Inside SLP

Welcome to Systems Literacy 101. In this episode, we step out of the social media noise and into the architecture of speech-language pathology, tracing how authority moves from accreditation to certification to licensure, and where responsibility begins and ends.

We explore:
  • Why accreditation (CAA) and certification (CFCC) were legally required to separate (and what that changed).
  • How ASHA’s leadership structure evolved, including why academic representation dominates and why executive stability is often cited as exceptional.
  • Why state licensing boards (not national associations) hold the only enforceable regulatory power.
  • How the interstate compact is stress-testing existing structures and quietly embedding national standards into state law.
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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. This series makes the most sense if you start at the beginning.

Megan Berg:

Each episode built on the last. And just a brief editorial note before we begin, I initially planned this as a weekly series but our analytics show that most of you are binging the episodes rather than waiting seven days between them so I want to honor how you're listening and rather than spreading this out over months, I'm releasing the series in three batches. This is the second batch and the final set of episodes will drop next week. Now let's look inside. So far we've explored the history of the CCC and the divorce of audiology but today we're stepping back for a bit of a 101.

Megan Berg:

We're going to demystify the architecture of our power. We're going to find out who actually decides how your workday looks, who regulates your license, and why in a system this fragmented it feels like no one is holding the whole picture. Today is your MicroMasterclass in system literacy. Let's find out who actually holds the pen. Let's start with the two acronyms that define your entry into the field: the CAA and the CFCC.

Megan Berg:

First, the Council on Academic Accreditation or the CAA. They regulate clinical education. They are the ones who decide if a university is allowed to grant you a degree. Currently, there is only one accrediting body for SLP but there is no law saying that there can only be one. In many other professions, multiple accrediting bodies compete with each other and while that can lead to confusion, it also prevents a single organization from having a total monopoly on what education looks like.

Megan Berg:

Then there is the Council for Clinical Certification or CFCC. They set the clinical training requirements, basically the checklist for the CCC. For decades, ASHA tied these requirements directly into the university accreditation standards but eventually the US Department of Education stepped in and they told ASHA they had to stop tying these two together. Why? Because effectively it was creating a monopoly.

Megan Berg:

It was forcing universities to teach a specific product, the CCC, rather than just teaching the profession. To understand how these gatekeepers operate, we have to look at the two different groups that make up the national office in Rockville, Maryland. First, there is the volunteer leadership known as the Board of Directors. These are the SLPs and Audiologists who serve as the Association's fiduciaries meaning they are legally bound to act in the best interest of the Association's survival. There are 15 members on this board including the president and several members at large whose job is to represent specific practice areas like schools or healthcare.

Megan Berg:

Here is a detail that often clears up some confusion. ASHA board members are not paid employees. They are volunteers who serve three year terms. Historically, this board has been heavily weighted toward those with advanced degrees and university positions. Part of that is purely logistical.

Megan Berg:

These roles require an immense amount of unpaid time and national travel which university schedules can often accommodate better than a school based clinician with a 90 student caseload. But logistics isn't the whole story either. It's about our historical DNA. As we talked about in episode three, ASHA didn't start as a grassroots union of working clinicians. From its birth in 1925, it was designed as an elite exclusive club for academics and scientists.

Megan Berg:

While other professional organizations were often founded by practitioners coming together to solve daily work problems, ASHA was founded by scholars looking to establish a science. That elite academic filter is baked into the foundation. If we look at our peer organizations like AOTA and APTA, we see a different architecture. Those boards often have a higher percentage of practicing clinicians sitting at the table and they frequently include members of the public, actual consumers to ensure the organization isn't just talking to itself. By comparison, ASHA has maintained much of that original 1925 exclusive club DNA in its leadership style.

Megan Berg:

I've noticed that even simply pointing this out, observing that the board is a majority of academics and administrators can trigger a high level of defensiveness from those inside the room. But for the clinician in the trenches, this isn't an attack, it's just a visible reality of the system. It remains structurally difficult for a working clinician to have their voice heard at that level. What we end up with is a system of C suite and academia at the top where the primary way working clinicians interact with the machine is through the occasional survey handed down to them. It's a top down relationship by design and that design hasn't really fundamentally changed in a century.

