Equitable Access to Speech Therapy

 Gemma Tait

Speech Language Pathology (or, Speech Pathology) is, frankly, a fairly unknown profession. If one was to look up “speech pathology” in the Oxford dictionary, they would get the following definition: 

speech pathology  n. the study and treatment of defective speech. 

Defective is certainly not the word I (or most people) would choose in addressing what speech language pathology addresses. In fact, although I wholly disagree with the use of the word ‘defective’ here, there is an observable link between societal perception of speech, and the actual practice of speech pathology, but more on that later. Speech Language Pathology is a necessary and important service for people of all ages, and it’s not just about speech. 

Part I. What does it mean to have speech in perfect working order? What does it mean to help?

Have you ever wondered if a person would truly listen to you in a conversation? If they weren’t just smiling politely while syllables flowed out of your mouth like a river? I did, and still do, but at age 6, as I sat in a brightly colored office filled with games and posters of the alphabet, I was still näive to the workings of the world and the central role speech would come to play in my life. As I grew up though, that role began to take a backseat in my mind, everpresent, always there. It was, however, recently brought back to the forefront of my mind sitting in a brightly lit room in front of my laptop on a Zoom call with a Speech Language Pathologist. What’s a speech language pathologist you may ask? Good question.

SLPs, or Speech Language Pathologists serve all kinds of speech and language disorders, as well as other motor functions surrounding eating and drinking. They work with people of all age groups, 0-100, in order to improve their quality of life, as well as confidence. While many people only associate SLPs with disorders such as lisps and stuttering, they have a wide-ranging portfolio of disorders and scenarios they are able to help with. Most children first access SLPs through a school system, and because of that, SLPs serve an incredibly diverse population of students across the country, in districts of varying income levels and with varying populations. In districts with lower funding, (and often higher Black, Indigenous and People of Color (BIPOC) populations) Speech Language Pathologists can be given caseloads of 80-90 kids, versus districts that are monetarily rich in resources, where caseloads can be 30-40. At this point, on our call, Gina Ossanna, a Portland based Speech Language Pathologist, sitting in a light filled room, said, “it’s really showing it doesn’t really have anything to do with the quality of instruction or the quality of the speech path, they both could be excellent at what they do, but the capacity of what you’re able to provide that high quality service.” It’s frankly impossible to provide high quality care when a SLP isn’t able to meet with kids on a regular basis, and has an overloaded schedule. It’s like stretching a piece of paper. It’s going to tear eventually, 

Some of the more common issues treated by Speech Language Pathologists are stutters and lisps, the same conditions that the Oxford Dictionary defines as defective. Defective. Like a broken car or a box with hinges that aren’t quite right. Considering that we live in a world with a plethora of accents and dialect differences, the fact that we still define people who don’t sound exactly like the majority as ‘defective’ is laughable. In fact, I’d argue that the word defective only self-confirms what many children and adults with speech disorders feel. Defective, as someone finishes your sentences (completely incorrectly) and turns to you with a smile, almost waiting for you to thank them as your mouth is still open, gasping on syllables that won’t come out. Defective, as someone asks if you know your own name as the first syllable sits belligerent in your throat. It’s not defective. Different, sure. But defective only encompasses and underscores the shame many people can feel about the way they talk. Speech pathology isn’t just about learning to speak fluently, in fact, in my opinion, speech language pathology is and should be centered on becoming comfortable with the way you talk, and learning tools to aid you in your future. I never achieved ‘perfect fluency,’ some do, some don’t, and maybe with time I could have. But for me, what was most important was learning to accept the way I talked and having confidence regardless, as well as developing a toolbox that has helped me time and time again. And honestly, is there really such a thing as speech in perfect working order?

Part II. What is speech conformity? How do societal expectations and existing structures drive what our perception of ‘mainstream’ speech is?   

