Inside SLP

In this episode of Inside SLP, Megan looks beyond speech-language pathology to ask how professions decide where authority should live. From AOTA’s decision to separate certification from its professional association to decades of antitrust challenges involving ASHA and other professions, this episode explores what happens when certification, advocacy, accreditation, and professional representation overlap. Who gets to speak for a profession? What makes that authority legitimate? And what mechanisms exist to challenge it when practitioners want something different?

Sources:
  • Bogus v. American Speech & Hearing Association, 582 F.2d 277 (3d Cir. 1978).
  • National Board for Certification in Occupational Therapy, Inc. v. American Occupational Therapy Association, 24 F. Supp. 2d 494 (D. Md. 1998).
  • Palazzi et al. v. National Court Reporters Association, No. 2:25-cv-00077 (D.N.J. filed Jan. 3, 2025).
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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:

Hi, everyone, and welcome back to Inside SLP. This series is about how our profession came to be and where it's heading. Most of us work inside a system we were never formally 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. And before we get too far into season two, I really want to encourage you to go back and listen to season one if you haven't already. There are 20 episodes and each one is only about ten minutes long. So in a little over three hours, you'll have the historical foundation for so many of the conversations we're going to have here. The CCC, licensure accreditation, graduate education, ASHA, and how all of these systems became intertwined.

Megan Berg:

You don't have to agree with my conclusions. The point is just to understand what we're actually talking about. Season two is going to ask harder questions about who holds authority in this profession, who gets to represent us, and what we might want to change. Season one gives you the context to participate in those conversations in a meaningful way. So in the 1930s, the American Occupational Therapy Association started certifying therapists.

Megan Berg:

And at the time, that wasn't particularly strange. This was before states had conceptualized the idea of government based licensing boards. As the National Professional Association for Occupational Therapy, AOTA helped develop the profession, provided resources to practitioners, and represented occupational therapists. And it also maintained a registry of people it considered qualified to practice. And for decades, those functions lived together.

Megan Berg:

Then in the nineteen eighties, AOTA became concerned about, of all things, antitrust law. According to a federal court opinion that would come years later, AOTA became concerned about the potential antitrust liability of being involved in professional certification while also providing membership services. So in 1986, AOTA did something pretty remarkable. It decided to get out of the certification business. AOTA created the American Occupational Therapy Certification Board initially as an autonomous unit within AOTA and transferred responsibility for certification to it.

Megan Berg:

Two years later that certification board became a separately incorporated organization. AOTA transferred the certification records, the testing materials, the finances, the equipment, the certification organization eventually became what occupational therapists today know as NBCOT, the National Board for Certification in Occupational Therapy. An AOTA was no longer responsible for deciding who was certified as an occupational therapist. Today, AOTA says this very plainly on its own website. Can you get your occupational therapy license from AOTA?

Megan Berg:

No. Can you get the national certification that establishes you as an OTR from AOTA? Also no. AOTA describes itself as the National Professional Association. NBCOT handles national certification and state agencies issue licenses.

Megan Berg:

These organizations interact, they collaborate, they influence the same profession, but they do not have the same authority. And here's where the story gets interesting because separating those functions didn't make everything simple and streamlined. Within about a decade, AOTA and the certification organization it had created ended up in federal court fighting with each other. The judge called it a bitter familial dispute and underneath a complicated fight involving trademarks and contracts was a very basic question. Who had the authority to define certification standards in occupational therapy?

Megan Berg:

Occupational therapy had deliberately separated two kinds of professional authority. One organization could represent occupational therapists, another could certify them and almost immediately the profession had to confront what the separation actually meant. Who owns the credential? Who gets to change its requirements? Who decides what qualifies someone to use a professional designation?

Megan Berg:

And what happens when the organization that represents practitioners disagrees with the that certifies them. And without getting too much into the weeds, it's worth noticing where these two organizations ultimately ended up financially. According to their 2024 IRS filings, ASHA reported about $75,000,000 in revenue and $184,000,000 in assets. AOTA reported about $23,000,000 in revenue and $39,000,000 in assets. AOTA's membership today represents about 30% of OT professionals while ASHA's membership reaches essentially the entire SLP profession and beyond.

Megan Berg:

Now, I'm not saying that AOTA gave up certification and therefore became a smaller organization. There's too many differences between the professions to make a causal claim, but when AOTA separated certification from membership, it gave up a function that creates both revenue and an ongoing financial relationship with practitioners whether or not those practitioners choose to belong to the professional association. And the organizations that emerge from these two histories look very different. So if you wanna go much deeper into those numbers and what they mean, you can go back to episode 13. But this story sent me down a rabbit hole because I'm an SLP and our profession made a different choice.

