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Learning Leveling and Leveling Learning
Judith Felson Duchan
Graduation Speech
Department of Communicative Disorders and Sciences
State University of New York at Buffalo
May 12, 2001

I have come to your graduation not only to congratulate you but to think with you about the potential impact of your education on your future. I will be asking you to reflect on what it is you will take away from what you have learned here. All of you have been engaged in a common project-that of learning about the nature of communication, about what sorts of things cause people to have difficulty communicating and about how to minimize their difficulties. Your teachers have been providing all of you with various levels of information about normal communication in children and adults, and about different speech, language or hearing disabilities.

One level of information is biological. You have learned about normal physiology, and anatomy of the speech, language, and hearing systems and about what sorts of things can go physically wrong to cause individuals to have difficulty communicating. A second level of information is psychological. You have learned how speech signals get made and interpreted and about the many psychological steps that a person goes through to understand and produce speech and language. A third level of information is the level of social interaction. It is what people do interactively when they communicate with one another, how they figure out who to talk to, what to talk about, and how they go about taking turns talking and developing social relationships.

You may have wondered as you conscientiously learned information provided at these levels of knowledge, how it all fits together. You and your teachers will recognize this as the "why do I need to know this?" question. It comes in different forms, one being "How is learning the cranial nerves relevant to working with clients?" A general answer to the various forms of this question is that happenings at each level affect changes in every other level and that to understand the whole person you must understand all of their parts. People's psychological and social interactions are affected by what goes on at the biological level. Neurological conditions that involve differences at the biological level such as cleft palate, cerebral palsy, or hearing loss, also impact on a person's psychological processing and social interactions.

Indeed, a way of thinking that has come to be called the "medical model" offers a clarity about how problems at one level can cause difficulties at other levels. Medical practices, organized around the medical model, presume that the physician's task is to diagnose diseases, to discover their causes and symptoms, and design treatments. The treatments are aimed at eliminating or minimizing the symptoms of the disease, or the cause of the disease, or the disease itself.

The medical model is made up of causal chains, of primary, secondary, and tertiary causes. The primary cause is often seen as the original cause. It is often depicted as a problem at the biological level. Germs cause the flu, brain damage from accidents or strokes cause communication disabilities. The symptoms of diseases are often cast in psychological terms. Brain damage can cause problems in understanding and producing language. A final link in the causal chain is usually seen as a social one-a language problem causes a person to withdraw from social situations or be excluded from them by others.

Let's take an example of how the medical model works in our field by describing a situation that is familiar for those of you who are about to assume the role of a speech-language pathologist. Imagine that you are about to meet someone for the first time--a young adult, say, who has been in an accident that has resulted in a head injury. Imagine that you have just been assigned to be that person's speech-language pathologist. She has come to you to for therapy. You have read the person's medical file to find out the physical nature of her injury, look at her psychological test results to learn how she performs in various areas of psychological processing such as short and long term memory and feel prepared to select clinical goals for her. At the meeting you discuss her problems with her, review her areas of deficit, and prescribe what you see as a viable therapy plan. She agrees, and you proceed to work on the first targeted goal, to help her develop strategies to improve her memory. You carefully design the tasks to be in keeping with the person's interests and practical concerns. In this case, your memory work involves her in taking dictation since she hopes to return to her work as an executive secretary.

Those of you in audiology can create a similar scenario having to with a first meeting with someone who has a suspected hearing loss. Speech-language pathologists and audiologists are likely to draw from each of the three levels of knowledge when doing their work-the biological when they read the medical reports, the psychological when they interpret test scores and decide on which of the psychological domains to target for therapy, and social when they tailor a treatment to fit the social needs and life goals of the client.

The medical model has served us well. A deep understanding of what is going in on communication, especially when there are communication breakdowns, involves synthesizing what is going on at the biological, psychological and social levels. Such as synthesis is offered by the causal logic of the medical model. But before we become complacent in thinking that we now have it exactly right, we need to consider the challenges of other models to the well worn medical approach.

