Social representation of speech therapists’ ethos in the metropolitan and Valparaiso regions of Chile

ABSTRACT

Purpose:

to describe the social representation of Speech Therapists’ ethos.

Methods:

qualitative research based on content analysis. The method consisted in focalized interviews to speech therapists from Valparaíso and the Metropolitan regions of Chile.

Results:

the data collected from the interviews was divided into seven categories called: experiences, skills, professional actions, beliefs, values, ethical foundation and professional identity. This information let us see the need the Speech Therapy discipline has to deepen its reflective practice.

Conclusion:

for Speech Therapy to become part of the bioethical discussion and have its own ethic discourse it is necessary to continue developing the reflective practice in order to strengthen the professional ethos.

Keywords:
Ethos; Social Representation; Speech, Language and Hearing Sciences; Ethics; Moral Education

RESUMEN

Objetivo:

describir la representación social del êthos de la fonoaudiología.

Métodos:

investigación de tipo cualitativo, por medio de análisis de contenido a entrevistas focalizadas, realizadas a fonoaudiólogas/os de las regiones de Valparaíso y Metropolitana de Chile.

Resultados:

del análisis de las entrevistas se levantaron 7 categorías de análisis denominadas: experiencias, habilidades, actuaciones profesionales, creencias, valores, fundamentación ética e identidad profesional que permiten visualizar la existencia de un desafío en la disciplina fonoaudiológica en profundizar sus bases reflexivas.

Conclusiones:

para que la fonoaudiología se integre a la discusión bioética y asuma su propio discurso ético se hace necesario continuar estudiando las bases reflexivas de la disciplina y enriquecer así su êthos profesional.

Palabras clave:
Êthos; Representación Social; Fonoaudiología; Ética; Educación Moral

Introduction

Professions are subject to constant change and challenges, and that is closely related to how they progressively build and strengthen their own identities. Along this professional development the shaping of the discipline’s ethos becomes a key task to give the profession an ethical orientation. Thus, this reflective and deliberative task has to be seen as a collective responsibility by the professionals who belong to a given discipline so as to encourage the building of a moral dimension. This responsibility needs to be taken by institutions which train future professionals, in this case, speech therapists.

While other health professions such as medicine and nursing have been able to mark off, define and publish the ethical foundation and principles that guide their practice, little literature is found regarding the way in which speech therapy develops its ethical guidelines and builds its professional êthos. Therefore, this research aims to contribute to speech therapy’s ethical reflection by proposing a research line and collective discussion; a pending and essential task to establish the principles and values which constitute the moral character of this profession. This way, from a speech therapy’s perspective, reflection will be done on how to identify a speech therapist’s moral status, and how they define “their being a therapist” for themselves.

Consequently, and as a first approach, this qualitative research seeks to describe, through social representation, the current ethos of speech therapists, with the belief that by doing so, a reflection process will be started on how speech therapy’s moral dimension is expressed.

In the coming sections of this work, the main themes which constitute the theoretical framework for this research will be presented. Social Representations will be briefly referenced; a definition of Ethics and its relationship with values will also be included in order to relate this with the process of therapeutic relationship and intersubjectivity.

Social representations

Social representations understood as¹: “a particular modality of knowledge whose function is to shape inter-individual behaviors and communication” can be the foundation to encourage reflection on how the êthos of a given profession can be described, analyzed and further developed. Moscovici¹ coined and defined the term “social representation” as: “formed by socialized figures and expressions. At the same time, social representations organize images and language because they identify and symbolize acts and situations which are or will become, common to us all. If we consider it in the passive mode, we can grasp a representation because it is a reflection, within an individual or collective consciousness, of an object or a bundle of ideas that exist outside that consciousness.” These representations are dynamic, they create behaviors and relations with the environment, thus becoming a modifying action both for the subject and the object; therefore, representations become theories which interpret and build reality at the same time.