Megan Berg:

The American Speech Language Hearing Association describes itself as the National Professional Scientific and Credentialing Association for Speech Language Pathologists and Audiologists. Professional Scientific Credentialing. Those words describe different kinds of authority and in speech language pathology, several of those kinds of authority exist within the same organizational ecosystem. ASHA advocates on behalf of the professions. ASHA provides membership services.

Megan Berg:

ASHA publishes scientific journals. ASHA operates continuing education programs. ASHA develops professional resources and through its Council for Clinical Certification or CFCC, ASHA establishes the standards for and awards the certificate of clinical competence CCC. ASHA's bylaws give the CFCC final authority over certification standards and certification decisions. The CFCC is semi autonomous.

Megan Berg:

Similarly, the Council on Academic Accreditation or CAA accredits graduate programs in speech language pathology and audiology. It has its own governance processes and independent authority over accreditation decisions and that's different from what occupational therapy eventually chose to do. Today, AOTA can advocate for occupational therapists but it cannot take away occupational therapist's NBCOT certification. NBCOT can change its certification requirements but it does not get to claim AOTA's members as its membership base. And neither organization can independently give someone legal permission to practice occupational therapy.

Megan Berg:

The state does that. So I started wondering why? Why did occupational therapy decide that certification and professional membership should exist in separate organizations? Why did speech language pathology retain those functions within the same institutional ecosystem? And does it even matter?

Megan Berg:

Speech language pathology has actually confronted a version of this question before. In episode 15, we talked about bogus versus ASHA. The 1970 antitrust case challenging ASHA's requirement that clinicians maintain ASHA membership in order to obtain and retain the CCC. So if you haven't listened to that episode, that's where we get into the history of the lawsuit, the legal concept of tying and how membership and certification eventually became separable. But what's important for our story today is what didn't separate.

Megan Berg:

You can now hold the CCC without being an ASHA member, but the organization selling the certification is still ASHA. Occupational therapy ultimately went further. AOTA didn't just separate membership dues from certification fees, it separated the institutions themselves. And if all of this sounds like some obscure professional association problem that lawyers stopped caring about sometime in 1982, I have some bad news. Because in January 2025, two court reporters filed a proposed class action lawsuit against the National Court Reporters Association.

Megan Berg:

Yes, court reporters. And their complaint should sound extremely familiar. NCRA is National Professional Association for Court Reporters and Captioners. It provides membership services, it advocates for the profession, it has a government relations operation, and it also offers professional certifications. The plaintiffs alleged that court reporters who want to maintain those certifications are required to maintain NCRA membership.

Megan Berg:

Their lawsuit argues that this amounts to an illegal tying arrangement under federal antitrust law. NCRA strongly disputes that. It has called the lawsuit frivolous and without merit and has asked the court to dismiss it. And as of this recording, the case is still pending. And when I talk to the plaintiffs over the phone, it's moving slower than that cup of thickened liquids the kitchen prepared six hours ago.

Megan Berg:

So I don't know how a court will ultimately answer the legal question, but that's not actually the question that I'm interested in. I'm interested in the fact that fifty years after Dale Bogus sued ASHA, professionals in an entirely different field are standing in federal court arguing about essentially the same organizational structure, which makes me wonder whether this isn't really an SLP problem at all. Maybe it's a professional governance problem. When one organization does two things, it decides who earns or maintains an important professional credential and asks those same professionals to support it as their representative organization. What happens to a professional associations incentive to represent its constituents when a substantial portion of those constituents have practical reasons to keep paying the organization regardless of whether they believe it represents them well.

Megan Berg:

Imagine an occupational therapist named Maya. Maya is unhappy with AOTA. Maybe she doesn't like its advocacy priorities. Priorities. Maybe she thinks membership costs too much.

Megan Berg:

Maybe she thinks the organization isn't responsive enough to practitioners. Maybe she just doesn't use the benefits. So Maya doesn't renew her AOTA membership. What happens to her NBCOT certification? Nothing.

Megan Berg:

Simply because she left AOTA. NBCOT is not AOTA. What happens to her state license? Again, nothing. Simply because she left AOTA.

Megan Berg:

Her state licensing agency isn't AOTA either. AOTA itself makes this distinction explicitly. It is the National Professional Association, but it has no authority to issue the entry level national certification or a state license. Now imagine Maya's friend is an SLP. She says, I'm done with ASHA.

Megan Berg:

Okay. What does that mean? Does she mean she's ending her ASHA membership? Or does she mean she's relinquishing the CCC? Those are two different decisions.

Megan Berg:

She can stop being an ASHA member and continue paying ASHA as a non member certificate holder. But if she wants to stop having a financial relationship with ASHA altogether, now the decision includes her national professional certification. This doesn't automatically make the arrangement inappropriate, but it does make it very structurally different. And I think it's worth understanding why. Because if Maya believes AOTA isn't representing her well, she can leave.

