• TABLE OF CONTENTS
HIDE
 Title Page
 Acknowledgement
 Table of Contents
 List of Tables
 Abstract
 Sociological aspects related to...
 Licensure and alternate forms of...
 A history of state licensing in...
 A comparison of selected aspects...
 An assessment of the practices,...
 Appendix A: Explanatory letter...
 Appendix B: State licensing agencies...
 References
 Biographical sketch














Title: State licensure
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Permanent Link: http://ufdc.ufl.edu/UF00097448/00001
 Material Information
Title: State licensure the professions of speech pathology and audiology
Physical Description: xi, 344 leaves : ; 28 cm.
Language: English
Creator: Heitman, Frederick Robert, 1946-
Publication Date: 1980
Copyright Date: 1980
 Subjects
Subject: Speech therapists -- Licenses -- States -- United States   ( lcsh )
Audiologists -- Licenses -- States -- United States   ( lcsh )
Speech thesis Ph. D   ( lcsh )
Dissertations, Academic -- Speech -- UF   ( lcsh )
Genre: bibliography   ( marcgt )
non-fiction   ( marcgt )
 Notes
Thesis: Thesis--University of Florida.
Bibliography: Bibliography: leaves 336-343.
Additional Physical Form: Also available on World Wide Web
Statement of Responsibility: by Frederick R. Heitman.
General Note: Typescript.
General Note: Vita.
 Record Information
Bibliographic ID: UF00097448
Volume ID: VID00001
Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
Resource Identifier: alephbibnum - 000098438
oclc - 06750381
notis - AAL3885

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Table of Contents
    Title Page
        Page i
        Page ii
    Acknowledgement
        Page iii
    Table of Contents
        Page iv
        Page v
        Page vi
    List of Tables
        Page vii
        Page viii
    Abstract
        Page ix
        Page x
        Page xi
    Sociological aspects related to professions: An overview
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    Licensure and alternate forms of control: Regulating the professions
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    A history of state licensing in speech pathology and audiology, 1967-1979
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    A comparison of selected aspects from thirty state statutes regulating speech pathologists and audiologists
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    An assessment of the practices, problems, and perceptions of agencies licensing speech pathologists and audiologists
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    Appendix A: Explanatory letter and questionnaire
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    Appendix B: State licensing agencies represented by questionnaire responses
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    References
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    Biographical sketch
        Page 344
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Full Text











STATE LICENSURE:
THE PROFESSIONS OF SPEECH
PATHOLOGY AND AUDIOLOGY






BY

FREDERICK R. HEITMAN


A DISSERTATION PRESENTED
TO THE GRADUATE COUNCIL
OF THE UNIVERSITY OF FLORIDA
IN PARTIAL FULFILLMENT OF THE
REQUIREMENTS FOR THE DEGREE
OF DOCTOR OF PHILOSOPHY


UNIVERSITY OF FLORIDA


1980
































Copyright 1980

by

Frederick R. Heitman














ACKNOWLEDGEMENTS


The author wishes to express his sincerest appreciation for the

assistance and encouragement provided by committee chairman, Dr. Thomas

B. Abbott,and by committee members Dr. Lowell C. Hammer, Dr. James W.

Longstreth, and Dr. G. Paul Moore. He also extends thanks to Mr.

Morrison Cain and Mrs. Donna Brown Grossman of the American Speech-

Language-Hearing Association for providing access to information vital

to the completion of this project. A special note of appreciation

is expressed to those state licensing board chairpersons who took their

time to respond to the project questionnaire. Without the quantity and

quality of their responses, this research would have been impossible.

Finally, to Elaine, his wife and typist, he acknowledges the provision

of more help and understanding than he had any right to expect.













TABLE OF CONTENTS


PAGE

ACKNOWLEDGEMENTS . . . . . . . . ... . . . iii

LIST OF TABLES . . . . . . . . ... .. . .. .vii

ABSTRACT . . . . . . . . ... . . . . . ix

CHAPTER

I SOCIOLOGICAL ASPECTS RELATED TO PROFESSIONS: AN OVERVIEW

Professions, Professionals, and Professionalization:
This Is Where It All Begins . . . . . . 2
The Profit Motive and Additional Elements of the
Professional/Nonprofessional Schism: Differences
That Make a Difference . . . . . . . 9
Professional Services: The Ethic, the Expectation,
the Reality . . . . . . . ... . . 13
The Professional Culture: Values, Norms, Standards,
and the Career Concept . . . . . . ... .16
Professional Goals: Sanction, Control, Authority,
Autonomy, Mandate, and Monopoly . . . ... 18
Professional Abuses and Conflict of Interest: No
Wonder the Public Is Angry . . . . . ... .26
Codes of Ethics: The Professions State Their Case 31
The Professional: Relationships with Clients,
Colleagues, and Trends of the Future . . ... 35
Professional Associations: Their Inception,
Relationships with Government, and Rationale for
Existence . . . . . . . . . 41
Emerging Professions and New Careerists: Nobody Said
It Was Going to be Easy . . . . . . . 46
Status and Mobility: Can Licensing be Far Behind? 52

