Inside SLP

Many SLPs experience ASHA membership as essential to survival even when, structurally, it is designed to be optional. This episode examines why that tension exists, and what it reveals about how professions stay healthy as they grow.

Rather than framing optional membership as a threat, we look at how it functions as a stabilizing feature in mature professional systems and why the fear of “splintering” often signals growth, not collapse.

We explore:
  • The rootbound analogy: How a structure built for a smaller profession can start to constrain adaptation.
  • Exit and voice: Why meaningful participation depends on the possibility of choice.
  • The 96% signal: What ASHA’s own internal report reveals about shared concern and institutional inertia.
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Creators and Guests

Producer
Megan Berg, SLP
Megan is an SLP based in Montana and owner of Therapy Insights.

What is Inside SLP?

Inside SLP is a limited series podcast that reveals how our profession came to be and why it functions the way it does. Most clinicians work inside a system they were never taught to see, shaped by decades of history, policy, economics, and unspoken assumptions. This show offers lightbulb moments that bring clarity to the structures beneath our everyday work and opens space for thoughtful, grounded understanding of the field we share.

Megan Berg:

Welcome to Inside SLP. This is a limited series podcast about how our profession came to be and where it's heading. Most of us work inside a system we were never taught to see. This podcast is about slowing down enough to understand that system with clarity, calm, and context. I'm Megan Berg.

Megan Berg:

Let's look inside. Over the last few episodes, talked about what ASHA is and what it legally isn't. We've unpacked who actually holds authority in this profession and we've started to separate certification, licensure, education, and advocacy into the distinct systems that they are. Today, I want to focus on something that is true but doesn't feel like it. ASHA membership is optional and that is not a problem.

Megan Berg:

In fact, it's the point. For many SLPs, the idea that ASHA membership is optional doesn't feel like a truth. It feels like a threat. The CFY and CCC is embedded in licensure and insurance regulations. Licensure and insurance reimbursement is embedded in employment.

Megan Berg:

Employment is embedded in survival. So when someone says ASHA is a voluntary association, it can feel dismissive. But underneath the practical fear, there is an emotional one. We as a field have this deep anxiety that without one central parent organization, the field will fracture. We worry that if we split into medical and educational groups or if we create a clinical doctorate or if we stop paying dues to the same place, we will splinter the profession.

Megan Berg:

We talk about splintering like it's a breaking of bones, like it's an injury. But I want to offer you a different image because what we're experiencing right now isn't the threat of death. It's the pain of a container that is too small. Imagine a house. When this profession started in 1925, it was a small family.

Megan Berg:

We all fit in one room. We all spoke the same language. We all had the same needs. Living in that one house together made sense. It was safe.

Megan Berg:

It was unified. But today, we are a massive, sprawling profession of over 200,000 people. Some of us are working with intubated patients in the ICU. Some of us are teaching literacy in kindergarten classrooms. Some of us are in private practice.

Megan Berg:

Some are in research labs and yet we are still trying to live in that same one room cottage. We are terrified that if we build an addition or a guesthouse or God forbid, move into different houses on the same street, the family will fall apart. But look at how healthy families actually work. When children grow up, they move out, they build their own homes, they develop their own identities, they don't stop being a family, they stop being roommates. Right now, speech language pathology is a root bound plant.

Megan Berg:

We are all crammed into the same pot, fighting for the same resources and our roots have nowhere to go. We aren't splintering. We are trying to grow. And in nature, if you don't let a root bound plant expand into new soil, it doesn't stay unified. It withers.

Megan Berg:

Differentiation isn't the death of a profession. It's the definition of maturity. So why hasn't the profession adapted? Why does the organization often feel so sluggish or resistant to this kind of growth? To understand this, we have to look outside of speech pathology to economics.

Megan Berg:

In 1970, an economist named Albert O. Hirschman published a book called Exit, Voice and Responses to Decline in Firms, Organizations and States. He was trying to answer a specific question: When When an organization starts to decline, when the quality goes down or the prices go up without clear benefits being added, how do the members fix it? Hirschman argued that in any system you have two primary mechanisms for change. Option one is voice.

Megan Berg:

You can stay and fight. You can complain. You can vote. You can petition. You can advocate.

Megan Berg:

You can try to fix the system from the inside. Option two is exit. You leave. You take your business elsewhere. You quit the club.

Megan Berg:

You switch brands. Here is Hirschman's critical insight. Voice only works effectively if exit is possible. If an organization knows you cannot leave, if you are a captive customer, your voice loses its leverage. They might hold a listening session, they might send out a survey, but they don't have to change because they know that at the end of the day, you have nowhere else to go.

Megan Berg:

Hirschman used the example of public schools versus private schools. If parents are unhappy with a private school, they can pull their child out. That threat keeps the private school on its toes. But in a public school system where families are zoned to a specific building and cannot afford to move, exit is taken off the table. The only tool left is voice, like complaining at school board meetings.

Megan Berg:

And as many parents know, without the threat of losing funding or students, bureaucratic systems can be incredibly slow to respond to that voice. Now apply this to us. For decades, ASHA has operated in a system where exit felt impossible. Because certification was tied to licensure and licensure was tied to employment, the exit door was locked. We became a captive market.

Megan Berg:

This explains why the website can be clunky for years, why fees can rise without clear justifications, why the certified non member option is often hidden behind a phone call. It's not because the people working at ASHA are villains, it's because they are operating in a monopoly. When a monopoly knows its customers have to pay anyway, innovation naturally slows down. The survival instinct that drives a normal business to improve just isn't there. This is why optional membership is so important.

Megan Berg:

It's the only thing that unlocks the exit door. And ironically, unlocking that door is the best thing we could possibly do for ASHA. If ASHA knows you could leave, that you could choose to join a different advocacy group or just pay for the certification at a more reasonable cost and skip the membership, they suddenly have to earn your loyalty. They have to innovate. They have to prove their value.

