A discussion of training standards for the field of speech language pathology in various countries around the world would be very interesting to me. I am certain the profession has much to learn from how other countries function in training speech-language pathologists. And as a person who stutters, I am particularly interested in how these standards affect training in the area of fluency and fluency disorders.

In January 2002 I was appointed as the public member to the Council for Clinical Competency (CFCC) of the American Speech-Language Hearing Association (ASHA). This is the body that establishes the standards for becoming certified as a speech-language pathologist or audiologist in the United States. Accredited university programs then design their academic and clinical training to meet or exceed these standards. The current standards have been under review for some time and new standards were approved in 2000. However, implementation of the new standards does not take affect until 2005 for speech-language pathology. In the meantime the CFCC is charged with writing language to help programs understand and implement the new standards.

While there will continue to be concerns regarding the training, experience levels, and ability to treat stuttering of many Speech-Language Pathologists (SLPs) I believe the new standards are an improvement over those that currently exist.

Before I get into the specifics of what the new standards call for I think some explanation and history of the process might be helpful.

History

In the United States, most professions are regulated by individual states through licensure. State licensure was created to protect the health, safety and welfare of the public. This is done by establishing some minimum level of competency for those wishing to provide professional goods or services. These are commonly referred to as standards or rules. Most of us are familiar with this system for physicians, attorneys, etc. However, state licensure for SLPs is relatively new. States only began to license SLPs in the late 70s and early 80s. In fact there are still two or three states that do not have licensure for speech-language pathology.

The primary reason for the profession of speech-language- pathology being so late to be regulated by state licensure is that speech pathology had its roots in the school systems. The entry-level degree was a bachelors degree and they were certified as speech teachers. This certificate was issued by the state education agency. Many of these earlier certified individuals had very little training in speech pathology but were interested in working with children with speech difficulties. It should be pointed out that many of these dedicated people went on to receive advanced training in speech disorders, pursued and received masters degrees, and continued to provide state of the art services to clients (children).

In an effort to advance the profession and keep pace with increasing knowledge and skills as well as wishing to elevate speech therapists to a professional status ASHA established a credential called the Certificate of Clinical Competency (CCC). Academic and clinical standards were established to qualify for this credential. University programs followed by designing their training to meet the ASHA standards so that graduates from a masters degree program in speech-language pathology could be certified by ASHA after completing a required one year clinical fellowship (similar to an internship). The Cs as they are referred to became the gold standard for entry level into the profession. The masters degree became the minimum academic level and a one-year clinical fellowship (internship) became the minimum clinical level necessary to qualify for the Cs.

Eventually, states began to develop licensure for speech-language pathology. They usually incorporated ASHA standards into their rules as the minimum level of competency required for a license to practice within that state. Many bachelors level SLPs were grandfathered into licensure. Most states continue to allow individuals who were certified by the state education agency with a bachelors degree and did not elect to become ASHA certified (requiring at least a masters degree) to continue to practice as SLPs in the schools. This will eventually play out because almost all school districts now require SLPs to have their Cs.

As the profession grew so did the scope of what it was being asked or required to do. Speech therapy had expanded to speech-language pathology. Disorders from simple articulation problems to autism were being managed by SLPs in school and other settings. To keep pace with the ever expanding knowledge and skills required within the field ASHA established a system to review and revise the standards for the CCC.

What Happened to Stuttering?

Prior to 1993 the standards required both coursework (academic) hours and practicum (clinical) hours for fluency disorders (stuttering) at the graduate level. Academic courses tended to cover theory and practicum hours were intended to provide the student with opportunities to observe a certified clinician conduct therapy as well as be observed while learning to conduct therapy themselves. The minimum number of clinical hours for stuttering was 25. The same was true for voice disorders and articulation, etc.

However, many clinical programs were complaining about not having enough stuttering or voice clients in their community to meet the standard for practicum hours. They were also citing the need to expand the scope of clinical practice to keep up with the demand for expanded services.

As a result ASHA changed the standards in 1993 by combining fluency, voice, articulation, and swallowing in the required 25 hours of practicum. This meant that graduate students could receive their required hours in either of these areas or in combination. Immediately, it became possible for a student to graduate from an ASHA accredited university, go to work in a school or any other setting and never have observed, practiced under supervision, or even seen a child, adolescent, or adult who stuttered! Both consumers and SLPs who were keenly interested in stuttering viewed this as a travesty.

