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. ) 14 H. K athard, E. N aude, M. Pillay and E. Ross on human behaviour. To exclude these from research, to at­ tempt to control for these variables or worse, to ignore them in explanations for what we find, leads to superficial and hege­ monic conclusions. Secondly this makes the really important questions in our field (such as ‘does therapy work?’) almost impossible to answer to the satisfaction of the scientific com­ munity. Take for example the heated debate around the (now) infamous Lancet study (Lincoln, Mulley, Jones, Mcguirk, Len- drem, & Mitchell, 1984) which showed that therapy for aphasic patients in a certain setting did not work or at least did not work any better than no therapy. This controversial and (as it turns out) scientifically flawed study retrospectively had a major in­ fluence on the field. It caused sufficient levels o f outrage and indignation among researchers and practitioners alike to gener­ ate a flurry o f counter arguments and a body o f well designed and reassuring studies on the efficacy o f aphasia therapy (Wertz et al., 1986; Wertz, 1987). Thankfully, some people were read­ ing the literature and justice was served. However the random­ ized controlled trial remains the gold standard for therapy effi­ cacy in aphasia and hence most articles will be excluded from international data bases such as the Cochrane collaboration (Clarke & Horton, 2001). As the lead article correctly suggests, the emphasis on evidence based practice (EBP) may have ig­ nored some highly relevant material. Further as the Lancet and other studies have shown, there has often been an insecurity in our disciplines which has come with the fact that we are a newer discipline and that we started o ff (and remain in some contexts) an “allied” discipline. Leary (1997) for example in relation to cerebral palsy describes the role of therapists in neurorehabilitation as “motivators, fa­ cilitators and informal counsellors”, further suggesting that “it is the therapist’s personality and approach to her patients rather than what she does which is to their advantage”. Dim praise indeed, perpetuating an image o f dependence, disempowerment and gender stereotype in the professions. But it is also possible that we have earned our own reputation and now we reap the fruits o f our labour (or lack thereof). Unfortunately this appears particularly true for the discipline in our country. Several rea­ sons suggest themselves. Firstly there has been a reluctance to publish systemati­ cally. There are very few research-active individuals in the country with a sustained record o f excellence. There are not enough postgraduate students in the field. This has been exacer­ bated by the introduction o f community service and the Depart­ ment o f Health’s insistence that clinicians may not register for a higher degree while fulfilling their community service (despite the profoundly valuable material they are working with). Out­ side the academic context, persons with higher degrees are not adequately recognized or remunerated. There is a considerable drop in the number o f papers submitted to and published in this journal. There is not enough diversity in the papers submitted and it is not clear what the standard of evaluation have been applied. This trend is not unique to our context. There is a chronic shortage o f doctoral students in the discipline in the United States (Gallagher, 2006). People would rather subscribe to clinical journals than to the Journal o f Speech and Hearing Research. Back home there are no research posts and little research funding available for our profession. University staffs, even those with particular research competence and leadership are obliged to focus on the clinical skills o f their students. Re­ searchers are leaving the field and joining other disciplines. It would be tempting to blame this state o f affairs on what Galla­ gher (2006, p. 34) refers to as “the prevailing academic culture Die Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vol. 54, 2007 in the discipline that emphasizes clinical activities, clinical in­ struction and clinical career models” but this is not the whole story. In the face of increasingly prescriptive curricula and training methods imposed by the professional bodies, some aspects o f the curriculum have to give. Sadly some training departments are considering dropping the 4th year research re­ quirement in this country or limiting the project to a literature review or the development o f a research proposal rather than the implementation o f such a project- despite a crying need and opportunity for relevant research especially. This is not unique. Many training programmes in the United States have even dropped a research requirement at Masters level. The hard- earned reputation of our profession may be losing ground. Second, the adoption o f methods from other disciplines appears to have been haphazard and often informed by neces­ sity rather than systematic choice. There is as we all know a difference between clinical significance and research signifi­ cance (Goldstein, 1990) but unless we can articulate this differ­ ence convincingly, our research will not be published. The problems we research require the application o f novel research methodologies and it is probable that historical methods may have been too narrow. As we confront many of our current clinical challenges, methods and explanatory paradigms may extend beyond those disciplines which initially fed us and guided our direction. For example Earle (2001) has argued very convincingly for the value o f teaching sociology to our disci­ plines as sociology is multi paradigmatic and inherently reflex­ ive and is thus most suited to social behaviour. As I have ar­ gued elsewhere, (Penn, 2004b; Penn, 2005) there is a rich heri­ tage o f methods from other fields which can and should be brought to bear on some o f the important issues especially in a culturally diverse context. However most courses in research methods