Ethics

The word Ethics comes from the greek word êthos², which originally meant a place of dwelling; later, it was understood as the character or personality that a person or group of people acquire along their lives. When the definition of êthos is applied to professional life, Risco³ states that: “êthos becomes the ontological foundation of a profession and the essential element which determines how someone needs to prepare to practice that profession and how those who do it need to behave to reach the full performance of their art or science.” In the same line, Maliandi⁴ states that êthos is “ a set of beliefs, attitudes, norm codes, customs”. This author divides êthos into two different moments, pre-reflective and reflective êthos, yet none of those moments is hierarchically superior to the other. Maliandi⁴ states that: “ This is not about some levels being “better” than others, differences lie in the way the reflective action is performed, the purpose of such action and, particularly regarding ethics, the level of normativeness present in the reflection.” According to this author^4), pre-reflective êthos is characterized by conducts adapted to a normative system in which there is not a clear reason underlying a norm. In other words, the set of moral beliefs, moral attitudes, norm codes and customs is not questioned, no reflection is present. Another moment comes when we go from pre-reflective to reflective êthos because it becomes necessary to learn about the application of a specific norm or when questions arise regarding our own moral judgement. This marks the transition to the first stage of reflective êthos, which brings moral reflection with it, raising questions about the reasons for the norm being referenced. Then, Maliandi⁴ points, knowing what to do or what to say is not enough, here we try to answer the question “why”; no more norms will be accepted without questioning.

Êthos and values

Professional êthos entails the integration of values. Much has been written about values, from different theoretical perspectives; therefore, in this research, considering the constraints of addressing an issue such as values, the proposals by bioethicist Diego Gracia will be adopted, as presented in his work⁵ “La cuestión del valor” (The question of value) .

Gracia⁵ points out that ethics is the very realization of values, where an interdependence between objective and subjective moments appears. According to this author, values must become the object of our individual and collective activity, which are realized through deliberation. Gracia⁵ adopts Zubiri’s perspective, where values are built through the relationship between the ‘perceived’ and the ‘appreciated’. What is perceived is appreciated, values are engendered from this appreciation, as a product of our emotional perception. Then, value judgements are cognitively made and those judgements are accompanied by conceptualizations. It could be derived then, that values belong to the world of relativism, since they are the product of a construction; however, Gracia⁵ does not agree with that since the construction of values comes from reality, what makes it richer. Values finish its construction process when they are realized; its realization occurs through deliberation which leads to reflective exchange⁵. Deliberation is defined by the author as⁵: “a process which is intellectual as well as emotional. The emotional moment is particularly important for this issue, given that values are emotionally acquired. Consequently, the construction of values needs certain emotional education”. Based on Gracia’s⁵ perspective then, the realization of values is a personal and collective task and responsibility. We can thus infer that the values which constitute a given professional êthos must be co-constructed through deliberation, among the members of that profession. In this value constructing process, higher education institutions take part, unquestionably; the professional formation they offer should not only be centered on theoretical and technical aspects of their professional practice, but also promote the personal development of their students. Based on this, universities must concern about the personal moral quality of their students and take an active role in this process, not merely relying on the students’ previous personal history.

Therapeutic relationship and intersubjectivity

Nowadays, as Camps⁶ puts it, professional careers have become ways to achieve monetary success and they have also regarded technical knowledge as the most important aspect. For this reason, professions, especially those healthcare-related, have diverted from an orientation towards developing certain necessary virtues for excellence in professional practice. Conill ⁷ agrees with this when he states that: “ Professions are legitimized for their purposes. In order to achieve those purposes, the individuals have to acquire certain values; that is to say, every professional activity creates their own êthos, which anyone who becomes a member needs to adhere to. This allows those who become part of a collective body to know what it is that they have to aspire to; in other words, be guided by those specific values are the foundation for the professional practice, to be able to develop a given êthos. The professional êthos has to be worked on by the collective bodies, nourishing moral aspects through a collaborative construction process, consciously taking individual responsibility, as part of the process, to become a professional. This way, it is possible to create guidelines for such profession, both individually and collectively taking the responsibility of practicing their profession with excellence. This, however, demands a reflective exercise, different from what is expected from formation centered on technical knowledge. When it comes to health professions, technical knowledge is definitely not enough. Excellence cannot be achieved merely based on technical mastery, but rather on the combination of technical command as supported by êthos, which provides the foundation to achieve a good practice. On this regard, Martínez⁸, presents the dichotomy between competent and excellent professional; competent would be the professional who has and masters the technical knowledge of their profession, and whose professional decision-making is based on their knowledge and information, whereas the excellent professional, who has developed the same professional competences, also expresses moral feelings which they blend with their technical knowledge. In Martínez’⁸ words: “Being a professional of excellence means being both competent and upstanding, and in order to achieve this, three basic requirements need to be met: being knowledgeable about one’s professional area, making sensible decisions regarding one’s profession, and showing moral feelings in agreement with the professional practice.”

