian terms (as ordering food in a restaurant, or requesting objects) rather than as life-fulfilling terms (being regarded as competent, becoming a valued member of a social group) (Kovarsky, Duchan, & Maxwell, 1999).
- When evaluating the effects of therapy, American clinicians tend to use methods that objectify performance rather than more client-centered approaches that tap their client's opinions about how the therapy meshes with their personal goals (Frattali, 1998).
What may have led those in the field of Speech-Language Therapy in America to disregard their cultural training in The Golden Rule? Why would they fail to abide by a principle that is so basic, so universal? There must be other, stronger pressures on professionals that would allow them to ignore their upbringing. Here are three possibilities:
1. The influence of the medical model in which the professional :
- focuses on the patient's problem, rather than the patient
- treats the patient's problem as a symptom of a disease or
- provides remedies to fix the problem
These elements inherited from the medical model can lead clinicians away from thinking of clients as people. The relationship between clinician and client is similar to that between a carpenter and a house. A carpenter fixes the broken window-- the clinician fixes the communication breakdown.
2. The myth of scientific objectivity
- the client's communication problem is defined in terms of measurable behaviors
- objective measures are used to determine whether the behaviors are significant departures from norms
- progress is judged as positive shifts in baseline data
- measures treat behaviors as separable and abstracted from the context in which communication takes place
The myth of scientific objectivity leads clinicians to ignore the aspects of a client's problem that they themselves might most identify with. It is difficult to objectively measure a client's sense of isolation, feelings of ineptitude, or what kind of support might be needed to be successful in everyday life situations. Objectivity leads to a disregard for the client's experience-so there is a disincentive for clinicians to base their practices on how the communication problems are subjectively experienced by those who have them.
3. The conduit view of communication and therapy
- communication is depicted as message passing
- sources of communication problems seen as being caused by a problem in the client as the sender or recipient of messages
- problems are identified as lack of linguistic knowledge or processing
- the therapist's aim is to improve linguistic knowledge or processing to improve message passing skills
- the eventual goal of the therapy would be for the communicator to send appropriate messages independently, without clinician support
The conduit view systematically treats communication as consisting of passing messages back and forth, leading clinicians into a domain that has no grounding in the Golden Rule. Alternatively, a collaborative or situated view of communication would require that the clinician work together with the client to create meaning. The clinician would need to figure out what clients are thinking and intending, so that they could be supported in formulating heartfelt ideas and expressing them. A view of communication as being intertwined with other parts of life would make communication with clinicians more like naturally experienced communication in which people contribute to a mutual creation of meaning.
I have seen new trends in America that give me hope for the eventual inclusion Golden Rule practices in our field.
1. There are recent cracks in the medical model in medicine as well as in ASHA's recommended practices;
- The World Health Organization is talking about not only focusing on fixing impairments, but on removing contextual barriers and supporting life participation for individuals with illness or disabilities (World Health Organization, 1997).
- The "narrative turn" in medicine represents a new trend in clinical practice to listen to the life stories of patients (Frank, 1995)
- Due process is being built into ASHA's professional practices. For example patients and clients are entitled to give informed consent to new procedures, and to be part of the decision making process (National Joint Committee for the Communicative Needs of Persons with Severe Disabilities, 1992).
2. There are alternatives to the practice of objective science that take into consideration the multiple ways the same phenomena can be legitimately interpreted:
- ethnographic practices, borrowed from anthropology are being used by professionals to study and understand the client's viewpoints (Simmons-Mackie & Damico, 1999)
- discourse studies of the language of perspective reveal how even the same utterance can contain multiple voices (Hermans & Kempen, 1993)
3. Substitution of a life participation view of communication for the conduit view.
- A life participation view sees meaning as co-constructed by partners rather than as being conveyed in a message (Duchan, 1999b).
- Clinicians using life participation approaches see themselves as supporters rather than interveners (Beukelman & Mirenda, 1992).
- Life participation approaches value participation over accuracy as measures of goal achievement (LPAA Project Group, 2000)
As I see the effects of these alternatives, I am encouraged that our clinical practices in America will be more in keeping with what clinicians would want to have for themselves. In order to track our progress, I am recommending to my American colleagues that we create outcome measures designed to assess whether we have done unto our clients what we would have done unto ourselves-100% of the time.
Beukelman, D. & Mirenda, P. (1992). Augmentative and alternative communication: Management of severe communication disorders in children and adults. Baltimore: Paul H. Brookes.
Duchan, J. (1999a). Reports written by speech-language pathologists: The role of agenda in constructing client competence. In D. Kovarsky, J. Duchan, & M. Maxwell (Eds.) Constructing (In) Competence: Disabling evaluations in clinical and social interaction. (pp. 223-244) Mahwah, NJ: Erlbaum.
Duchan, J. (1999b) Views of facilitated communication: What's the point? Language Speech and Hearing Services in Schools, 30, 401-407.
Frank, A. (1995). The wounded storyteller. Chicago, IL: University of Chicago Press.
Frattali, C. (Ed.) (1998). Measuring outcomes in speech-language pathology. NY: Thieme.
Hermans, H. & Kempen, H. (1993). The dialogical self. NY: Academic Press.
Kagan, A. & Gailey, G. (1993). Functional is not enough: Training conversation partners for aphasic adults. In A. Holland & M. Forbes (Eds.). Aphasia treatment: world perspectives. (pp. 199-215). San Diego, CA: Singular Publishing Group.
Kovarsky, D., Duchan, J., & Maxwell, M. (Eds.). (1999). Constructing (In)Competence. Mahwah, NJ: Erlbaum.
LPAA Project Group (2000). Life participation approach to aphasia: A statement of values for the future. ASHA Forum.
Middleton, G., Pannbacker, M., Vekovius, G., Sanders, K., Puett, V. (1992). Report writing for speech-language pathologists. Tucson, AZ: Communication Skill Builders.
National Joint Committee for the Communicative Needs of Persons with Severe Disabilities (1992). Guidelines for meeting the communication needs of persons with severe disabilities. ASHA, 34 (March, Supp. 7), 1-8.
Simmons-Mackie, N. & Damico, J. (1999). Qualitative methods in aphasia research: Ethography. Aphasiology, 13, 681-688.
World Health Organization (1997). International Classification of Impairments, Activities and Participation. A manual of dimensions of disablement and functions. Beta-1draft for field trials. Geneva, Switzerland: Author.top
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