Im proving the R elevance o f Speech-L anguage Pathology and A udiology R esearch and P ractice 11 appropriate for the task. A phenomenological, in contrast to a positivist, research paradigm assumes that the world is socially construed and therefore all truth is subjective and relative (Newman, 1997). Combining research along the continuum o f the positivist and phenomenological extremes, investigating both abstract and concrete concepts to describe, solve, understand and explore professional practice and client profiles is therefore war­ ranted. This holistic or eclectic approach can provide a richer body o f professional knowledge that produces scientific fact within an understanding o f the subjective realities of the socio­ cultural populations which we serve. It is therefore not a matter o f abandoning old methods but rather o f embracing new ones alongside traditional research methods. To an increasing extent, this has been a trend in recent studies conducted by the profes­ sions in South Africa (Louw & Avenant, 2002; van Dijk, 2003; Swanepoel et al., 2005). Whilst it is necessary and useful to critically consider the research paradigms to be employed by the professions o f audiol­ ogy and speech-language pathology, on a more practical level it is essential that whatever the research being pursued, it must ultimately be published. Research conducted by our professions in South Africa unfortunately, remains unpublished in the over­ whelming majority o f cases. A marginal number o f publications, and especially international publications, have emerged from the respective fields o f audiology and speech-language pathology since the establishment o f the professions in South Africa over five decades ago (Swanepoel, 2006). Credence and advocacy for our services rely in large part on the recognition o f the research we conduct. This is especially true in an era where evidence- based practice has become a core principle o f professional prac­ tice. It is therefore o f great importance that we not only ensure the use of an holistic paradigm in our research but that we dem­ onstrate the worth o f our efforts by bringing them to fruition in the form o f internationally recognized peer-reviewed publica­ tions. The collective responsibility for establishing world-class research outputs that are locally relevant rests on the profession as a whole, and in particular on the academics and postgraduate students at tertiary institutions for audiology and speech- language pathology. > ‘‘Sociopolitical changes j have come and gone, but the challenge fo r the profession has remained the same - to provide accountable services to the entire population based on quality training and contextual research efforts” (Swanepoel, 2006, p.266). Improving the relevance o f the research and practice of the professions o f audiology and speech-language pathology in South Africa, as argued in response to the issues raised by Response: ErnaAlant Kathard et al., therefore relies on 1) the clear recognition o f the professions as sciences reliant on research development; 2) the adherence to basic principles of human dignity and respect for all persons instead of political ideologies; 3) the engagement of social justice and equity in our professional capacity only as these principles relate to scope of practice and the populations which we serve; 4) the utilization o f holistic research paradigms by embracing phenomenological methods alongside existing positivist methods; 5) the culmination o f research efforts being acknowledged in internationally recognized publications which serve an advocacy function in respect o f the professions and the respective services they render to the broader South African population. A N C T oday (2005). R esponding b etter to the health care n eeds o f com m unities. A N C T oday, 5(4 3 ). h ttp ://w w w .a n c .o rg .z a /a n c d o c s /a n c to d a y /2 0 0 5 / a t4 3 .h tm # artl de V os, A. (2002). Scientific theory and pro fessio n al research. In A.S. de V os (Ed.), R esea rch a t Grass R oots. (2nd ed.) P retoria: V an Schaik. 28-48. K ubba, H., M acA ndie, C., R itchie, K. & M acF arlane, M. (2004). Is deafness a disease o f p overty? T he association betw een socio-econom ic deprivation and congenital hearing im pairm ent. In tern a tio n a l Jo u r n a l o f A u diology, 43, 123-125. L ouw , B. & A venant, C. (2002). C ulture as co n tex t for intervention: developing a cu ltu rally co n g ru en t early intervention program . International P ediatrics, 17(3), 145-150. M axw ell, D.L. & Satake, E. (2006). R eseach a n d sta tistic a l m ethods in co m m u ­ nication sc ien ces a n d disorders. C lifton Park: T hom son D elm ar L earning. N eum an, W .L. (1997). So cia l R esearch M ethods: Q ualitative a n d Q uantitative A p p ro a ch es (3rd ed.), A llyn and B acon, Boston. O ’C onnor, A. (2004). T he persistence in poverty. In D. Potes & T. Bow yer- B ow er (E ds.) E a stern a n d Southern A frica. D e ve lo p m en t challenges in a volatile region. E ssex: Pearson E ducation L im ited.