2 LICENSURE AND ALTERNATE FORMS OF CONTROL: REGULATING
THE PROFESSIONS . . . . . . . . ... .56

A Brief History of Individual Licensure . ... .. . 57
The Philosophy of Licensing . . . . . .. 63
Traditional Means of Control ............. 65
The Role of the University, Professional, or Training
School and the Question of Accreditation . . .. 69










TABLE OF CONTENTS (CONTINUED)


CHAPTER PAGE

2 (continued)

Occupational Entry and Licensing: Requirements,
Limitations, and Barriers . . . . . 76
Legislative and Judicial Considerations . . ... .86
Professional Associations and Politics . . ... .92
The Legislative Process . . . . . . . . 95
A Case for Licensure . . . . . . . ... 102
Attack on Licensing and Credentialing . . . . 104
Alternatives to Traditional Forms of Control ... 112
State Licensure Boards . . . . . . ... .121

3 A HISTORY OF STATE LICENSING IN SPEECH PATHOLOGY AND
AUDIOLOGY, 1967-1979 . . . . . . . . 134

The Association's Position, 1966 . . . . .. 137
The Association's Position, 1968 . . . . . 143
The First State Law and the Association's Position,
1969 . . . . . . . . . . . . 147
The Move Toward Licensure and the Association's
Position, 1971 . . . . . . . . .. 151
The Proliferation of Licensure, 1972-1978 ...... 154

4 A COMPARISON OF SELECTED ASPECTS FROM THIRTY STATE
STATUTES REGULATING SPEECH PATHOLOGISTS AND
AUDIOLOGISTS . . . . . . . . ... . 169

A Comparison of Elements Relating to State Licensing
Boards: Supervising Authorities, Membership
Criteria and Appointment, Compensation, Composition,
and Duties . . . . . . . . . . 170
A Comparison of Fee Schedules, Renewal Standards, and
Continuing Education . . . . . . ... .192
Statutory Provisions Related to Grandfathering and
Exemptions . . . . . . . . . . 200
Licensure Requirements in Reference to Interim Practice,
Trainees, Supportive Personnel, and Reciprocal
Licensing . . . . . . .... .. . . 214
Requirements for Licensure and the Compatibility of
State Prerequisites with ASHA Certification
Requirements . . . . . . . . ... 223
Supplementary Licensing Provisions . . . . .. 229
Enforcement of Licensing Provisions: Revocation,
Suspension, and Penalties . . . . . ... .231
Sunset Legislation . .. . . . . . . 231









TABLE OF CONTENTS (CONTINUED)


CHAPTER PAGE

5 AN ASSESSMENT OF THE PRACTICES, PROBLEMS, AND
PERCEPTIONS OF AGENCIES LICENSING SPEECH PATHOLOGISTS
AND AUDIOLOGISTS . . . . . . . . . 247

Purposes . . . . . . . . ... . . 247
Procedures . . . . . . . . . . . 248
Results and Discussion . . . . . . . . 249
Conclusions . . . . . . . . ... .. . 316

APPENDICES

A EXPLANATORY LETTER AND QUESTIONNAIRE . . . ... 323

B STATE LICENSING AGENCIES REPRESENTED BY QUESTIONNAIRE
RESPONSES . . . . . . . . . . . 334

REFERENCES . . . . . . . . . . ...... 336

BIOGRAPHICAL SKETCH . . . . . . . . ... . . 344
















LIST OF TABLES


TABLE PAGE

I THE LEGAL STATUS OF PHYSICAL THERAPY, OCCUPATIONAL
THERAPY, AND SPEECH THERAPY WITHIN THE STATES PRIOR
TO 1970 . . . . . . . . .. . . . 139

II LEGAL CITATIONS, ORDER OF ENACTMENT, AND EFFECTIVE
DATES FOR STATE LICENSURE LAWS IN SPEECH PATHOLOGY
AND AUDIOLOGY . . . . . . . .. .. . 171