Excellence in health professions lies in the professional’s capacity to establish intersubjective relationships with the user. In every health profession, to achieve the excellence Martinez⁸ describes, an intersubjectivity process is necessary, which means acknowledging the other. Intersubjectivity is understood, according to Giannini⁹, as the meeting place where acknowledgement of the other occurs, based on communication.

The relationship that is created during speech therapy is one of those meeting places, where the therapist/subject and the patient/subject share a given moment and space. Then, ethical excellence is strongly manifested in the establishment of a intersubjective therapeutic relationship.

According to Giannini⁹, intersubjectivity requires reciprocity, which manifests through communication, a communicative action which implies the acknowledgement of the other based on three aspects: there is something which involves both of them (therapeutically speaking, that something would be providing and requiring care); another aspect would be the act of being before the other, and finally, counting on the autonomous response of that otherness.

Consequently, the therapeutic relationship becomes an ethical-political space, where the therapist/subject and the patient/subject should mutually acknowledge each other. Giannini⁹ states that: “such acknowledgement, implicit in the interaction, opens and legitimizes the whole dialogic process through which a common space, based on the ethical- political principle of reciprocity, is created. It opens and legitimizes the citizen’s space.”

Another factor which takes part in the ethical practice of intersubjectivity is the own therapist’s subjectivity, in this case, the speech therapist. This subjectivity comes from their symbolic representations, which determine how they see the world and how they act in it¹⁰. Thus, the part-takers of this intersubjective meeting are determined by their life story, their previous experiences and personal contexts.

The afore-mentioned aspect poses a difficult challenge in the formation of speech therapists. This implies guiding them through a curriculum that encourages the students’ ethical and bioethical competences so that they can: develop a reflective êthos, be able to create intersubjective spaces with colleagues and users, and make changes in the systems which hinder excellence in the practice. In this regard, León¹¹, taking Abel’s words, suggests certain teaching objectives which include the progressive development of specific professional competences as well as the promotion of: “the balance between values of specialized technical-scientific knowledge and the values of a person’s global and humanistic knowledge.”, highlighting too the necessary synergy between the health policy objectives and the way in which means and resources to bring them to fruition are implemented.”

Methods

This study was carried out through the application of a qualitative approach, since it aimed at describing the social representation of speech therapists’ êthos from the professionals’ subjective perspective; taking meaning from their narrations in order to obtain what Canales¹² calls: “the understanding of the other, which does not imply measuring according to the researcher’s judgement, but according to their own sense of judgement, that which is part of them.”

The sample was selected by means of discretionary sampling, which is used to make content analysis easier, as indicated by Andréu¹³, where the selection of the participants is not relied upon probability or calculations. It was estimated that the sample should cover wide age ranges and professionals working in the Metropolitan and Valparaíso regions.

During field work similar information began to be collected, with no new perspectives and the repetition of certain topics. Because of this, after 9 interviews, field work was stopped and considered completed, based on a saturation criterion. The group to be studied included 9 professional speech therapists, 6 female subjects and 3 male subjects. Their age ranged from 25 to 80 years, 39 as the average age. They all obtained their degrees from traditional Chilean universities. Some of them worked both in the Valparaíso and the Metropolitan regions. All of them were somehow related to higher education institutions. They had either administrative or academic positions or were involved in professional training supervision. Except for 3 of the interviewees, all of them performed clinic practice.

The technique that was used for the data collection was focalized interviews. The interviews were recorded in audio format, also including field notes. The day of the interview an Informed Consent, authorized by the corresponding faculty’s Ethics Committee, was obtained. Confidentiality was assured, and all records were digitally stored anonymously, only having a date code given by the researcher.

To ensure rigor in this study and reliability in the categorization system, all data collected and categorizations created were examined by two collaborators, from the areas of health and humanities respectively, both having a formation in bioethics. Besides, the categorization matrix was checked and corrected by the methodology advisor for this research.

For data interpretation the content analysis technique was used. This qualitative technique combines production and interpretation of collected data in order to make replicable and valid inferences by interpreting and coding textual material.

Results

During field work, the participants were interviewed about: characteristics of êthos, professional practice, professional identity, role of university formation, among others. Seven categories were derived from the participants’ answers and were organized by growing reflection levels, moving from those which refer to more concrete and practical aspects to those related to more reflective and abstract aspects. In Figure 1 (SEE) Presentation of Categories categories and subcategories are shown together with their operational definition.

Figure 1:
Presentation of categories

Experiences

In this category information appeared regarding how the interviewees mentioned and highlighted personal or professional experiences which have transversely contributed the way in which they see life, and that have had an impact on their professional area.