(pp. 89-117). S w anepoel, D. (2006). A udiology in South A frica. In tern a tio n a l J o u rn a l o f A u d io lo g y, 45, 262-266. S w anepoel, D ., H ugo, R. & Louw, B. (2005). Im plem enting infant hearing screening at m aternal and child health clinics: context and interactional processes. H ea lth SA G esondheid, 10(4), 3-15. V an D ijk, C.A . (2003). A n educational a u d io lo g y se rvice d elivery m odel: needs o f teachers o f children w ith hearing loss. U npublished D .Phil. C om m unica­ tion P athology degree. U niversity o f Pretoria. W alley, J., K han, M .A ., Shah, S.K ., W itter, S. & W e, X. (2007). H ow to get research into practice: first g et p ractice into research. B ulletin o f th e W orld H ea lth O rganization, 85(6), 424-425. Director: Centre for Alternative and Augmentative Communication, University o f Pretoria, SA. A bou t being relevant: a com m ent on Kathard, Naude, Pillay & Ross (2007). I accepted the invitation to respond to this paper with pleasure, not only because I welcomed the critical thinking reflected in the paper, but also because I think the issues raised are vital to the long-term sustainability o f the professions of SLP/Audiology in this country. Like others, I also have been deeply concerned about the profession and its future within the African continent. This concern is not based on a belief that the profession is irrele­ vant or peripheral to local development, but rather on the com­ plexities of the issues facing the field o f Speech-Language Pa­ thology and Audiology as well as other rehabilitation profes­ sions within poverty contexts. Kathard et al. (2007) raises important issues upon which I would like to comment and include: • the issue o f relevance and different types o f research, • the role o f evidence-based practice and finally, • intervention in poverty contexts. For a long time, the western world has dominated the profession of Speech-Language Pathology and Audiology for good reasons. However, as the developing countries come into their own, the realization dawns that we can not translate strategies used in 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. ) http://www.anc.org.za/ancdocs/anctoday/2005/ 12 H. K athard, E. N aude, M. Pillay and E. Ross industrialized contexts to developing contexts in uncritical ways. Similarly, the knowledge-base o f the western world is equally limited in addressing issues o f poverty and diversity. We know that a significant proportion o f what we have learned and success­ fully applied in this countiy is based (at least partly) on what our international counterparts have developed. Many o f the interven­ tion issues that parents and professionals in the western countries experience are similar. However, on a continuum many o f these issues are intensified within poverty contexts. The issue o f HIV/ AIDS certainly adds a further critical dimension. An example is the fragmentation of services relating to early childhood interven­ tion, which is a major problem in many countries. In South Africa where parents have lack o f access to services to start off with, fragmentation o f services can have a pronounced impact on fami­ lies in poverty and their ability to participate in intervention, par­ ticularly also in the context o f HIV/AIDS. The average more edu­ cated parent has significantly more resources in coping with di­ verse messages impacting from different professional angles. How do we manage an effective intervention service to young children in a country that rates low (UNICEF, 2006) in terms o f provision o f health and education to children? What is the responsibility o f the profession in the face o f these issues? Do we ignore them, or actively engage with them? Do we really have a choice? Whilst this is not a profession-specific problem, the issue o f transdisciplinary service provision clearly is an important con­ sideration. Why when we know that community-based interven­ tion in homes is more effective than institution-based intervention are most o f our interventions still in hospitals and school clinics? The CAAC recently conducted a nationwide survey with some of our multi-professional graduates (Speech-Language Pathology, Audiology, Occupational Therapy, etc.) on the location o f where services are rendered. Just about all the therapy was focused on multi-disciplinary, institution based models o f intervention. These practice contexts prompt questions such as the following: In SA, are we getting better at addressing the issues we face when provid­ ing young children in need with access to therapy? Are we plan­ ning and training for impact if we promote multidisciplinary ser­ vice models in contexts where there seldom are rehabilitation pro­ fessionals to fill a team? Let me admit that I do understand (and have been reluctantly involved in) the professional boundary is­ sues in relation to what is Occupational Therapy, Speech- Language Therapy/Audiology and physiotherapy domains. Does this type o f “professional protection” really advance our services to those in need? Are we moving forward by systematically build­ ing a bigger private practice speech/language therapy and audiol­ ogy professional base? When is our commitment to our profession more overtly going to focus on government support and liaisons to develop service and intervention models that could work for reha­ bilitation in our country? One o f the present-day realities for any profession focuses on the accountability o f the outcomes o f services - and not only outcomes, also impact. Kathard et al. (2007) refer to the UN Mil­ lennium Development Goals to alleviate poverty and state that we should be guided by priorities to create a more equitable world. This point highlights the issue of sustainability o f our intervention outcomes over time (Alant, 2005). Is it enough to prove effective­ ness? What about long-term efficacy and sustainability o f change? The authors continue by stating that “the use o f highly valued em­ pirical research methodologies has functioned to develop our pro­ fessional interest” and then proceed to question the social validity o