III LICENSING AGENCIES AND SUPERVISORY AUTHORITIES IN STATES
REGULATING SPEECH PATHOLOGISTS AND AUDIOLOGISTS . 175

IV SELECTED PROVISIONS RELATED TO BOARD MEMBERSHIP ON
SPEECH PATHOLOGY AND AUDIOLOGY LICENSING BOARDS . 182

V COMPOSITION OF STATE EXAMINING/ADVISORY BOARDS FOR THE
LICENSING OF SPEECH PATHOLOGISTS AND AUDIOLOGISTS 187

VI A COMPILATION OF DUTIES TO BE PERFORMED BY LICENSING
BOARDS IN SPEECH PATHOLOGY AND AUDIOLOGY . . .. 190

VII FEES CHARGED FOR LICENSING IN SPEECH PATHOLOGY AND
AUDIOLOGY . . . . . . . . ... . . 193

VIII STANDARDS FOR RENEWAL OF LICENSURE AS CONTAINED IN STATE
STATUTES LICENSING SPEECH PATHOLOGISTS AND
AUDIOLOGISTS . . . . . . . . . 197

IX STATUTORY PROVISIONS RELATING TO CONTINUING EDUCATION IN
STATES WHERE CONTINUING EDUCATION IS NOT MANDATORY FOR
LICENSE RENEWAL . . . . . . . ... .201

X GRANDFATHER PROVISIONS AS FOUND IN STATE LAWS LICENSING
SPEECH PATHOLOGISTS AND AUDIOLOGISTS . . ... 203

XI A COMPILATION OF EXEMPTIONS FROM STATE LICENSING LAWS IN
SPEECH PATHOLOGY AND AUDIOLOGY . . . . .. 212

XII A COMPARISON OF SPECIAL PROVISIONS RELATING TO INTERIM
PRACTICE, TRAINEES, SUPPORTIVE PERSONNEL AND
RECIPROCAL LICENSING .. . . . . . .. 216









LIST OF TABLES (CONTINUED)


TABLE PAGE

XIII COMPATIBILITY OF STATE LICENSING REQUIREMENTS WITH
ASHA'S REQUIREMENTS FOR THE CERTIFICATE OF CLINICAL
COMPETENCE . . . . . . . . ... .. . 225

XIV GROUNDS FOR LICENSE REVOCATION/SUSPENSION CONTAINED
WITHIN STATE LAWS LICENSING SPEECH PATHOLOGISTS AND
AUDIOLOGISTS . . . . . . . .... . 232

XV PENALTIES FOR VIOLATION OF STATE STATUTES LICENSING
SPEECH PATHOLOGISTS AND AUDIOLOGISTS . . ... 238

XVI SUNSET TERMINATION DATA FOR STATES LICENSING SPEECH
PATHOLOGISTS AND AUDIOLOGISTS . . . . . 241

XVII RESPONSE TO QUESTION 6 AS A FUNCTION OF PUBLIC
REPRESENTATION ON STATE LICENSING BOARDS . . .. 259

XVIII THE RESPONSES OF STATE LICENSING BOARD CHAIRPERSONS TO
QUESTION 10 . . . . . . . .... .. 268

XIX PERCENTAGE OF TIME SPENT IN DISCUSSING OR ACTIVELY
PURSUING FULFILLMENT OF BOARD DUTIES . . ... 274

XX MEAN RANKINGS FOR IMPORTANCE OF DUTIES AND BOARD'S
ABILITY TO COMPLETE DUTIES . . . . . ... .277

XXI LICENSURE REVOCATIONS AND SUSPENSIONS IN RELATION TO
TOTAL INITIAL LICENSES ISSUED . . . . ... .289


viii















Abstract of Dissertation Presented to the Graduate
Council of the University of Florida in Partial
Fulfillment of the Requirements for the
Degree of Doctor of Philosophy



STATE LICENSURE:
THE PROFESSIONS OF SPEECH
PATHOLOGY AND AUDIOLOGY





By


Frederick R. Heitman
June, 1980


Chairman: Dr. Thomas B. Abbott
Major Department: Department of Speech


The current status of professional licensing in the disciplines of

speech pathology and audiology was examined in light of literature per-

taining to professionalism and general professional regulation. Initial

analysis was undertaken through a compilation of the history of state

licensure in these professions from 1967 to 1979. Focus was upon the

problems faced by state associations as they attempted to secure favor-

able licensing legislation and upon the gradual alteration in the

official position and support role of the American Speech and Hearing

Association (now the American Speech-Language-Hearing Association).

Particular attention was given to repercussions of landmark statutory

enactments and to notable failures to achieve state legislation considered








favorable to the professions. It was concluded that the problems which

have perplexed the legislative efforts of nonlicensed states are, with

few exceptions, still in force. The critical time period for licensure

having passed, states without licensure will find that the procurement

of regulation will become increasingly difficult.