I.3-LE: “I feel empathy before any speech pathology or just any difficulty, because my mother suffered from cancer when I was 11, and that period of my life left a mark, I tried to find an answer somewhere, but I never found it.”

I.6-LE: “In my case, during my primary education I studied at a Jesuit school and they have a strong commitment with social causes, so when you’re very young, since kindergarten, they take you to the streets to give away food, and they instill that in you, that you have the duty of giving to others”.

What can be seen here is that inseparable relationship between the personal and the professional experiences; that is to say, what is experienced in everyday life as a subject cannot be detached from professional life, where that same subject works bringing their emotions, life story and experiences. Therefore, those who had more enriching stories may better understand certain aspects of the ‘other’ taking part in the care context. Working on the balance between the characteristics that the therapist who is a ‘subject-person’ and a ‘subject-professional’ requires becomes a challenge for the profession, where, as mentioned by Gracia⁵ emotional education becomes relevant since subject objectivization¹⁴ does not occur only in the person who receives the care; the professional can self-objectify, taking their subject qualities away, what makes them human, in order to keep an optimal clinic relationship, but by doing so, they are at risk of becoming dehumanized and dehumanizing the other in the act.

Skills

In this category, the professionals highlighted the characteristics that a speech therapist seeking professional practice of quality should have, especially regarding empathy, which is regarded as a key element in the therapeutic relationship and the relationship with other professionals:

I.1-PS1: “They need to have empathy, at the very least.”

I.8-PS2: “Empathy is fundamental, a therapist who does not understand the needs of others is of no use.”

For the interviewees, empathy is established as an ability that the therapist and speech therapy students must have. Based on this, the challenge is to create an interpersonal work plan directed to the speech therapist so they can develop their therapeutic self.

Another skill mentioned by the participants is the communication capacity, also referred to as the capacity for personal exchange and being a good listener. In the responses provided this skill is regarded as a personal skill rather than a professional skill to be acquired; even as a skill to be acquired prior to the speech therapy professional formation:

I.3-PS1: “fluent interpersonal communication, because when first year students arrive, you can tell or have an a priori opinion that a given student can be a good speech therapist based on their communication skills, whereas when they are shy you wonder how they are going to deal with a patient. I think they should bring that skill from home, because we also assume it comes with them, besides, it’s hard to develop efficient communicative skills in 5 years.”

I.4-PS1: “I think they should have communicative skills as a base. They should be people that when communicating, it comes natural to them, as a part of them”, “anything linguistic should come natural to them.”

Among the interviewees, a great number of skills which are not related to the technical area were mentioned; all of them related to the cognitive and emotional domain, which the professional is expected to develop. In this respect, a serious challenge is posed regarding the extent to which the curricula allows for these skills to be developed and whether they provide room for these skills to be discussed, socialized and worked on. From the interviewees’ responses it can be derived that the speech therapist-individual needs a set of characteristics as a base in order to be able to practice his profession. These characteristics entail a profound ethical development which the speech therapist student is expected to develop or have already developed. Thus, skills prominently mentioned included being: empathic, sensitive to the needs of others, proactive, studious, receptive, mature, warm, flexible, a good communicator, motivated, responsible, someone who cares about developing a healthy personality, who can establish limits, who is a good listener, someone who has tolerance to frustration, is prepared for unexpected situations and works well in teams.

Professional actions

This third category contributes to the achievement of one of the specific objectives, which seeks to identify the values and beliefs around the speech therapist’s êthos through their professional actions.

Within this category, the interviewees highlighted the need, during the clinic relationship, to motivate and get the commitment of the patient and their family in the therapeutic process:

I.1-PA: “this needs to translate into taking care of others, listening to them, making suggestions, but they also need to be active”; “So, that’s when they need to be creative, pushing the family to tell them ‘look, this is something different, there are other issues that have to be addressed’, and finally, being able to keep that credibility and trust.”

I.2-PA: “They need to be extremely motivating during the intervention, and not only during the intervention because when it a long-term therapy they need to connect with the patient and the family, keeping them hooked.”

It was also mentioned that the speech therapist’s action has its own pace and rhythm, different from other professions such as that of the doctor. The speech therapist builds a particular therapeutic relationship, which needs to be managed appropriately not only to fulfill the care purpose, but also to create a warm environment for the patient and their family, to keep them engaged and to explain the possible stages the therapy might have:

I.2-FA: “I think it has to do with having an effective communicative style. They need to be warm, provide the family with information that is clear, and yet be available in case there is any question. I think that the more assertive and close one is to the family, the better and more long-lasting bonds one creates… We need to explain what is going to happen, the good and the bad things to come… understand and empathize with what is going on in the family.”

