The South African Journal o f Communication Disorders, Vol. 54, 2007 Lead Article IMPROVING THE RELEVANCE OF SPEECH-LANGUAGE PATHOLOGY & AUDIOLOGY RESEARCH AND PRACTICE Kathard, H., Naude, E., Pillay, M & Ross, E. Editorial Board: South African Journal o f Communication Disorders H o w d o th e p r o fe s s io n s o f S p e e c h -L a n g u a g e P a th o lo g y a n d A u d io lo g y p r a c tic e ? H o w do th e y p r o d u c e th e ir k n o w le d g e ? The focus o f this article is on the nature o f research within the joint professions o f Speech-Language Pathology (SLP) and Audiology. Specifically, we foreground the issue o f relevance within professional research for professional practice. In doing so, we not only seek to promote a certain symbiosis between researchers and practitioners but also to promote greater compe­ tence toward improving the lives o f people living with commu­ nication and/or swallowing disorders - which direct its research and practice foci. Essentially, SLP and Audiology’s project is really about accessing the lived experience o f people with com­ munication/swallowing disorders. As lives are deeply related to the professions’ foci, then it is reasonable to assume that its re­ search and practice ought to engage what is o f relevance to peo­ ple and their lives. Gender, race, socio-economic status, culture, political determinants and such like are interpenetrating factors that determine one’s experiences of, for example, living with an acquired language disorder. Predominantly, how has SLP and Audiology researched its foci? Mainly, we have researched the pathology by sanitizing peoples’ social, political and cultural influences o f their lives. Historically, research for and within the professions have relied on good empirical, scientific methods to situate communi­ cation disorders. For example,, in perusing publications associ­ ated with the beginnings (early 19th Century) o f SLP and Audiol­ ogy research in the western world it is not unusual to encounter articles with titles such as: J o Observations on the History ,̂ Use, and Construction o f Obtu­ rators, or What Have Hitherto Been Called in This Country Artificial Palates (Snell, 1824) ® Clinical report on Robert B ates’ cure fo r stammering (Meigs, 1852) i ® Mutilation o f Stutterers. Surgical Operations which Have Been Performed fo r the Cure o f Defects o f Speech (Werner, 1881) ® The Possibility o f Obtaining M arked Improvement in the Treatment o f Deafness and Supposed Deaf-Mutism by Acous­ tic Gymnastics; A System o f Vocal Training o f the Auditory Nerve as Advocated by Urbantschitsch, o f Vienna (Goldstein, 1895) Writing styles aside, these titles reflect the way SLP and Audio­ logy have developed their knowledge with the use o f an empiri­ cal, positivist scientific frame which positions: • reality as apprehensible, driven by natural laws and mecha­ nisms (deterministic) and therefore reducible to parts which may be manipulated in an objective fashion. • truth as existing outside o f the researcher, and accessible via various objective techniques, and • uses methods which emphasise experiments, the predictabil­ ity o f phenomena, allows for the testing o f hypotheses and controls for confounding conditions. Empiricism is preferred and valued as a research and practice orientation by SLP and Audiology practitioners and is used to focus the body as the site of prime interest. In referring to communication via this biological metaphor o f the body; ‘assessment’, ‘treatment’, ‘diagnoses’ and ‘prognoses’ are now well established SLP and Audiology clinical frameworks. As such, good professional research is regarded as that which not only promotes the use o f logical rationality, objectivity, cause- effect relationships, and experimental verification amongst a plethora o f similar axioms; but also one understands people with communication disorders from a biological, medically- orientated perspective. At its core,' across practice sites in edu­ cation or health care, the professions engage a medical gaze (Foucault, 1976) to research and practice. The use o f highly valued empirical research methodolo­ gies has functioned to develop our professional interests. For SLP and Audiology, as it is with other caring professions, re­ search meets several key professional development functions. In the first instance, doing research fulfils practitioners’ ethical obligations to contribute to their professions’ knowledge base. Research is the dominant, usual method o f sharing knowledge amongst professionals. Furthermore, this latter function is related to the understanding that professional research and practice ought to nurture and inform each other. While sensi­ ble, the reciprocal nature o f the practice-research relationship does, however, require optimizing. Indeed, Kamhi (1999) ex­ horted researchers and clinicians to work together, not only to improve clinical practice through research, but also to make researchers more responsive to the needs o f practitioners. It is a widely held expectation that research itself once disseminated, shared and applied can enhance the effective­ ness o f practice. Currently, this sharing o f research is placed in bare tension with the trend toward evidence based practice (EBP). Strenuous demands are placed on practitioners to test and evaluate what was previously recognised as ‘best prac­ tice’. Practitioners have to follow clinical research literature in order to evaluate the relevance o f the findings and make in­ formed decisions to the benefit o f the families and communi­ ties they serve (Bothe, 2004). According to Kamhi (1999) practitioners are well qualified to evaluate the effectiveness of new approaches suggested by research findings. In fact, prac­ titioners are becoming ever more critical of activities not grounded in research-proven evidence. Therefore, the rela­ tionship between research and practice which is implicit in EBP also guides relevant research and accountable clinical practice for practitioners in South Africa (SA) and