A second mode of analysis compared selected aspects of 30 state

statutes regulating speech pathologists and audiologists. Areas of

comparison included:

1. board supervisory authorities;

2. board membership criteria and appointment;

3. board composition and duties;

4. compensation of board members;

5. fee schedules for licensure;

6. renewal standards for licensure;

7. requirements for continuing education;

8. requirements for grandfathering and exemptions;

9. requirements for interim practice, trainees, supportive
personnel, and reciprocal licensing;

10. compatibility of state licensure prerequisites with ASHA
certification requirements;

11. supplementary licensing provisions;

12. enforcement of licensing provisions (revocation, suspension,
and penalties);

13. sunset legislation.

Conclusions were specific to each area investigated.

For the third segment of this study, a 39-item questionnaire was

mailed to the chairpersons of the 31 state boards licensing speech

pathologists and audiologists. Twenty-four (77.4%) agency chairpersons









returned questionnaires. These questionnaires were then analyzed to

draw conclusions from data received

1. relative to administration of state laws regulating
speech pathologists and audiologists,

2. relative to chairpersons' opinions and beliefs
concerning current controversial questions in the area
of professional regulation,

3. relative to changes in board operation in the event of
a given circumstance.

Responses gave evidence to the polarization that exists with regard to

issues such as continuing education and specialty certification, and

the agreement that is present in such areas as lay participation on

state licensing boards and infringement by other licensing boards. Time

limitations placed on board members, inexperience, and the part-time

status of board representatives were found to be partially responsible

for overall weaknesses noted in the enforcement of licensing statutes,

information sharing, and the construction and implementation of special

programs. However, licensing boards regulating the disciplines of speech

pathology and audiology failed in many respects to satisfy the negative

stereotype of professional licensing boards promulgated by many authors.













CHAPTER I

SOCIOLOGICAL ASPECTS RELATED TO PROFESSIONS: AN OVERVIEW

With more and more occupations seeking professional status and

boasting of professional status, it seems reasonable to conclude that

the established professional is in a most enviable position. It is

here, however, that a paradox exists. For as Americans clamor to join

the ranks of the professionals, and as new professions emerge almost

overnight, the professions are undergoing a public scrutiny which is

threatening the very foundations upon which these professions were

built. Thus, the sweeping powers which many professions possess are

being curtailed. Yet even those who cry the loudest that the pro-

fessions have become dehumanized, corrupt due to internal control, and

smug in their ability to effectively legislate against change, are

quick to admit that they will accept nothing less than a "professional"

career for their sons and daughters. Thus,the ranks of the professions

swell, allegations notwithstanding, and the role of the profession in

American life continues to expand.

In order to understand professional licensure, it is necessary to

comprehend the nature of professions and professionalism. Therefore,

this chapter will be devoted to a review of those characteristics which

determine how professions and professionals react to the environment

in which they must co-exist within the framework of society's laws and

regulations.








It is apparent that the wealthier a country is, the greater the

percentage of the labor force engaged in service-oriented work.

Indeed, as Moore (1970) points out, the United States is increasingly

being viewed as a "service economy" and "the professions appear to be

perhaps the most rapidly expanding group in the service structure of

this country" (p. 53). Since professions hold a position of great

importance in a society such as ours, it is understandable that their

regulation and control has been the object of much research and debate.

While it is not within the scope of this dissertation to provide

a detailed history of the emergence of professions or of the profes-

sional ethic, Whitehead (1948) does develop an interesting distinction

between professions being characteristic of the modern world as crafts

were of the ancient world. Whitehead states that a craft is "an

avocation based upon customary activities and modified by the trial and

error of individual practice." A profession, in contrast, is "an avo-

cation whose activities are subject to theoretical analysis, and are

modified by theoretical conclusions derived from that analysis" (pp.

73-74). Lynn (1965) feels that these two activities are separated by

an intellectual revolution. Gilb (1966), however, believes that "the

American socioeconomic-political system is closer to its medieval

ancestors than it is to the preindustrial system of the early nine-

teenth century" (p. 227).


Professions, Professionals, and Professionalization:
This Is Where It All Begins

While researchers may debate the similarities and differences

between ancient craft guild activities and modern professional life,







they are in general agreement with regard to defining "a profession"

and listing its essential attributes. As will be pointed out later,

this agreement is not as universal with regard to perspectives on the

process of professional ization.