Beliefs

This category presents what the participants mentioned with respect to their role as a professional, the role of the institutions which form speech therapists and their role as people. This category addresses the specific objective which aims at describing the beliefs represented in the professional êthos. This category includes the belief that a speech therapist needs to possess empathy, as a professional characteristic. Together with this characteristic, social vocation and the desire to help others are other attributes that the speech therapist is expected to have, as an innate condition that they bring with them before entering college, qualities which are not taught there but should be used in their professional practice:

I.3-PB: “I believe speech therapists, in general, are people who always empathize with different kinds of people and situations. We do this on a daily bases with people who are close to us or new people we encounter, not necessarily patients or people we treat.”

I.6-UB: “You see, speech therapists have a personality which is typical, it’s like there’s no unpleasant speech therapist. Like some say, it’s a more direct role, which is well-received by the person.”

I.6-UB: “I don’t think universities should start formation of a student when they begin their major. At university they should become involved with the professional environment, for instance, through health plan operations. When they get to university, I think they have to reinforce that feeling of social service and vocation that they bring with them. The fact you feel the need or have the ability to empathize with the other is something that comes from birth; it is in someone’s DNA.”

It was also mentioned by the interviewees that a common characteristic of speech therapists is that they have a pleasant personality. If there are individuals who have a personality which hinders proximity with the person being treated, it is recommended working in other specific areas of speech therapy where personal qualities are not so relevant. They also noticed the fact that attitudinal aspects are not given much importance when evaluating a student and are rarely a reason to fail them.

I.6-UB: “Regardless of the university you study at, nobody is going to fail you because you are unpleasant or because you don’t have a good relationship with a patient. They will tell you ‘work as an audiologist’ as you will have less interaction with the patient.”

The participants highlighted their perception that society still does not have a clear understanding of their role and their career projections:

I.1-PB: “but, in society, I feel people still have questions as to what it is that we do. I’m referring to how I think they see us. I think we are undervalued in that sense.”

Regarding university as the provider of a model of professional practice, a variety of beliefs were observed:

I.9-UB: “I believe the teaching is not important but the model, the model that is given to students and the one that they receive. The students receive a professional practice model, when they do research, as they have a cup of coffee with their professor. They take all those conducts as an example or a reference. The model has a big responsibility, because there is someone being modelled.”

The lack of clarity with respect to the university role indicates a poor job done in the attitudinal aspect, which implies the need to develop a better defined curriculum in that area, as seen in the following extract:

E5-UB: “But in our formation, the attitudinal aspect, for example, has been quite disorganized. That thing about communicating with the patient. Very little of that was covered in our curriculum, which is something psychologists do have. This emphasis on the relationship with the patient.”

Values

This category presents the responses by the interviewees with respect to the values that they believe speech therapists need to have; this relates to the specific objective aiming at describing the values represented in the professional êthos. The respondents’ opinions showed that it is relevant for the speech therapist to own values inherent to their profession; however, they had no clarity as to what those values might be. In relation to this, they mentioned that personal values had to be applied to the speech therapy practice; yet, the values to be considered inherent to the profession were not described.

I.1-PV1: “the most important value is respect for life. Respect for the person’s life, whatever their condition, to respect them as people.”

I.8-PV1: “the value of responsibility, giving the other a sense of happiness and faith. Regardless of who the user is, it’s about giving them hope in the face of their prognosis.”

I.6-PV1: “I think the most important value that a speech therapist must have is the capacity to empathize with others, even if that is something which can never be fully achieved.”

A similar situation to the previous case is seen here, where there is no clarity as to where these values belong. They could be regarded either as personal or professional values, if the latter is the case, then educational institutions which form speech therapists should be responsible for teaching them:

I.1-PV1: “These are qualities that we as teachers should try to make sure these youngsters somehow develop, but also allowing them to have their own individual qualities. “

I.7-PV2: “This is a complex matter, because I think that values, their moral formation must come from home. Families cannot leave the responsibility of certain things to kindergarten, schools and later on, universities.”

If we relate the current state of speech therapy in our country to Gracia’s⁵ theoretical perspective, which states that values are constructed through deliberation, we can derive that there is a pending task regarding the deliberation of values inherent to speech therapy’s êthos. From the data collected, it is only clear that values are important. This situation poses the challenge of how to create instances for the realization of values, as proposed by Gracia. Ethics implies the realization of values, which in turn requires education for them to be constructed.