“A woman who utters such depressing and disgusting sounds has no right to be anywhere- no right to live”  (Shaw 23). This is the phrase uttered by an upper class man to a lower class woman in response to her attempts to speak to him in the opening act of George Bernanrd Shaw’s Pygmalion. Written in 1912, this play nods to an idea which was and remains especially prevalent in Great Britain and also around the world, the intersection of class, speech and what it means to be ‘normal’. The woman is later able to impersonate an upper class person successfully, losing the stigma that her ‘old’ accent had. While a satire, this play comments on a truth; one of the origins of Western speech therapy lies in ‘accent correction,’ generally attributed to the British elocution movement of the late 1700s, which aimed to supplement the public speaking and rhetoric skills of society members (Duchan). This sentiment is echoed by the same upper class man in the play, as he says “Remember that you are a human being with a soul and the divine gift of articulate speech: that your native language is the language of Shakespear and Milton and The Bible; and don’t sit there crooning like a bilious pigeon” (Shaw 23).  

Shaw lived in and wrote this play on the basis of British cultural norms at the time, and if we examine Great Britain as one of the epicenters of Western Speech Language Pathology, we can see the trends that have carried over hundreds of years, beginning with the addition of Wales and Scotland to England in the creation of Great Britain. (Duchan) Welsh and Scottish accents were seen as uncivilized, or less articulate when compared to the upper-class London accent, or what is now known as Received Pronunciation or BBC English (“Rhetoric: The Renaissance”). When the way someone speaks is put underneath a microscope, those with ‘correct’ speech are often patronizing, causing something that should absolutely not be a burden, the way you talk, to be just that. This trend of accent perception and stigma is able to be observed in many modern countries around the world, however, it is and has been extremely prevalent in the United States, and can be viewed throughout history. 

This critical attention to the act of trying to purge ‘other-ness’ and ‘imperfections’ from speech can be viewed relatively recently in the United States, specifically with language variants such as African American English (AAE), Chicano English and Appalachian English (Gray et al. [“Language and Identity”]). For example, in the 1960s it was relatively commonplace for BIPOC children and adults to be diagnosed with a speech disorder, when many times, the differences between their speech and Mainstream English was due to cultural differences in the delivery of speech (Sabourin). As an aside, Mainstream English, frankly, doesn’t mean a whole lot outside of technical terms, but if I were to define it loosely, it would be someone in the United States who has stepped out of their regional accent towards a more neutral accent – the most prominent likely example being a news reporter or a politician. The fact that being ‘articulate’ is generally confined to a certain accent range underlines the politics of speech, and the hierarchy of the different ways we talk. The attempt in the 60’s, and in the years following to purge cultural language practices from various dialects, is also an attempt to purge various aspects of culture from those very same communities. Language is a weapon and a tool, and can and has been used as both. The racism embedded in the core of these practices extends to access to care as well, as historical inequality for BIPOC students only heightens factors that are already preventing students from getting the care they need. 

Part III. What historic inequalities have existed and/or persist in the field of speech? Why?

There is a current, massive disparity in the access BIPOC children have to speech therapy resources as a whole. This disparity in access has been shown in several academic studies over the years, one of which, answering the question “Who Receives Speech/Language Services by 5 Years of Age in the United States?,” comes to the conclusion that “despite being otherwise similar with White children, we observed that Black children were disproportionately less likely to receive speech/language services in the United States,” (Morgan et al.).  In a study conducted from birth to 24 months of age, it was shown that Black children are 5 times less likely to receive early intervention services than their white peers. (Feinberg et al.) This trend negatively affects BIPOC students as a whole, and denies them the opportunity to receive the same level of care as their white peers, the care itself having shown to have hugely positive effects on both the student’s communication skills, but also their overall self-confidence. COVID-19 has only widened this disparity, and technology barriers to online school and speech services have only widened the opportunity chasm.

Speech Language Pathology, is, as Ossanna describes it, “a very homogeneous field,” corroborated by a report done by Jacquelynne C. Rodriguez in the American Speech and Hearing Association (ASHA) Leader, where it’s stated that in the 2013-2014 academic year, only 15.8% of enrolled students in Speech Language Pathology programs self-identified as BIPOC, and in 2016, only 8% of ASHA members and affiliates self-identified as BIPOC (Rodriguez). This disparity is especially apparent among bilingual communities; many SLPs are taught Spanish or Mandarin in high school or college, but there is still a cultural barrier in those languages as well as less served languages such as Russian, Ukrainian, Tongan, etc. 