The fact is that stuttering has always been a confusing and difficult disorder to treat. The 1993 changes did not create the problems associated with the diagnosis and treatment of stuttering but they went a long way toward reducing the minimum knowledge and skills SLPs so desperately needed. and I might add wanted.

What about the new standards?

The new standards follow the new trend in education. This trend is referred to as outcome based. Generally speaking they represent a paradigm shift in teaching. The old standards were based on what is referred to as prescriptive. That is the standards prescribed not only how many hours in each area of intended learning and practice was to take place but also specifically what those hours would entail.

The new standards still have minimum hours for academic and practicum training and they specify what knowledge and skills are required but they do not dictate or prescribe how an individual program uses those hours to achieve the knowledge and skills. The good news is that competency in stuttering (knowledge AND skills) is once again one of the core areas required for certification.

It will remain to be seen how different university programs implement the new standards. The non-prescriptive nature provides programs with a lot of flexibility to create some very innovative teaching models. Time will tell but at least knowledge and skills in stuttering is required again!

The fallacy of training

Now that increased training for stuttering is back in the standards again is that going to solve the problems of adequate treatment? The unequivocal answer is no. University training alone is not the answer. A degree and a certificate are only the keys for learning. It is the same with any profession. There is no way to train experts in every facet of a profession in school. No, the real learning begins after college when one begins to apply their trade. Just as every physician is not cracked up to be a surgeon not every SLP is cracked up to be good at treating stuttering. Service delivery is a complex problem with a number of interrelated issues.

Schools

Over half of ASHA certified SLPs work in a school setting. As I mentioned earlier the scope of practice for SLPs has expanded greatly over the years. At the same time the schools have become responsible for providing more services to children than ever before. In a private practice or hospital setting a professional who feels unqualified to treat someone has the option and the ethical obligation to refer that individual to a specialist or at least another professional more equipped to treat a particular problem.

In a school setting the SLP has the same ethical obligation but the option to refer is not as easy as it might seem. They are under tremendous pressure to serve all populations not to mention the incredible amount of government regulations, mandates and paperwork piled on them.

I am not suggesting that all of this is OK. It is not! I'm simply trying to explain some of the problem.

Private Practice and Other Practice Settings

The new standards also for the first time require a certificate holder to obtain ongoing continuing education to maintain their credentials. This online conference is one way that SLPs can expand their knowledge in the area of stuttering. Hopefully, as the National Stuttering Association (NSA), Stuttering Foundation of America (SFA), and ASHA increase their continuing education opportunities more SLPs will choose to increase their knowledge about stuttering.

The Role of the Consumer

While the new standards should help to better prepare graduates to become more knowledgeable about stuttering it is still ultimately the responsibility of the consumer to check the credentials and experience level of those from whom we seek treatment. This is also true for parents of children who are being provided treatment in school. It is not appropriate to simply assume that every SLP possesses the requisite knowledge and skills necessary to treat stuttering effectively. Neither is it appropriate to expect that even the best trained and experienced speech-language pathologist can "fix" us. While we rely on them to help educate us, to teach us skills to improve our fluency , to help us confront and work through the emotional scars and negative thought processes resulting from stuttering, and to encourage us all along to do the work it is still ultimately up to us.

The Future

I think the future for children and adults who stutter has never been more promising. We have now for the first time in history board certified specialists in fluency disorders, a special interest division within ASHA devoted to fluency disorders, and a growing consumer support system and advocacy movement through the NSA.

Even so, challenges remain. While specialization is available it is still new and there are not enough specialists in the field yet. The numbers of graduate students remaining in an academic and research tract is seriously declining. We need to encourage bright and talented young SLPs to consider research and teaching as a career.

We need to work with school based SLPs who are interested in stuttering by providing information, encouragement and support. We also need to help SLPs who are not comfortable treating stuttering by encouraging them to refer students to those more qualified and then standing behind them when they do.

Mostly, we need to continue to be a rational but persistent voice for all of those who stutter and their families. By working with the professional community instead of against it we can help to shape the future of the understanding and treatment of stuttering for generations to come.

-Discussion-