One alternative framework to consider when carrying out clinical practice is the participation model. It does not allow for an easy combining of levels. Rather, the model may work best if you put what you know about someone's physical and psychological profiles on a back burner. Rather, the focus when interacting with someone such as the woman described above with the head injury, is to find out how that person is living her life. Your primary interest in the first meeting is not on her diagnosis, or her symptoms, or her psychological test results, but on what she sees as her main worries and hopes.

This emphasis in the participation model is not the same as what goes on at the social interaction level I described earlier. Whereas the social interaction level has involved assessing how well a client performs in social situations, the social emphasis in the participation model is on whether a client has good access to such situations. In the participation model clinicians focus on how others treat their clients and whether their clients are excluded from social situations because of their disability.

There are many ways that this participation model is changing what clinicians do. They are having their clients choose their own therapy goals and plan the course of therapies rather than prescribing for them. They are assessing the interaction contexts that clients experience in their daily lives to see if those situations can be made more communicatively accessible. They are basing the evaluation of the success of therapies on whether their clients are meaningfully engaged in everyday life events, not just on whether their clients are speaking or listening better.

Whereas the causal logic of the medical model provides clinicians with a way to combine the biological, psychological and social levels of knowledge, the participation model does not. A diagnosis can serve as a stigmatizing label just as damaging as a racial epithet. Like other labels, one labeling a communication difficulty can create a false sense of understanding and can result in people making broad and inaccurate generalizations about their clients. It is incorrect to assume that all people with autism have trouble relating to others, or that all people with hearing loss are socially withdrawn, or that all people with Down syndrome have cognitive deficits preventing them from learning to read. Diagnostic labels can cause prejudice, leading the person diagnosed into behaving in negative ways and thereby fulfilling the labelers' expectations. Similarly, interpreting abnormal behavior as a symptom of a disease to be ignored or admonished, may serve to minimize the person 's communicative opportunities and eventually lead to increased frustration or social withdrawal.

Let me summarize. So far I have argued that the medical model has an advantage over the participation model in that it allows you to use all levels of your knowledge and fit things together conceptually in a causal framework-the biological level causes things to happen at the psychological level that causes things to happen at the social level. Germs cause diseases, those cause symptoms, those cause social interaction problems.

I have described an alternative to the medical model-the participation model. I have argued from the point of view of the participation model that knowing about someone's diagnoses and seeing that person's abnormal behavior as a symptom of a disorder can get in the way of seeing the intended relevance of that behavior. This can result in inhibiting meaningful social interactions with that person. I concluded that the participation model requires that we set aside the knowledge about biological and psychological deficits of people when we interact with them and concentrate on who they are, how they experience their lives, and their life goals.

Now, I need to say something about how well or even or whether the medical and participation model can co-exist. I think they can and for those of you who are going to be starting jobs as speech-language pathologists or audiologists, I would like to make a few suggestions for how to take the best from both approaches.

  1. That you let your clients in on the medical model-telling them what you see as causing their difficulties and the various treatments they have to choose from.
  2. That you keep track of how things are for your clients-how they see their communication problems, where they are experiencing difficulties, what they would like to see different.
  3. That you interact with you clients in terms of their biography not their biology, focusing on their life experience rather than their disease.
  4. That you put any prejudices aside about the presumed deficits of your clients and focus on their potential competencies.
  5. That you focus on changing social barriers to your client's participation as well as on changing your client's communication patterns.
  6. That you think about what you are doing not just as minimizing your client's problems but as supporting your client's participation.

For those graduates and those in the audience who do not aspire to become clinicians, I have a couple of suggestions that grow out of my comments today:

  1. That you encourage professionals you are in contact with to treat their clients as a person rather than as a disease.
  2. That you engage in positive and meaningful ways with those whom you know to have disabilities, so that they are not socially ostracized and so that you are part of the solution rather than a barrier to their social participation.

I now join your families and the CDS faculty in congratulating you on your remarkable achievement through these years of study. I know you will apply your knowledge wisely and humanely, and that you will continue to ponder about how to make the best use of your various levels of learning. I hope you will never stop learning and that you will always being on the lookout for new ways of integrating and applying what you know in order to best benefit those with communication disabilities.

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Copyright © 2001 - 2010 by Judith Felson Duchan
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Please send comments or corrections to duchan@acsu.buffalo.edu