This is a public post of an e-mail written for a colleague. Comments please!
I have been turning over this notion of the relationship between diagnosis and treatment in our field, trying to distill all these myriad thoughts. What I've arrived at is:
Our philosophy in speech therapy is entirely diagnosis-driven. This works in both directions: if there is a diagnosis, treatment is necessitated; if treatment is desired, a diagnosis is required. The latter of course is largely driven by institutional requirements which to some extent may be necessary practical evils to make a large system work (IDEA, IEPs, insurance, Medicare, etc.), but this has seeped pretty deep into what we actually believe about what we do, I think.
The social model of disability obviously has a lot to say about the diagnosis --> treatment assumption (we're not broken, stop trying to "fix" us).
I think we are doing a disservice to the public by taking this "diagnosis required" stance. This is largely from my experience with my own clients. Probably about 1/3 of them don't have a "diagnosis". Yet, the struggle is there, and it is real and palpable. It is not just all in their heads. "You're fine, get over it," would be an unethical dismissal in my opinion. Yet, they've often heard that from various professionals. They do need and benefit from behavioral intervention, and the progress and outcomes (both functional and skill-specific) precisely align with what we expect and hope to see in "diagnosed" populations.
The EBP push is moving us further along this diagnosis-driven road. "What is the best evidence for treating stuttering/apraxia/articulation disorders?" Look at the titles of ASHA presentations and most clinical research studies...we sort based on population, on diagnosis category. Again, good practical reasons for this-- but what is the underlying message? "Diagnosis matters most in clinical decision-making. Start with the diagnosis." If you can't diagnose it, does it not exist? Can you not treat it ethically?
Outside of stuttering and voice* (and dysphagia, but that feels different), there is minimal discussion of life impact. There is more and more tacit understanding that psychosocial plays a huge role in stuttering, but for some reason that principle has not extended to other diagnosis categories. I've had clients who make career decisions based on a lisp, and I have others who are well aware of a distorted /ɹ/ and are just fine with it. And I'm supposed to approach these the same (from an EBP standpoint) because, technically, each person presents with a single distorted speech sound?
And now for something completely different...
What would an impact-driven evaluation and treatment approach to speech therapy, across the board, look like? What if we stopped treating clients in according to what they are (apraxic/disfluent/aphasic), and instead treated them according to what they need? To start, we would need to overhaul the way graduate programs are taught entirely...
The evolution of approaches in stuttering is interesting when you consider that this subspecialty has been pioneered mostly by actual people with the "disorder" (is there another word? "Condition" doesn't sound great either.) Research in childhood speech sound disorders or primary progressive aphasia, etc. is externally driven, for obvious practical reasons. (Seems there is a social model connection here too...)
*I think the voice folks pretty much follow this person- and need-based approach, even more so than in stuttering. At least, they don't seem to be having infighting about it from what I can tell, but maybe (probably) I also don't read enough voice literature.