elsewhere. The methodological shape of EBP is inextricably intertwined with the professions’ adoption o f empirical research method­ ologies. The South African Journal o f Communication Disorders, Vol. 54, 2007 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) 6 H. K athard, E. N aude, M. Pillay and E. R0ss It may be said that, thus far, empirical research has been an excellent vehicle without which SLP and Audiology may not have developed their current status as valid professions working with speech, language, voice, hearing and swallowing disorders. However, as we use empirically orientated frame­ works such as EBP, professional research and practice must consider not only that evidence is necessary to develop prac­ tice; but also how practitioners’ use evidence in ways that bear relevance to the lives o f people they encounter in their clinical practice. As such, the utility value o f our research, our profes­ sional knowledge base is brought into question. For SLP and Audiology most professional knowledge is based on research with mainly male, urban, middle-class, Judeo -Christian, European language speakers (Taylor, 1986; Pillay, 1997; Marshall, Goldbart & Evans, 2004). The adequacy (and relevance) o f our research for all aspects o f our professional work becomes dubious when we consider SLP and Audiology across the world’s social, cultural, economic and political reali­ ties. For the majority world populations, most who live in pov­ erty, it may be said that our research inadequately supports the needs o f people in societal "black holes" (Soludo, 2001). Such people refer to those living in indigenous Australian communi­ ties, American ghettos, Indian slums, Emirates’ labour camps and South African informal settlements. Post-apartheid SA has, as it is with other world democracies like India, Brazil and America; provided us with an opportunity to re-assess how, especially residents o f societal black holes, may benefit from grand notions o f democracy, equality, and anti-discrimination. These political ideologies affect everything we do, including our professional research and clinical practices. To structure the implementation o f democratic ideolo­ gies international organizations have developed several strate­ gies to generate practices that address our world’s social, politi­ cal and cultural realities. For example, as health care practitio­ ners, we are urged to pursue the collective wishes o f the world as stated within the United Nation’s (UN) Millennium Devel­ opment Goals (UN, 2005). SLP research and practice ought to be configured in relation to the eight millennium development goals which range from the eradication o f extreme poverty and hunger to the development o f global partnerships for develop­ ment. Therefore we should be guided by these priorities to help create a more equitable world. And as we do this, we should direct ourselves toward re-positioning our dominant medical understanding o f disability within a social model that empha­ sizes human functioning as promoted by the International Clas­ sification o f Functioning (WHO, 2001). Betwixt and between these world directives are issues o f deep social and political concerns. What SLP and Audiology practitioners need to ask is: Should we be involved in addressing such social and politi­ cal issues? Should we not just stay out o f politics? Perhaps we need to clearly demarcate issues o f professional. science from political issues. Indeed, it may be argued that sexism, racism, homophobia, poverty and such issues are really outside the professions’ domain o f practice. Almost thirty years ago, a similar argument was pre­ sented at an American Speech and Hearing Association's (ASHA) Convention in 1968. Orlando Taylor, a pre-eminent SLP in multicultural practice, explicitly linked his professional development to the greater political events o f the time, i.e. a time when America was experiencing "...severe national dis­ cord over the Vietnam War and civil unrest by Blacks in nu­ merous urban centers" (Taylor, 1986, p.2). Taylor argued that: “ ...professional organizations should articulate a point o f view on the important social and political issues o f the day, making it possible for the corpo- Die Suid-Afrikaanse Tydskrif vir Kommunikasieajwykings, Vol. 54, 2007 rate body to influence decisions...I urge the Ameri­ can Speech and Hearing Association to provide ag­ gressive leadership for moral, ethical, and judicial behavior in areas o f significant social signifi­ cance...” (Taylor, 1986, p.2) Taylor presented the above argument to John Michel . (University o f Kansas, USA) who responded with the follow­ ing: “It is unwise to jeopardize the purely professional nature of ASHA and the harmony among our Mem­ bers by introducing current issues outside the realm o f speech and hearing. It is both healthy and admira­ ble that individual Members are sensitive to social issues and have the courage to organize opinion against unsatisfactoiy aspects o f our society.” (Taylor, 1986, p. 2) In essence, Michel argued that, while being sensitive, profes­ sionals should not be involved in engaging social, political, and cultural issues. O f course, SLP and Audiology has always fo­ cused on cultural, social, political, gender and related issues. It is just that this focus is largely untheorised as politically situ­ ated even though it has produced knowledge predominantly rooted in, and beneficial to, politically dominant populations of the world. However, as citizens o f a world populated by a di­ versity o f classes, genders, races, cultures and so on; SLP and Audiology practitioners must necessarily concern themselves with the everyday, lived experiences o f most o f the world’s peoples. When considering the nature o f the relationship be­ tween practice and research (or between practitioner and re­ searcher) a basic premise ought to be considered, viz.: the coin­ cidence o f researchers’ and practitioners’ realities with the re­ alities o f majority world populations. Researchers and practitio­ ners alike