f these processes. Towards the end of the paper they also argue for the development o f ecological frameworks o f practice. These issues are indeed relevant, as, regardless o f methodologies used, one needs to ask how findings and data translate into the improve­ ment o f everyday working reality for those in need. Die Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vol. 54, 2007 There is a significant difference between research ap­ proaches focused on identification o f generalities, i.e. the no­ tion o f context-free laboratory-type experiments, and those interested in understanding phenomena entrenched within the social context o f living. As we know, these are not mutually exclusive but both form an important part o f development of knowledge and applications in any field. However, good re­ search or high level evidence is, as we know, not determined by the methods used, but by the degree to which the processes and recording show a high regard for issues relating to trust­ worthiness or validity. The real issue therefore is not so much whether we need to use different research approaches in an­ swering different questions essential to improving practice, but a deep commitment towards making sure that the methods used are credible in the data and interpretations proposed. Having said that, it is important to ensure that we ask relevant questions in guiding practice and that we do allow different researchers to add to the existing body o f knowledge by not imposing pre-conceived notions of what is “good re­ search” on the process. In this regard David Beukelman (2001), based on the work o f Boyers and Rice (1990), identi­ fies at least five different types o f researchers necessary to expand a field, which include researches focused on the repre­ sentation o f knowledge, integration o f knowledge, advance­ ment o f generalized knowledge, advancement o f individual­ ized knowledge and application o f knowledge. All these dif­ ferent types o f researchers are important to develop a field and we need to remain cognizant o f the importance o f encour­ aging different ways o f inquiry to add to the richness in un­ derstanding complex phenomena o f the field. Can research findings, however, dictate decisions on clinical practice? How do we decide on what is the best inter­ vention approach to take with a specific client? Schlosser and Raghavendra (2004) outlined what they describe as the proc­ ess o f evidence-based practice in Augmentative and Alterna­ tive Communication as focusing on three factors, i.e. best and current research evidence, clinical/educational expertise and thirdly relevant stakeholder perspectives. From this model it is clear that an evidence-based practice does not mean the aban­ donment of stakeholder involvement or clinical and educa­ tional expertise, but rather the incorporation of these in the process o f sound decision-making relating to a specific client and context. Evidence-based practice thus implies that the clinician is not only able to search and access relevant re­ search findings, but also that s/he is able to meaningfully in­ terpret these findings within his/her own working context/ expertise together with a sound understanding and interaction with the client s/he serves. The responsibility that lies with the speech-language pathologist/audiologist thus remains one o f integrating the research evidence with the professional exper­ tise and consultation with the client served. Herein lies a ma­ jor ethical and professional responsibility - not just to use the therapeutic approaches best known to the speech-language pathologist/audiologist, but to ensure that the choice o f strate­ gies applied are those most relevant to the client! The authors ask the question “Can we rely on an em­ pirical science to enable us to adequately engage what are issues o f social justice?” Clearly, one can never replace hu­ man responsibility with scientific processes. Clinical expertise o f the interventionists, their understanding arid caring will always remain pivotal to the process o f meaningful interven­ tion. The challenge is to explore the relationship between the part and the whole,,the individual and the system or con­ text without confusing them as being the same or inter­ 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 Practice 13 changeable. We have to understand what is going on in the whole system to understand the individual just as we need to inquire about the individual to learn about the whole. As we listen to the stories o f individuals and families in distress, we also need to “be-in-the-world” (Heidegger’s concept o f “da- sein”, 1996) which implies an openness and understanding o f possibilities within the world. This will enable us to pick up impressions and ideas and explore these with our clients and families in moving towards discovering ways to assist them not only to cope and survive, but live. Speech-language patholo- gists/audiologists need to be conscious enough o f their own assumptions to ensure that these do not become an imposition on others. Only by realizing one’s own limitations and preju­ dices can one move forward in understanding and meaningfully assist those who live in society’s “black holes”. This idea is best expressed in the words of Eudora Welty, quoted by Marga­ ret Wheatly (1999, p. vi) “ My continuing passion is to part a curtain, that invisible shadow that falls between people, the veil o f indifference to each other’s presence, each other’s wonder, each other’s human plight”. Response: Claire Penn A lant, E. (2005). Intervention Issues. In E. A lan