Ethical foundation

In order to identify the presence of values and beliefs in the speech therapist’s professional practice represented in the professional êthos, the data from the interviews was analyzed within the category ‘ethical foundation’.

The interviewees associated the ethical dimension only with complying with the established rules and norms, but leaving aside the reflective component that it should have. This action is similar to what, from Maliandi’s perspective, would conform the pre-reflective êthos, where norms to be obeyed exist yet the reason why they exist is not questioned. The ethical foundations which contribute to shaping the professional character of the speech therapist are not clear or specific because ethics is mentioned as something generic.

I.1-CEF “It’s about being ethical, showing ethics in your profession. We have laid down a series of rights, the patient’s rights. Ethical in terms of not breaking the norms, not infringing upon the rights of the patients, not lying to them, letting them know where they stand with regards to their disease, giving them all the information available to us without bending the truth. In any way, written, spoken, etc. All ethical codes that theoretically revolve around the health professions have to be put into practice there.”

A lack of reflection regarding the ethical dimension and its impact on the therapeutic relationship is highlighted:

I.5-CEF: “autonomy, the capacity of not imposing. That is something I feel is lacking here, knowledge from an ethical practice. We sort of impose a treatment, you see, constantly. Let the patient decide whether they want to be here or not, whether they want to do it one way or the other way. That means that we need to show them all the alternatives and ways; I feel like we impose things on the patient and their autonomy is lost there.”

Professional Identity

This last category to be presented can be related to others which have already been described. This category addresses the general objective of our research which seeks to describe the social representation of the professional êthos. Within this category it can be seen that the speech therapist’s identity is shaped based on the exercise of their profession, that is to say, it comes from their “doing” not their “being”:

I.1-TPI: “I think the work environment is what it really is, the specializations we have, that’s what I think is our self”…” the way it is defined everywhere else, like those communication professionals.”

I.5-TPI: “We don’t have a well-defined protocol. We are pretty amateurish… the Chilean speech therapist, I mean. This situation I tell you of not having contact with others, because the Chilean society does that, the union of speech therapists does establish that. They are all about trade-union things, not science… In order to say what we are. I mean if you ask people about it, the answer will be related to procedures, we are whatever area we treat… coming from values, the profile. I think few people talk about it, precisely because it is a little discussed topic.”

In addition to this, it can be observed in the discourses that the convergence of different disciplines in speech therapy creates a sense of confusion with respect to their professional identity, which, from an ethical perspective, can hinder the construction of self, that is to say, a characteristic professional êthos:

I.4-TPI: “It’s just that the speech therapist is a professional hybrid, a mix of the different disciplines which nourish it”. “See, I believe that one of the things that define it is that it is in that intersection between health, social sciences, psychology, education, in that overlapping of areas.”

Discussion

The results obtained in this research show that the social representation of speech therapists’ professional êthos currently reflects an unclear êthos, lacking a common reflective base. In this regard, it is necessary to address two aspects which should configure the speech therapist’s êthos; the ‘being’ and the ‘doing’; the being should be reflected in the practice. Nonetheless, the data obtained account for a professional practice which is more competent tan excellent⁸. Thus, in speech therapy, what is done in direct care, be it giving a prognosis, providing therapy, working on a communicative dysfunction, can become an activity deprived of ‘being’ (even if one is competent). This situation can be identified as a pre-reflective êthos⁴ and this invites the speech therapy community to discuss the philosophical foundations that it should be built upon, in order to develop disciplinary theories of their own. Such as those developed by medicine and nursing.

To achieve this, it is essential to have the commitment on part of the Speech Therapist’s Unions, which are responsible for laying down the professional ethical codes and regulating their observance. Currently, an international consensus regarding speech therapy’s ethical guidelines has not been achieved. There actually is an absence of international ethical guidelines, and the national ethical codes are mere lists of rights and duties, with corresponding sanctions¹⁵. In this aspect, disciplinary efforts which establish a new representation of the professional êthos’s state should be made, thus generating dialogues internationally with the aim of creating ethical codes based both on the ‘being’ as well the ‘doing’ of the profession. This idea is further supported by the ‘beliefs and values’ categories in this investigation, where the participants express the idea that there is no shared professional base on which to build the different professional roles. It is also voiced that speech therapists should have certain values, however, there is no agreement about the specific values that should be constitute the ‘professional self/being’.