must ask: Is evidence fro m professional research that is dominantly based on minority world populations such as Caucasian, middle-class, monolingual, English-speakers rele­ vant fo r practice with majority world populations? Locally, for SA, what would it mean to practice SLP and Audiology in rela­ tion to issues ofpoverty? What o f SLP and Audiology research when we consider the burden o f diseases such as tuberculosis, AID S/H IV or malaria? Indeed, the kind o f engagement required involves more than relocating services to community clinics or re-focusing an empirical research lens to, for example, Black African lan­ guages. All this may serve to do is re-produce the same kind of restrictive ways o f knowing, the same level o f knowledge util­ ity. Here, the question raised is really not about ‘culture’ or ‘race’ or ‘politics’ and suchlike. Rather, it is about the science we use to engage the issues. As a cultural artifact in itself em­ pirical science must be considered for its usefulness to move the profession into the millennium. Perhaps, the time has come to listen to Taylor and consider ways in which we research and practice. While, Michel’s sentiment may remain within profes­ sional ideologies and practices, the profession may still need to explore its response relative to “ ...moral, ethical, a n d judicial behavior in areas o f significant social significance...” The question now is: can we rely on an empirical science to enable us to adequately engage what are issues o f social justice? In SA, policy changes have provided a fertile conceptual resource for the profession to consider issues o f social justice. Equality and anti-discrimination, Ubuntu/human dignity an respect, democracy, equity, transparency and a cco u n ta b ility are all excellent signposts for the professions’ researchers and/or practitioners to consider when thinking about social justice. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) Im proving the R elevance o f Speech-L anguage Pathology and A udiology R esearch and P ractice 7 While our local focus is on how we live with the contradictions o f 'colour' (an ideological issue) we are really engaged in a broader project o f humanity. Ours is a political-social experiment that focuses how we relate to each other because o f our social condi­ tioning and o f our political condition. The world has a pointed interest in SA for how we develop our human relationships, our humanity. Our policies, our political project is actually a world project because South African policies have largely been imag­ ined around how we exist as people. Furthermore, although SLP and Audiology practices vary internationally and are shaped by local contextual realities, the core historical-cultural medical pro­ fessional practices remain entrenched (Pillay, 1997). In this way, as SLP and Audiology researchers/practitioners we may comforta­ bly and ably dialogue with colleagues in other countries who share similar aspirations through international organizations that espouse liberal, democratic ideologies such as the World Bank, the United Nations (UN), and the World Health Organisation (WHO). In the last few decades, several shifts in professional prac­ tice have occurred that may (retrospectively) be understood rela­ tive to democratic ideologies engendered within global develop­ ment maps like the Millennium Development Goals and the Inter­ national Classification o f Functioning. Consider the focus on mul­ ticultural/multilingual practice which has challenged the domi­ nant theoretical frames that did not consider the implications of non-White, non-English, and non-middle class values. An associ­ ated trend has been the development of ecological frameworks o f practice such as whole language (Norris, 1990) and ecological audiology (Borg, 1998). Similarly, socially-orientated services such as community based rehabilitation (CBR) and/or or primary health care (PHC) within SLP and Audiology has promoted ser­ vices to people with communication disorders in their homes and/ or via community structures (Jager, 1994; Wirz, 1995). Signifi­ cantly, qualitative methods have been explored for practice within SLP and Audiology (Eastwood, 1988; Hetu, Riverin, Lalande, Getty, & St-Cyr, 1998). Qualitative methods have gained meas­ ured success with the recognition o f strategies such criterion refer­ encing (Westby, StevensDominguez & Oetter, 1996) and research (Kearns, 1999). Finally, narrative methods o f practice have slowly been gaining credence since at least the late 1990's within, for example, the field o f aphasia (Parr, Byng, Gilpin & Ireland, 1997). j _ These shifts link to sources 'outside' o f the professions’ own peculiar foci. For example, they draw on inspirations from the social sciences, education] social anthropology, philosophy and suchlike. They also serve as a challenge to the professional knowledge base by presenting concepts that must actively account for a range of contextual factors such as culture, race, social and economic factors. If suitable, how may we use qualitative re­ search to effect changes in practice? What about the use o f ran­ domized control trials when working with the multidimensional complexities o f people that inherently defy controlling? Are all research questions suited to ethnographic studies, life histories and similar phenomenological approaches? What about the rele­ vance o f research that uses good empirical science that enables us to manage people with swallowing disorders? Ca!n hearing disor­ ders benefit from ecological audiology? What lies beyond electro- physiological assessments o f hearing? How do SLPs and Audiolo­ gists work with ‘normal’ people to prevent disorders? How do we research non-curative, preventative ways of working? What re­ mains is for SLP and Audiology to develop ways o f guiding rele­ vant research for relevant practice. In the next few responses, leading researchers and/or practitioners highlight their thoughts in relation to these questions. 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