do not teach these (or do not teach them properly). Certainly the textbooks written for researchers in our field often specifically eschew or ignore these aspects. There may be a level o f insecurity for the researcher who seeks valid applicable methods in the field of anthropology or interactional sociolinguistics, for example. And venturing into this new uncharted domain requires caution. The choice o f method should be driven by the research question. No researcher or discipline should abandon quantita­ tive methods simply because they cannot understand them. I fear that the questioning o f Mathematics as a potential entrance requirement at universities will have that impact, not just in our field but in other areas such as Education. The consequence of this is that researchers will choose elementary qualitative meth­ ods simply because they cannot choose anything else - ‘if you don’t (or can’t) teach statistics then they will not do statistics’. As I see research emanating from different sources in this coun­ try, I believe that I can already see a direct relationship between the type o f research conducted and the changes in admission criteria for the disciplines at training institutions. There is a trend called “qualitative” in our field \yhich does not really meet the rigorous requirements o f proper re­ search. It is really too easy to indicate that context is so impor­ tant and our measures so complex that we don’t need methods o f the past. But there are equally many misconceptions about qualitative research which are rife. As many authors have pointed out there are a range o f criteria for rigorous qualitative research (Johnson & Long, 2000; Evans & Pearson, 2001; Sharts-Hopko, 2002; Simmons Mackie & Damico, 2003; Walsh & Downe, 2006). Ethnography is not a “helicopter” visit (to use the words o f a respected mentor, Peter Cleaton-Jones) but at least a six- month commitment to participant observation. 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 Research and Practice 15 Properly conducted scientific qualitative research is time-consuming and profoundly challenging and as I can per­ sonally attest, publishing it in our field is even more difficult! The guidelines that exist for evaluating the quality o f qualita­ tive research should be heeded and applied particularly by editors and reviewers o f our journals if we are to make pro­ gress when judging the scientific merit of an article. The edi­ tors o f this journal have an important role to play in quality control as well as in empowering the researcher. And in ad­ vancing research Effective science is when you use the right method for the right question. The most difficult scientific choice occurs at the beginning o f the project when you have to match the method to the question. Acknowledgements o f the influence o f cultural and contextual indices such as family, gender, arte­ fact, history, geography, religion, education, myths and atti­ tudes does not imply that these factors cannot be studied meaningfully in a quantitative way. It depends on the research question. I believe it is quite possible for a research question to have equipoise in terms o f the method o f choice. In other words it may well be answered in a number of different ways. If I ask whether a particular voice technique works for patients with Parkinson disease, I have a choice of design: I could adopt a group approach and do it in a time- series way (following a psychology tradition); I could use a control group who does not have the intervention (see Sapir, Spielman, Ramig, Story, & Fox, 2007 for an example o f this); I could measure outcomes on a spectrograph (drawing on technology and theory from linguistics); I could measure out­ comes via open ended questionnaire and satisfaction scales (drawing on psychology and Quality of Life research); I could observe the use of voice in a number o f contexts (using meth­ ods o f description and observation); I could ask caregivers and family members o f the participants about the social impact of the voice, or I could use any o f the above in combination. All o f these would be acceptable methods provided there is a reason, and that reason may depend on the phase of the investigation, the scope o f the study, the time frame and its clinical imperatives. What seems to matter is that I am aware that there are such options in research design and that there is scientific rigour as 1 move along. To ignore alternative de­ signs, because of a limitation o f knowledge is to deny the roots and the essence of our discipline. I believe it is not only acceptable, but a sign o f academic maturity to adopt and com­ bine methods and theory from some of our disciplinary part­ ners. But when this is done, it must be done properly. It seems a pity that the iwriters of the lead article do not explore more carefully the publications that have been pro­ duced in their own journal and other journals in the field, nor the issues which have been researched in this country. I think they would find some pioneering and honest attempts to re­ solve the challenges they have posed and to embrace and merge different paradigms. Some common approaches to research deserve some attention. Therapy effectiveness studies have a long tradition and often take the format o f single case studies (see Herson & Barlow, 1984). Such studies are ideally suited for our field, because o f the diversity o f our clinic populations, the huge difficulty in finding sufficient participants for a group study and because of the compelling nature o f therapy effectiveness. But there is often confusion between scientific single case studies and clinical case studies and as Finn, Bothe and Bram-| 5 lett (2005) have pointed out, the field abounds with single case reports which are no more than a case description and which do not incorporate the essential elements of control which are the hallmarks of a true single case study including the multiple baseline measurement, randomization as well as clarity , reliability and validity o f measure. Another