On the other hand, the professional’s personal skills, such as communicative skills or empathy and social responsibility, were regarded as central concepts to speech therapy care. Whether these skills should be asked as a requirement to those who begin to study this major or be promoted as part of the curriculum remains a matter to reflect upon. Having an excellent therapeutic relationship entails it being based on an intersubjective exchange, both between the therapist and the user and the therapist and other subjects taking part in the multi and interdisciplinary care. It is important to point out that intersubjectivity is related to communication; therefore, if the communicative skills were only seen as a pre-requisite and not further developed during the person’s professional formation, there is the risk that the therapeutic relationship lacks intersubjectivity, and it turns into an objective exchange (during which the therapist regards the users as a care object and not as a subjective- subject). It is also important to remember that, in intersubjectivity, an encounter of subjectivities occurs. These are determined by the life story and personal experiences of those who interact. In this respect, Franco¹⁰ points out that a subject has access to different “semiotic fields”, which determine their interaction and attitude towards the environment, in this case, the healthcare work environment. These attitudes, in turn, depend on the person’s symbolic representations, and this gives certain subjectivity to their caring actions and interactions within the health care organizational network. These subjectivities will have an impact on the professional’s therapeutic relationship style, since¹⁶: “care practices are determined by the singularities of every professional.” Therefore, these subjectivities and their capacity to create intersubjectivity, have to undoubtedly be considered in the professional’s formation.

It is the speech therapist’s character which, faced with the speech alterations that the subject being treated has, contributes to making the therapeutic experience a part of the user’s happiness project. Then, we need to ask the question posed by Ayres¹⁷: “What is our contribution in the construction of those happiness projects we are helping conceive?”

It is seen here how the act of providing therapy becomes a great ethical responsibility; it becomes a moment which greatly contributes to the good living projects the users have. Merhy and Franco point out that, in healthcare, people who take part in the care process¹⁶: “can create an invisible energy field which works in circulating flows that surround the act of care and configure ‘life lines’ or ‘death lines’ depending on whether the therapist- user relationship engenders acceptance, bonds, autonomy and satisfaction, or a time-limited, bureaucratic relationship causing heteronomy and dissatisfaction.” In order to be a contribution, the therapist needs to have a capacity for ethical inner leadership¹⁸ causing them to observe their practice in a self-reflective and self-analytical manner: to observe the care process paying attention to the effects it has on themselves and the other. These are the reflection levels which generate real intersubjectivity.

In addition to what has already been mentioned, it is important to point out that the speech therapy practice also entails political and social responsibility roles which should be part of the professional êthos. These roles, however, were not clearly established by the interviewees in this study. If speech therapists can successfully develop their ethical inner leadership, they will be able to use their knowledge to create networks of change in the social fabric, starting in their workplace, where they would tend to form intersubjective, creative and compassionate bonds. According to Franco¹⁰, self-analysis, at the healthcare collective level, can be understood as the process through which this community produces and takes ownership of knowledge about themselves. This knowledge is applied to their real work environment, which includes their needs, desires, requirements, problems, solutions and limitations. This knowledge also gives the subjects the possibility to modify and build reality in order to encourage healthcare services to be solidary and warm, based on positive bonds, feeling responsible for the user’s wellbeing¹⁰.

At the individual level, the speech therapist’s political role manifests through strategies that contribute to the development of skills the users need. The therapist creates instances that foster participation in citizen’s spaces of interaction, encouraging the user’s autonomy, which in turn, allows them to develop or recover tools favoring the collective coexistence. Therefore, being a therapist who works in the communicative area inevitably becomes a political act, as it has an impact on life as a community.

Ultimately, the political therapy role constitutes a great social responsibility because this role enables the subjects, including those with different capacities, to make full use of their citizenship. This is why the political dimension of communication should be better developed from the speech therapist’s êthos. This poses a challenge for current speech therapy regarding how this socio-political knowledge¹⁹ can be incorporated in the therapeutic relationship. It seems pertinent to reference Couceiro - Vidal ²⁰ ,who define healthcare professionalism as: “ the set of principles and commitments meant to improve the patient’s health results and maximize their autonomy, which create relationships characterized by integrity, ethical practice, social justice and teamwork.”