Language is an essential part of culture, one cannot exist without the other. While talking on the ASHA Voices podcast, author Ijeoma Oluo, pointed out that “it’s really important to recognize what a powerful tool of oppression it is to deny people the language to describe what they’re going through.” (Gray et al. [“Ijeoma Oluo”]). These false diagnoses served as a tool of oppression, attempting to smother out an entire language and force a language to fit into a mold it was not created for. This inherent relationship raises the need to effectively and purposefully dismantle the language and systems that perpetuate this cycle of oppression, and rebuild it into a fairer, safer and more effective system for all.

Part IV. Has anything changed? What’s the bigger picture? What does intersectionality and cultural responsiveness look like in Speech Language Pathology?

When considering any kind of health service, be it physical, mental, etc. it is essential to consider the intersectionality of the care being provided to a person, regardless of age. The racism structurally embedded into our healthcare systems, and by extension, our Speech Language Pathology needs to be dismantled, and in some ways, people are beginning to do the work. One of the only ways for safe and equitable access to SLP services is through this dismantling, and the learning of culturally responsive practices in order to better serve communities at large. 

 During our conversation, Ossanna pointed out that “based on what I know as a white person to be good communication skills are very different from what somebody from Tonga is going to consider to be good communication skills,” underlining a need for SLPs from all backgrounds to more effectively serve their communities. This point is elaborated on in the article Language Sampling and Semantics in Dynamic Assessment: Value, Biases, Solutions, originally published in the Journal of the National Black Association for Speech Language and Hearing, as the authors state 

“we have a responsibility to take steps to avoid biases in our assessments of children who 

may not share our cultural and linguistic heritage. We must invest time and effort to learn 

about the phonology, morphology, and syntax of languages spoken by the diversity of 

clients that we treat,” (Moses et al. 99). 

It is essential that there is the commitment from the SLP to learn and understand the cultural heritage of the students they work with. It becomes exponentially more difficult to work in a safe, respectful way when the student and the SLP aren’t on the same page. 

  The improvement and expansion of SLP services should come from recruiting more BIPOC students and teaching culturally responsive practices in schools. Some of these efforts are beginning to appear, an example being a textbook written by Yvette D. Hyter and Marlene B. Salas-Provance, titled “Culturally Responsive Practices in Speech, Language, and Hearing Sciences,” which is “a conceptual framework to guide speech-language pathologists and audiologists toward cultural competence by becoming critically engaged users of culturally responsive and globally engaged practices,” (Hyter and Salas-Provance). This is essentially a step towards teaching Speech Language Pathologists in their core curriculum, how to provide each student and family with a more effective, respectful and safe experience by learning to challenge one’s own biases and role in the current framework. There is beginning to be a real push, both in the face of the Black Lives Matter movement and a reckoning inside of the field of Speech Language Pathology itself to diversify the field and open it to BIPOC voices, as well as transgender and nonbinary voices.  

Understand that Speech Language Pathology is an essential service. Full stop, end of sentence. It can help a range of skills, from speech to eating, and it can help people feel more comfortable with themselves by giving them the tools they need to succeed and feel like they can succeed. What’s needed in order for the practice to take its next steps is greater personal awareness by SLPs and structural change in the way that SLPs are taught. Colleges and Masters programs should make a conscious effort to both spread the word that Speech Language Pathology exists and work to dismantle racism from their own institutions. That word is beginning to be spread, but time will tell if the outreach works, and if the people in charge of educational and research institutions are really committed to doing the work.

Honestly though, Speech Language Pathology is a field of study where passionate people are not difficult to find, and Ossanna’s passion for her job was evident, as this is a field of people who work in an overlooked job that serves to aid so many people in their daily lives. As she puts it, 

“I think we can have a tremendous impact, and I think the people that have worked with good speech pathologists have felt that in their lives. Honestly, that’s what keeps me in the field every year. I can have some really difficult years or other years where I just feel like I’ve been doing the same thing, but I think that there’s just an incredible importance to being able to communicate and to express yourself then also to eat safely and drink safely.”

Equitable access to a Speech Language pathologist that fits the needs of each family is an essential service that vastly improves quality of life and self esteem of people of all ages. In order for Speech Language Therapy to progress, the current system must be rebuilt with a focus on access and equity for all, in a safe and respectful environment.

Works Cited

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