Megan Berg:

AOTA loses her membership and her money. If enough OTs do that, AOTA has a pretty unmistakable problem. An SLP can also leave ASHA membership, but if she wants to retain the CCC, ASHA doesn't completely lose that financial relationship. She becomes a non member certificate holder instead. So the signal gets murkier.

Megan Berg:

I don't want you representing me anymore does not necessarily mean I'm going to stop paying you. And that made me wonder whether ability to leave is itself one of the ways a professional association stays accountable to the people it represents. Once I started looking for these distinctions, I started seeing them everywhere. Consider attorneys. We casually say things like the bar as though there's one giant organization somewhere controlling American lawyers, but there isn't.

Megan Berg:

The legal profession is spectacular mess of overlapping institutions. Law schools are accredited through a process involving the American Bar Association's counsel of the section of legal education and admissions to the bar, which exercises independent authority in its accreditation function. But the ABA doesn't give an attorney legal permission to practice in California or Montana or Nebraska. Admission to practice is controlled at the state level generally under the authority of state supreme courts and their regulatory systems. And professional representation is something else.

Megan Berg:

An attorney might join the American Bar Association, she might join a state or local bar association, she might join specialty association. She might support an organization organized around a particular area of law or professional interest. Or she may decide that the ABA doesn't represent her interest particularly well and decline to belong to it. She does not then cease being a lawyer. So imagine your attorney quits the ABA tomorrow because she absolutely hates its position on some issue.

Megan Berg:

Can she still represent you? Assuming she's otherwise in standing with the authority that actually regulates her practice, yes. Because who regulates this lawyer and who represents this lawyer's professional interests do not necessarily have the same institutional answer. Also, next time you're with your attorney friend, ask them which professional certifications they hold and watch them laugh. Now we've arrived at the second question I wanted to ask today.

Megan Berg:

The first was who gets to decide who is an SLP? The second is who gets to represent SLPs? Imagine that tomorrow 10,000 speech language pathologists create a new organization. Let's call it the National Coalition of Extremely Tired SLP's. They have had it.

Megan Berg:

They are angry about reimbursement. So they start raising money, and they're good at it. They raise million dollars. They hire health economists. They commission a sophisticated national analysis of what it actually costs to provide speech language pathology services.

Megan Berg:

They hire attorneys and policy experts. They develop relationships at CMS. They meet with members of Congress. They collect stories from clinicians. They organize thousands of SLP's to contact policymakers and let's say they're extremely effective.

Megan Berg:

Eventually, somebody representing this organization walks into a federal meeting and says, speech language pathologists need but stop. Who gave them permission to finish that sentence? Is it the 10,000 clinicians who joined? Would 50,000 be enough? What if they had a 100,000 Instagram followers but only 5,000 paying members?

Megan Berg:

What if almost nobody joined but their economic research was excellent? What if policymakers listened to them because they were more effective than every existing organization? Does effectiveness create legitimacy? Does expertise? Does membership?

Megan Berg:

Does money? Does transparency, does an elected board, does longevity, does the ability to mobilize people, does government recognition, like what exactly gives an organization the authority to say we represent speech language pathologists? And here's the uncomfortable part. Whatever answer we come up with should probably apply to existing organizations too. ASHA didn't descend from the sky carrying a congressional charter that said you are now the official voice of every speech language pathologist in The United States.

Megan Berg:

It developed alongside the profession and over time it accumulated a remarkable number of functions. ASHA is a membership association. ASHA advocates for the professions. ASHA publishes scientific journals. ASHA develops professional standards.

Megan Berg:

ASHA operates a certification system. And within the broader ASHA structure, there are bodies involved in accreditation and certification that have their own authority and governance. That's a lot of different jobs. And I think we sometimes make a strange assumption about organizations that if you're good at one of these jobs, you must somehow be qualified to do all of the others. But why?

Megan Berg:

Being good at determining whether someone has met a certification standard doesn't mean you're good at representing that person's economic interests. Being good at publishing scientific research doesn't mean you know what school based clinicians need from a professional association. Being good at federal advocacy doesn't mean you should determine graduate education standards. And these aren't just different tasks, sometimes they can create competing interests. Imagine an organization that simultaneously trying to advocate for practicing clinicians, maintain relationships with graduate programs, protect the credibility of its certification, administer professional standards, work with regulators and payers, preserve its own financial stability, and respond to demands for major changes to the system?

Megan Berg:

What happens when the thing clinicians want threatens another part of that system? What happens when changing graduate education affects accreditation? What happens when changing certification requirements affects the value of the credential? What happens when taking an aggressive advocacy position could complicate a relationship organization needs somewhere else. Nobody has to be corrupt for this to become extremely difficult.