example comes from the measurement o f the impact of training programmes (understandably a common interest in this context). A mistake is made to assume that a training programme is effective merely because there is a change in the participants’ knowledge after that training pro­ gramme. For example if there is a training programme to teach nurses about dysphagia and they show improved scores on a dysphagia quiz after that training, it proves nothing about the effectiveness o f the training programme, only about the nurses’ memory. Yet this is a standard design which I have seen pub­ lished and would be classified as a weak or “pseudo” design (Finn et al., 2005). To turn this into a proper research study would involve comparing this programme with another, and measuring the impact on the quality of nursing care measured, either in terms o f quantitative outcome (such as patient weight, or length o f stay in hospital) or qualitative measures (such as patient satisfaction). The retention of such practice is also an important variable to measure. Survey research is another method frequently used in our field. Knowledge, attitude and practice (KAP) research is frequently done, and its methods familiar and comforting but its relevance has to be questioned in some cases (Cleland, 1973). There seems to be little scientific merit in showing what we already know and what is instantly obvious. What do GPs know about language impairment? What do nurses know about dysphagia? (e.g. Pelletier, 2004) What services are lacking in rural areas? Do new graduates feel confident with hearing aid fittings? Unless you are the health minister (or perhaps in our current case, because you are the health minister) there is not much use exploring the attitudes o f health professionals to­ wards post shortages. Even armed with that outcome, there is little that can be done with that research to change practice or policy. We could generate a number o f research questions which could be asked. But are all worth asking? Feasibility and relevance are different things and should not be confused. This links closely the central theme o f relevance dis­ cussed in the lead article. I agree that there is an urgency of service delivery in South Africa I am the first to agree we can­ not ignore the political agenda o f our context. Indeed statutory bodies and universities pick up such challenges and define and fund specific research thrusts. But these may not overlap with the ethical imperatives o f our profession and some communi­ ties may hence be severely marginalized. One has to think for example o f the impact o f the AIDS epidemic on research fund­ ing opportunities outside that broad field in this country and the huge grant money in the US currently diverted to the field o f cognitive neuroscience. Research goes where the money is and when last I checked, very little was flowing into research for the cerebral palsied in rural populations in this country de­ spite a desperate need for understanding barriers to care (Barratt, 2007). Sadly many practicing clinicians fail to see the rele­ vance o f research at all. This brings me back to the haunting recurrent words o f the title of this article. Without the disci­ pline o f science, we will simply remain a group o f ‘practicing’ clinicians and we will never achieve mastery or acknowledge­ ment. We can ‘practice’ doing science but what is needed is for science to be done with authority, with an audience, with peer review, with argumentation and with energy. Conclusions This much I know. Unless our disciplines in this country strive 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. ) 16 H. K athard, E. N aude, M. Pillay and E. Ross for, sustain and improve their research agenda and profile, we are vulnerable in the extreme. We will be absorbed first into multidisciplinary schools and into multidisciplinary service cohorts and then eventually into technikons. Our functions will be (if they are not already) subsumed by ENTs, secretaries and assistants. The signs are there for all to see. We are expensive; we are probably too few in number to be heard. We have a limited proven effectiveness (Reilly, Douglas, & Oates, 2004) and the leaders o f our professional body appear to have com­ pletely different agendas from those o f research excellence and scientific autonomy. I end with some questions and challenges to the profession, the universities and the journal: • Why is there such a shortage o f postgraduate students? • Why can’t people do research without research funding? • What steps have our national professional bodies taken to encourage, endorse and fund research? • Why do people think that research is only for those who are not clinically inclined? • What will happen when this ageing cohort o f researchers in this country (amongst whom I proudly place myself) stops doing it? • What will happen if the international profile and contribu­ tion that we have earned is eroded as we cease to publish in international journals and as our own journal readership dwindles? As the lead article suggests, South Africa is a unique testing ground and clinician-researchers here have a huge potential to inform world practice and theory around issues o f diversity, multilingualism and the unique disease profile. Based on our caseloads, our training, our daily interface and the splendid goals o f our country’s constitution, we could be world leaders in critical Speech-Language Pathology and Audiology (Penn, 2000). Why is this not happening? While heavy caseloads are frequently cited as a reason why clinicians cannot engage in research, conversely that very fact should make the research process more compelling, accessible and easier. It is up to us to recognize and act on these opportunities and to publish them where they will make a difference. Perkins (1985, p. 13) said that “Our field is haunted by a fallacy. We are predominantly a profession o f practicing cli­ nicians. That was not our origin. Beginning as scientists in search o f understanding the nature o f