All the above mentioned cannot spontaneously be developed in the students during their speech therapy formation, much less is it possible to be present a priori, as a result of their life story. It is necessary then to resume discussion about the role of professionals who form speech therapists and the need to reflect and work on the professional êthos the speech therapy professor should have. This is a key element for success in the development of the future speech therapists’ character. The formation of the professionals needs to be wholesome, taking the multidimensional quality of humans into account. In this regard, Gracia⁵ states that emotional education is something that has to be present in all educational levels, including university. He states that this kind of education provides the tools to be able to undergo deliberation processes. Emotional education addresses the construction of personal and professional êthos. Therefore, it can be deduced, that the formation of future professionals should be left in the hands of professionals who are not only speech therapists but who also have a pedagogical formation, and are trained especially in moral and affective education. This would allow for the creation of curricula which include learning outcomes incorporating the students’ moral and affective dimensions (not just the cognitive and technical dimensions), apart from the corresponding teaching and learning contents and strategies. To achieve this, León ¹¹ suggests three basic aspects the educator should consider: getting to know their students, encouraging attitudes and capacity for dialogue, and creating educational actions aiming for attitudinal change.

Currently, the number of speech therapists is progressively on the rise, we, as a professional body, need to make a pause to reflect on the way we should build speech therapy’s critical base, in order to have professional coherence along speech therapy instruction, with a resulting impact on the professional practice. Thus, the speech therapist will have more than just technical knowledge at the moment of establishing a relationship with those they treat, with their work teams and society in general. This way, a professional can construct a wholesome professional êthos, preventing the occurrence of mere procedure-following, reflection-lacking, behavior,

In relation to the professional formation of speech therapists, educators should keep the responsibility of modelling and reflecting in mind when forming professionals, since being an educator of this kind of majors implies constant learning not only about technical matters but also at the personal level. From Domingo’s ²¹ perspective, both the development of the professional’s practical wisdom as well as their reflection capacity has to be fostered, this, however, cannot be achieved only through case studies or by replicating principles. This requires establishing relationships with people from an integral, critical standpoint. When educators make use of this practical wisdom it allows for the strengthening of a profession’s character and gives those who practice it the possibility to overcome the bureaucratic êthos which has taken over professions, turning them into businesses, diminishing their ethical richness. Consequently, during the professional formation process, the speech therapy professor must prevent falling into a teaching model which objectivizes the student²², the same way sometimes users are objectivized in the therapeutic practice. Treating the student as a patient-student can then be a double risk in healthcare instruction.

The invitation is then for speech therapy to review its disciplinary ethical foundations. Other healthcare professions such as nursing have done this before. They questioned the way care would be looked at and defined, reshaping their paradigms based on experience, changing the way they refer to the patient-subject and building their reflection around the way they understand the person and their environment, aspects which have nourished and formed their êthos. In this collective and reflective manner the nursing profession has been able to establish its own nomenclature, creating an ethical code which is valid internationally; taking the care in their hands. The example set by nursing, when compared to the results obtained in this study, poses a challenge for speech therapists regarding how and from what perspective do we understand the other, the therapeutic relationship, the communicative exchange process and our role in society.

Conclusions

It can be concluded from this research that the speech therapy ethical dimension requires a deeper reflection process because it is mostly related to normative aspects, where professional ethics is understood as ambiguous and generic contents, and the way in which the professional êthos is constructed cannot be appreciated. There are disciplinary challenges stemming from this, regarding how the theoretical reflection will be incorporated in the research and disciplinary development process, so that the profession does not only center around the different areas of technical performance ( language, speech, voice, swallowing, hearing, orofacial mobility, etc.). There are some actions which could encourage the construction of a professional êthos collectively. First of all, creating reflection and deliberation instances such as a Latin American ethics and speech therapy congress, to form a Latin American or international council which defines the ethical guidelines for the profession. Apart from that it would be necessary to create a Latin American network for speech therapy and ethics. These actions would allow for the description of professional values, the therapist’s skills, and defining the political, social and clinical communication dimension. Together with this, we need to work on the definition of our social role and carry out theoretical research to strengthen reflection. Similarly, educational institutions which form speech therapists should discuss the progressive establishment of the moral dimension in their instruction. It is important, therefore, to define a common ethical support for the speech therapist; this could happen by creating spaces or courses which further develop personal characteristics. This would allow the new professional to continue developing specific characteristics their professional practice requires. Another option would be post-degree studies according to performance area to develop a specific êthos depending on the specialization area. All these actions aim at promoting an excellent not only competent professional character in the speech therapist.

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Publication Dates

• Publication in this collection
  Feb 2017

History

• Received
  19 Apr 2016
• Accepted
  02 Nov 2016