t & L.L. L loyd (Eds). A u g m en ­ tative and A lternative C om m unication and S evere D isabilities: Beyond Poverty. W h u rr P ublications: L ondon (pp. 9-29). B eukelm an, D. R. (1993). A A C research: A m ultidim ensional learning com ­ m unity. A u g m en ta tiv e a n d A ltern a tive C om m unication, P (l), 63-68. Boyers, E., & R ice, R.E. (1990). The N e w A m erica n Scholar. C arnegie F oun­ dation: Pittsburgh. H eidegger, M. (1996). B eing and T im e (A tran slatio n o f Sein und Z eit). A l­ bany, State U n iv ersity o f N ew Y ork Press. Schlosser, R. W ., & R aghavendra, P. (2004). E vidence-based practice in aug­ m entative and alternative com m unication. A u g m en ta tiv e & A ltern a tive C om m unication, 20(1), 1-21. U N IC E F (2006). The sta te o f the w orld's children 2007: W omen a n d children, the d o u b le d iv id e n d o f g e n d e r e q u a lity N e w Y ork: U N IC E F. W heatley, M . J. (1999). L ea d ersh ip a n d the n ew science: D isc o verin g o rd e r in a chaotic w o rld (2nd ed.). San Francisco: B errett-K oehler. School o f Human and Community Development, University o f the Witwatersrand, SA. “D o n ’tg iv e m e the theory, ju s t tell m e w hat to do in therapy!”: The slippery slope challenge f o r the South A frican professions o f Speech- Language Pathology a n d A udiology The above frequent plea o f the clinician attending a refresher course has resonated in my ears over the years. In this paper I address the reasons and frustrations caused by this enjoinder and in responding to the lead article, will reconsider priorities o f our discipline and its implications for selection, training, funding and practice. I will argue that the discipline in this country is at an important crossroads and that future flourishing will depend on a proactive and firmly grounded commitment to scientific research. ; Regardless o f context, the twin disciplines o f Speech- language Pathology and Audiology have always fought for sci­ entific identity. The reasons for this have been multiple. The fact that their subject matter - J human communication - is an interdisciplinary one has required a grounding in several main and historically secure fields: medicine, psychology, linguistics and physics to mention a few. Thus methods used for research in our disciplines have often been those borrowed from such fields and include a range o f clinically based observations, ex­ perimental and descriptive designs. While there has been a his­ torical effort to establish a unique identity for the disciplines, as reflected in some interesting debates on this topic, we are not yet there (Ringel, Trachtman, & Prutting, 1984; Perkins, 1985; Siegel, 1987; Siegel & Ingham, 1987). The discipline in this country is 70 years old and this makes it a mere teenager in relation to some o f its parents - and like a teenager, possibly still uncertain o f its identity and auton­ omy and o f which route to take towards this. If one looks at the history o f our discipline, both here and elsewhere, we have fol­ lowed and not taken the lead. Thus there has been a tendency to follow the current Zeitgeist o f medicine, psychology, and lin­ guistics when searching for methods and explanatory frame­ works. We take others’ methods and theories and adapt them. In order to play the grant game and the publications game in research, this adherence to mainstream enables funding, ac­ knowledgement, promotion and recognition. When you live at the cusp o f another discipline you w on’t be noticed until you play that game and speak their language. An example is offered from the field o f aphasia, my own specialization, which can be characterized as having a number o f distinct phases. Starting in the field o f neurology with a strong tradition o f case studies one can trace the influ­ ences of psychology, the preference for large scale group stud­ ies and the influences o f early linguistic theory and the behav­ ioural approach to communication o f the 1960s. Pragmatics dominated the 1980s leading to current social approaches and we now see a return to the neural model with the advent of advanced functional neuroimaging. The influence o f the WHO framework has been pervasive and is also mentioned in the lead article (see Penn, 2004a and Penn, 2005 for further consid­ eration o f these issues). Any scholar o f aphasia who is caught unawares and proposes a non-mainstream idea during a particular era has a challenging time getting an audience or arguing their case. Non mainstream ideas are tolerated or perhaps used as a platform for dialogue and debate. Those who work and think outside the box certainly add texture and depth to the discipline and serve (if a political analogy is allowed) as a type o f opposition party in order to refresh and remind those who are heading towards a dictatorship. Often such streams o f thought are published in different journals and at best attend parallel sessions at the same conferences. But such argument and debate we are told is essential for paradigm change and no discipline can thrive or grow without such mechanisms (Kuhn, 1970). The search for a scientific and research identity and autonomy in our disciplines has been difficult, and remains in my opinion, elusive. The first reason may be because o f the profoundly complex domain o f study. Human behaviour is unpredictable and is influenced each day by a myriad o f fac­ tors, as the lead article makes explicit. The influence o f gender, race, poverty and socio political history have profound effects 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. )