disordered speech were hardly out o f our infancy before our scientific pursuits were outdistanced by the pressing need to help the millions who were speech and hearing handicapped”. Our identity is still a problem in this country. Review committees don’t know where to place us. University restruc­ turing committees and Faculty members are puzzled by our multidisciplinary curricula. Barring this journal we don’t know where to publish our articles. There will be no progress in our identity for our professions until we have proven their scien­ tific status. I f we don’t know what we are, we can hardly ex­ pect others to know. Being teenaged is not all bad but there is a critical time for introspection. Our identity has to have scien­ tific credibility and should be respected so members o f the profession can compete with others at scientific fora and for research money. There is a place for hard science. There is a place for other methods, but until it is done properly in either domain we will not get the recognition we need. The Universities have a critical role to ensure research productivity in staff and to develop post graduate numbers. We need curriculum changes, additional funding and support for postgraduate study, representation on national research bodies and importantly, an attitude o f curiosity. Above all there should be an appeal to explanatory theory, if necessary drawn from more mature, well grounded and respected scientific disci­ plines. This journal has a critical role to play in encouraging and developing research which meets international standards. This research can (and should) be original and proactive and inform world practice about relevant issues o f culture. The journal has a critical role to play in the profession in South Af­ rica and in reminding its members about our origins. It has the responsibility not only o f calling for papers but o f setting the scientific tone o f the profession, by advocating and endorsing the full range o f scientific methods, for applying international standards o f excellence in review o f different methods and out­ come research (Robey & Schultz, 1998; Finn et al., 2005) and for asking for help when it is needed. Our accountability to our clients and to our own profes­ sion’s continued existence lies not solely in our clinical skills and our ability to convince the likes o f Leary that we have nice personalities. I believe that some current developments in the South African profession are setting us back and I offer a chal­ lenge to the profession and its members and particularly to the journal to address and rectify those problems. Autonomy is the ability to thrive and “the capacity to think, decide and act on the basis o f such thought and decision freely and independ­ ently” from the controlling interferences both by others and from personal limitations that prevent meaningful choice (after Gillon, 1985, p. 60). The autonomy o f our profession lies pri­ marily in demonstrating its scientific basis. It also involves establishing a strong relationship with its partners. To ignore this is to continue a slow descent into obscurity. In conclusion I commend the authors o f the lead article in posing a challenge. It is timely and should be heeded. I con­ cur that it is time to tackle the challenges o f context and to adopt frameworks o f investigation and explanation which may be alternative to the mainstream positivistic ones. I do however recommend that this shift is done with caution and is grounded properly in the traditions o f the disciplines framing such a shift. We cannot afford to be lukewarm about scientific endeavour. The requirement o f scientific rigour transcends any one particular approach and remains the only way in which, our own disciplines can flourish through meaningful interface with other professions, with the international community and with the communities we serve. I Acknowledgements Many o f my ideas have emerged and slowly developed from an exciting opportunity I had to engage in a series o f interactions on the topic “Is Speech Pathology a Science?” with Gerald Siegel, Carol Prutting and Gene Brutten. Their insights and ideas have profoundly affected our profession and my own career path and they taught and inspired research by-example. I am grateful to Jennifer Watermeyer for her research assistance and to Peter Fridjhon for his critical and helpful ear as well as many hours o f shared enthusiasm on this topic. 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A rch ives o f N eurology, 43, 653-658. A p la ce f o r m ixed methodologies? Response to: The relevance o f Speech-Language Pathology and Audiology Research and Practice - Challenges f o r the Professions The authors are to be commended for raising pertinent issues relating to the ways in which the professions conduct research and the relevance for accountable practice, especially at this point in our professions’ and nation’s history. Given our past and current realities the challenge is to advance research and professional practice responsibly and responsively. In the new spirit o f redressing previous inequities, and increasing the access o f the majority o f South Africans to professional ser­ vices, there has arisen an urgent need for research that guides ethical service delivery in the context o f cultural and linguistic diversity, poverty, and the ravages o f pandemics such as Tu­ berculosis and HIV/AIDS. Posing solutions to the questions raised by the authors might sug­ gest that there are ready answers which is, manifestly not the case. Hence this treatise considers some o f the issues relating to the production o f knowledge and the challenge of making it respon­ sive to professional practice. How do we produce knowledge? The ways in which knowledge is produced reflects particular worldviews - which have changed over time. Critics (such as Habermas, 1972; and Lincoln & Guba, 1985) o f the modem posi­ tivist approach which espouses that the natural causal laws gov- 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. )