Megan Berg:

The C Suite is the other half of the machine, the professional staff who run the business. These are professional association managers, not necessarily clinicians. They have roles like CEO, CFO, CMO, etc. And on social media, you'll often see clinicians critical of these executive salaries which can reach into the mid figures. In a vacuum, those numbers look bloated, but in the world of nonprofits, this is the market reality.

Megan Berg:

To manage a $170,000,000 organization with 200,000 customers, you have to hire people who could otherwise be running major hospitals or tech firms. You aren't paying for clinical passion, you are paying for corporate stability. And to the business world, Asha is a superstar. In 2018, Asha's CEO was named Association Executive of the Year by her industry. This recognition wasn't based on clinical outcomes, was based on membership retention which consistently hovers around 92.

Megan Berg:

To the association industry a 92% retention rate is a miracle. It signals absolute stability but for the clinician on the ground, that retention doesn't always feel like loyalty. For most of us, you have to buy the certificate to access the majority of professional When ASHA wins awards for retention, they are being recognized for building a perfectly stable institution. ASHA isn't just trying to be a parental figure, it's trying to be a successful, durable corporation. And in a system where the product is your professional legitimacy, survival and stability become the highest goals of the machine.

Megan Berg:

Here is the biggest myth in our field that ASHA is the police. They aren't. Your legal right to work comes from your state licensing board. These boards are made up of volunteer SLPs and community members whose primary job is to protect consumers. They handle granting your license and investigating ethics violations.

Megan Berg:

When someone reports a clinician to ASHA, ASHA ultimately passes that information to the state board for disciplinary action. ASHA has zero legal authority over you. They can only take away your CCC. Only the state government can actually stop you from practicing with a threat of fines and criminal prosecution. And here is the systems literacy kicker.

Megan Berg:

A state board can disagree with ASHA. Just because ASHA thinks a clinician violated the code of ethics doesn't mean that the state will agree and vice versa. The law and the brand are two different things. Licensing boards are government entities usually funded by your licensure fees, but state associations, the ones who lobby for your caseload caps and reimbursement rates, are nonprofits. They are funded almost entirely by membership fees and conference revenue.

Megan Berg:

Right now, engagement at the grassroots level is at an all time low. As I travel to state conferences, I see the struggle, dwindling memberships and empty board seats. We are entering a generational gap where SLPs are not volunteering to lead these institutions or paying money to support them. And if we leave these seats empty, a vacuum is created and in a vacuum the pen is picked up by insurance lobbyists or corporate entities who want to deregulate the field. Without clinicians in these rooms, professionalism is redefined by people who have never sat in a therapy room.

Megan Berg:

People often ask, How do I get involved with ASHA? Unlike a local election where you run for a seat, ASHA is a highly selective organization. You let them know you'd like to volunteer and they decide if and when you participate. For board positions, a committee selects the candidates. If there is an election, it's often a yesno vote on a preselected slate, not a choice between multiple running candidates.

Megan Berg:

Historically, this structure was designed to prevent specific interest groups like large universities from swinging every vote in their favor. It was meant to ensure diversity but the result is a system that can feel very closed off, often prioritizing academic voices over the clinicians working in the trenches. This fragmentation hits hardest during the clinical fellowship year. Because we've split training between the university and the employer, the CF is a no man's land. You are no longer a student so you don't have university support but you aren't fully certified so you don't have full professional autonomy.

Megan Berg:

If something goes wrong, like if a supervisor is unethical or a setting is toxic, the CF's only recourse is often to quit their job. That is an enormous burden for someone just starting their career with a fresh load of student debt. This isn't a failure of the individual CF, it's a failure of an underbuilt architecture that leaves our most vulnerable clinicians without a safety net. To understand how fragmentation plays out in real life, let's look at one of the most significant shifts in our recent history, the Interstate Compact. On paper, the compact is a twenty first century solution.

Megan Berg:

It promises mobility, an end to the burden of navigating five different state licensure systems to do your job. But when you lay a unified framework over a fifty year old patchwork of state regulations, you don't get a bridge, you get a mirror. Every crack in the foundation becomes more visible. Because here's what actually happened. The compact didn't begin as a grassroots effort by SLPs.