Megan Berg:

Hirschman would argue that by restoring the possibility of exit, we actually make voice powerful again. If you need proof that this works, just look at medicine. Physicians in The United States don't all belong to one giant association of medicine. That would be absurd. A neurosurgeon and a pediatrician have completely different needs.

Megan Berg:

Instead, they have specialized. Pediatricians join the American Academy of Pediatrics. Surgeons join the American College of Surgeons. They have their own journals, their own lobbyists, their own conferences. Did medicine splinter and die?

Megan Berg:

No. It grew and matured. By allowing specialized groups to form, they created stronger advocacy. The pediatricians fight for children's health laws. The cardiologists fight for heart research.

Megan Berg:

They are all still doctors but they stopped pretending that one board of directors could solve every problem for every patient. Speech language pathology is the only major healthcare profession that is still trying to run a general store in a world of specialists. We aren't protecting our unity, we're holding back our own expertise. If you think I'm being too hard on the system or that I'm imagining this lack of innovation, I want to give you the receipts. In 2023, ASHA released a report from the Ad Hoc Committee to plan next steps to redesign entry level education, which I'll link to in the show notes.

Megan Berg:

This wasn't a fringe group. This was an internal committee of experts tasked with looking at the future of how we train SLPs. They surveyed the people who actually run the grad programs and the people out in the trenches. And the result was staggering. 96%.

Megan Berg:

96% of stakeholders agreed that the current model of entry level education must be re examined or changed. They noted that because the CF is employer based and because the mentor only has to show up for six hours every three months, the quality of the mentored experience depends entirely on the luck of the draw. If you're in a high productivity sniff with a mentor who is also drowning in a caseload at another facility an hour away, those thirty six hours of guaranteed help over nine months are not a bridge. They are a formality. 96%.

Megan Berg:

In a profession that can't even agree on how to treat a tongue tie, 96% of us agree that the way we are being trained and certified is no longer working. The report admits that our scope of practice has expanded so much in the last seventy years that a standard master's degree can't keep up. It admits that nearly half of all graduate programs don't feel that they have the faculty expertise to even teach the big nine areas like dysphagia or AAC at a high level. The report openly acknowledges that our hours based system, where we count twelve sixty work hours and check off a mere thirty six hours of supervision is a relic of the 1960s. It acknowledges that this model is great at creating certified clinicians but isn't necessarily ensuring competent ones.

Megan Berg:

But let's just pause and sit on that 96% agreement for a second. Despite this crystal clear mandate for change, the clinical fellowship still relies on a mentor who is only required to show up for six hours every three months. This is Hirschman's theory in the flesh. When 96% of a system's users say this is broken but the organization doesn't feel the threat of exit, they don't have to move with urgency. They can acknowledge the 96%, they can publish the report and then they can push for reform that stays safely inside the existing CFY CCC container.

Megan Berg:

They can revamp the mentorship requirements or tweak the competency checklists but they will always steer the ship back toward the status quo that keeps them in control. Without the possibility of exit, even a 96% voice isn't a mandate for change. It's just a suggestion for a renovation. I want to close with a conversation I had recently in DC. I was talking with a smart, experienced clinician and at one point she lowered her voice and asked me a question that stopped me in my tracks.

Megan Berg:

She asked, Is it against the law to create a new membership association? I was absolutely struck by that. It revealed just how successful the monopoly has been at positioning itself as the ultimate authority. We have reached a point where SLPs honestly wonder if ASHA has the legal power to prevent anyone else from organizing. The answer obviously is no, it isn't illegal.

Megan Berg:

It's just hard. Bringing back the possibility of exit is not about destroying ASHA, it's about challenging it to be worthy of us. Imagine an organization that has to innovate because it knows you have a choice. Imagine a system where a 96% consensus on reform doesn't just result in a report, but in a revolution. That isn't a broken system, that's a healthy ecosystem.

Megan Berg:

And the truth is the door was never actually locked. We've just been waiting for someone to show us how to turn the handle. And as it turns out, in 1968 at a tense convention in Denver, a group of clinicians did more than just turn a handle. They realized that if the big house wouldn't build a room for them, they would have to step outside and build an entire neighborhood. Next time, we're going to look at exactly what happened in that room in 1968 because if you want to know how to navigate a monopoly, you have to talk to the people who were the first to walk out.

Megan Berg:

I'm Megan Berg. This is inside SLP. If you are finding this podcast informational and helpful, please leave it a rating in a written review. This helps other people find the show. My intention with these episodes is to help us all move forward as a profession and the more we all understand how the system works, the more we can move forward together.

Megan Berg:

If you'd like me to present this information to your workplace, grad program, or SLP book club, please contact me at therapyinsights dot com slash inside SLP. I've also put that link in the show notes for easy clicking. If you want to understand this system more deeply, I invite you to learn about the PACT survey, a national effort to capture how SLPs, audiologists, employers, and consumers experience our profession. You can sign up for updates at pactsurvey.com. That's p a c t survey dot com.

Megan Berg:

PACT stands for perspectives in accountability credentialing and training. This series has been informed by conversations with speech language pathologists and audiologists who generously shared their experiences, questions and institutional memory with me. I'm deeply grateful for the time, care, and honesty they brought to these conversations. Historical context for this episode draws in part from the book The First seventy five Years, An Oral History of the American Speech Language Hearing Association published in 1999 by ASHA and written by Russ Malone as well as publicly available reports, legal records, and financial documents. This podcast represents my independent analysis and interpretation of these materials.

Megan Berg:

It is not affiliated with, endorsed by, or speaking on behalf of ASHA, any academic institution, or any licensing or credentialing body. Any errors are my own.