Megan Berg:

You can create bureaucratic gridlock simply by putting an organization in a position where every change pulls on five other things it is also responsible for protecting. Because ASHA's different roles give it different kinds of authority. Its scientific work can give expertise. Its relationships with policy makers can give it influence. Its history can give it institutional credibility.

Megan Berg:

Its certification system gives it another kind of power entirely. Its members give it a constituency. But none of those automatically produces the others. Expertise isn't representation. Certification isn't representation.

Megan Berg:

Institutional influence isn't representation. And even membership gets complicated when some of the people financially connected to the organization are there primarily because they want to maintain a professional credential. So when ASHA says it represents speech language pathologists, I think there are actually two questions worth asking. First, what makes an organization legitimate enough to speak on behalf of a profession? And second, what makes that organization accountable when the people it represent think it's getting something wrong?

Megan Berg:

There's a question that comes up whenever people become dissatisfied with a major professional organization. If not them, then who? And I get it. Institutions are easier to imagine when they have a name, a building, a logo, a board, a president, someone who can walk into a meeting and say, I'm here on behalf of the profession. But maybe we've bundled too many different problems into the word representation.

Megan Berg:

Who should advocate for SLP reimbursement? Who should advocate for school caseload limits? Who should negotiate employment conditions? Who should determine graduate education standards? Who should regulate clinical practice?

Megan Berg:

Who should define ethical expectations? Who should fund scientific research? Who should communicate with CMS? Who should advocate in state legislatures? Who should represent private practice owners?

Megan Berg:

Who should represent school based clinicians? Who should represent hospital clinicians? Who should represent researchers? Who should represent patients and people with disabilities affected by our clinical decisions? Why would we assume all of those questions need the same answer?

Megan Berg:

Medicine doesn't have one organization that meaningfully represents every physician in every context. Law doesn't have one organization that exercises every form of professional authority. Occupational therapy deliberately separated national certification from its professional membership association and even that separation created conflict. Maybe there isn't a perfect organizational structure. Concentrating functions can create coordination.

Megan Berg:

Separating them can create checks. Concentration can also create conflicts of interest. Separation can create duplication, bureaucracy, competing standards, and confusion. A profession with five organizations might distribute authority beautifully or it might require practitioners to pay five sets of fees while nobody knows who's responsible for anything. A profession with one dominant organization might coordinate extraordinarily well or practitioners may struggle to distinguish between the organization's different forms of authority.

Megan Berg:

Structure doesn't automatically tell us whether an institution is good, but structure tells us where to look when we ask who is accountable to whom. And I think this is where my own thinking about speech language pathology has changed. For years, many of our professional arguments have been framed as arguments about organizations. ASHA should do this. ASHA shouldn't do that.

Megan Berg:

We need ASHA. We don't need ASHA. We need an alternative to ASHA. But those arguments may be skipping a much more basic question. Which function are we actually talking about?

Megan Berg:

Because I may want one organization setting a national certification standard and an entirely different organization advocating for my reimbursement. I might trust an accrediting body to evaluate graduate programs without believing that body should represent clinicians politically. I might support a grassroots organization working on one reimbursement issue without granting it authority to speak for me about graduate education. I might belong to a professional association because I value its journals and policy expertise while disagreeing with some of its advocacy priorities. Those positions aren't contradictory.

Megan Berg:

They're only contradictory if we assume that professional authority is indivisible, and historically, it isn't. Different professions have divided it differently. Sometimes intentionally, sometimes because of litigation, sometimes because of regulation, sometimes because one organization spun another one off, and probably quite often because institutions just accumulated functions until everyone forgot that there were other ways to arrange them. Which brings me back to that fight between AOTA and NBCOT. I love this story because it prevents us from reaching for an easy answer.

Megan Berg:

AOTA separated certification because it was concerned about potential antitrust liability from simultaneously certifying practitioners and providing membership services. You might hear that and think, great problem solved. Just separate everything. Except then, the two organizations fought over certification authority. Separation created a different question.

Megan Berg:

If the professional association doesn't control certification anymore, what happens when the association believes the certifying organization is taking the profession in the wrong direction? Who speaks for practitioners then? Who protects the public? Who owns the standards and who gets to change them? There is no organizational chart that eliminates power.

Megan Berg:

It only determines where power lives, how it is constrained, and who can challenge it. And maybe that's the question speech language pathology should be asking. Not who should have power, but what kinds of power exist in this profession, where are they currently located, located? And what mechanisms exist for challenging them? I'm Megan Berg, and this is Inside SLP.

Megan Berg:

I also wanna give you a quick update on the PACT survey project. We continue to move forward with the production of the survey. I'm now working with doctor Emily Eccle, a sociologist out of Ohio State University along with our advisory board, and we continue to shape the survey to answer these kinds of questions. So if you're interested in learning more about that, and being alerted when the survey goes live, you can head to pactsurvey.com.