Megan Berg:

It was initiated largely in response to pressure from the Department of Defense, which needed licensed professionals who could move with military families. ASHA stepped in to facilitate the process and state associations were mobilized to get legislation passed. But as those bills reached governors' desks, an old unresolved question resurfaced, one that has followed the profession since 1952: Who defines competence? As we've discussed, the states do not agree. Some states allow licensure without a formal clinical fellowship, others don't.

Megan Berg:

Yet the compact legislation itself, the very language being passed state by state, requires a supervised postgraduate professional experience. This is where the wink and nod begins. The law uses broad neutral language but in practice there is only one clearly structured widely recognized pathway to meet that requirement: the ASHA Clinical Fellowship. If postgraduate training were embedded within graduate education as it is for PT and OT and many other professions, this tension wouldn't exist. Instead, we chose a model where postgraduate training lives outside the degree, governed largely by a private national association and enforced by employers.

Megan Berg:

And if you look at who was present when those standards were shaped, the pattern becomes more clear. These Commission meetings are public. Anyone can attend. Anyone can speak. But who is consistently in the room?

Megan Berg:

ASHA. Who is funding a substantial portion of the compact's development? ASHA. So when we write postgraduate supervised clinical experience into law we are effectively codifying ASHA standards back into state statutes without ever openly naming that reality. The system works smoothly for those who follow the recognized branded pathway but it fails to reckon with the fact that our profession remains structurally fragmented.

Megan Berg:

The states hold the authority. We hold the legal right to decide how competence is defined. But as long as clinicians stay out of the room, we're not shaping the language, We're watching the ink dry while the same hands keep drawing the same lines. And that is how history repeats itself. We've spent this episode demystifying the machine, looking at the boards in Rockville and the volunteers in your state capital.

Megan Berg:

We've traced how decisions get made. We've named who holds the pen. But there's a deeper tension underneath all of this. Advocacy feels like a core expectation of the modern SLP. We're told to show up, speak out, write letters, attend hearings because if we don't, decisions get made without us and that's true but what's easy to forget is that this expectation is relatively new.

Megan Berg:

For much of our history, advocacy was not central to the profession at all. ASHA didn't begin as a body designed to negotiate power, shape law or wrestle with regulation. It began as that academic society, small, elite, and intentionally insulated from politics. These were researchers and scholars who believed professional legitimacy came from distance, not influence. So when we look at moments like the interstate compact where laws are written, standards are quietly aligned, and clinicians are largely absent, it's tempting to frame that absence as disengagement, but it's more accurate to call it inheritance.

Megan Berg:

We're working inside a system that was never built to train clinicians to see themselves as political actors. Decisions were made upstream often in response to external pressures and then handed down as finished products. By the time most clinicians entered the field, the rules already looked fixed. That's why the compact feels so familiar. Not because it's new, but because it follows the same old pattern.

Megan Berg:

Outside forces create urgency, established organizations step in to stabilize the process, and broad language gets written that quietly preserves existing power structures. The difference now is that the consequences are harder to ignore. We do hold the authority. We do have the legal right to shape how competence is defined, but exercising that authority requires a kind of participation the profession was never structurally prepared for. So we find ourselves here being asked to advocate inside a system that never taught us how, watching the ink dry while the same hands keep drawing the same lines.

Megan Berg:

This isn't a failure of individual clinicians, It's a historical design problem and that's where we're headed next. Back to the moment when the pen first started moving and the choices that still dictate the margins of our work today. Thank you for staying with the complexity. I'm Megan Berg. This is inside SLP.

Megan Berg:

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. 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 insideslp. I've also put that link in the show notes for easy clicking.

Megan Berg:

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 updates at pactsurvey.com. That's pactsurvey.com. PACT stands for perspectives and accountability credentialing and training. This podcast reflects my own research, analysis, and interpretation.

Megan Berg:

It is is not affiliated with, endorsed by, or produced in collaboration with ASHA or any other professional association. Historical information referenced in this episode is drawn from publicly available sources, including the book The First seventy five Years an Oral History of the American Speech-Language-Hearing Association (1999), by Russ Malone, former Public Information Director for ASHA, along with publicly available legislative records and archival materials. Any errors or interpretations are my own.