A sociological approach, one that is espoused by Greenwood (1957)

and others, views a profession as

an organized group which is constantly interacting with
the society that forms its matrix, which performs its
social functions through a network of formal and informal
relationships, and which creates its own subculture re-
quiring adjustments to it as a prerequisite for career
success. (p. 45)

Gilb (1966), in attempting to answer the question, "What is a pro-

fession?" asserts that different professions have defined the term

differently from era to era. However, she finds that all professions

stress the application of special knowledge which requires long train-

ing on the part of its recipient, the exercise of discretion, and a

willingness on the part of the practitioner to commit himself to some

standard to which the pursuit of self-interest is subordinated. This

commitment is referred to by Moore (1970) as "a calling" and involves

acceptance of appropriate norms and values.

Seldon (1972), while admitting that there is no widely accepted

precise definition of a profession, nevertheless posits six essential

features of a profession:

1. skill based upon theoretical knowledge,

2. skill requiring education and training,

3. demonstration of competence by the passing of a
test or tests,

4. integrity maintained by adherence to a code of conduct,








5. service provided for the public good,

6. organization of practitioners into a body, the
professional association. (p. 25)

Thorner (1942) adds that the function performed by the profession

must be socially necessary, while Greenwood (1957) postulates that all

professions seem to possess, among other attributes, authority, commu-

nity sanction, and a culture. Some of these attributes will be dealt

with later in this text.

The study of the process of professionalization has been greeted

with as much enthusiasm as has been the search for the parameters of a

profession. Johnson (1972) contends that the term "professionalization"

is used in four ways:

1. It is used to refer to broad changes in the occupational
structure whereby professional or even white-collar jobs
increase in number relative to other occupations.

2. It is used in a way which implies little more than an
increase in the number of occupational associations
attempting to regularize recruitment to and practice in
a specific occupation.

3. It is used as a much more complex process in which an
occupation comes to exhibit a number of attributes which
are essentially professional and are said to be the core
elements of professionalism.

4. It is used to refer to a process and there is sometimes
the explicit argument put forth that this process occurs
as a determinate sequence of events (pp. 21-22).

Wilensky (1964) has attempted to outline this "determinate se-

quence of events." Initially, there must emerge an occupational group

which works full-tine on a specific set of problems. It is most

important that this work be non-manual, or only manual in so far as it

is necessary to perform personal services. Professionalism, according

to Wilensky, will more likely occur where an emerging occupation







already has some connection with an established profession. The

remaining stages in the process of professionalization, as distin-

guished by Wilensky, can be viewed as efforts on the part of the

occupation to secure its position in relation to the broader society.

I. The second stage is the establishment of training and
selection procedures.

2. The third stage is the formation of a professional
association.

3. The fourth stage is where the occupation agitates for
public recognition and legal support for its control
over entry and modes of practice.

4. The fifth stage is where the occupation will elaborate
a formal code of ethics (pp. 142-145).

Goode (1960), rather than attempting to enumerate specific stages

of professionalization, stresses the idea that one should think of a

given occupation as falling somewhere along a continuum of profession-

alism. He posits two "core" characteristics: prolonged specialized

training in an abstract knowledge and a collectivity or service orien-

tation, as being extremely important in determining the degree of pro-

fessionalization. Some occupations, such as nursing, rank high with

regard to service orientation but low with regard to Goode's first

''core" characteristic. In the case of the nursing profession, Goode

feels that nursing "has been unable to demonstrate that its training

is more than a lower-level medical education" (p. 903).




Goode continues by stating that some occupations, for example
social work, public accountancy, and librarianship, have made steady
progress on both dimensions. It appears obvious that many emerging
professions, such as speech pathology, must "walk a tightrope" between
courting the favor of stronger, more established professions in their
battle to survive and gain licensure and presenting the image that







Hughes (1958), one of the foremost writers in this area, views

professions, professionals, and professionalization from yet another

perspective, one of self-concept, status, and professional mandate.

My own experience in the study of occupations illustrates
the point that concepts may be blinders. My first essay into
the field was a study of the real estate agents in Chicago. .
I started the study with the idea of finding out an answer
to this familiar question, "Are these men professionals?" It
was a false question, for the concept "profession" in our
society is not so much a descriptive term as one of value and
prestige. It happens over and over that the people who prac-
tice an occupation attempt to revise the conceptions which
their various publics have of the occupation and the people in
it. In doing so, they also attempt to revise their own con-
ceptions of themselves and their work. The model which these
occupations set before themselves is that of the "profession;"
thus the term "profession" is a symbol for a desired concep-
tion of one's work and, hence, of one's self. The movement to
"professionalize" an occupation is thus collective mobility of
some among the people in an occupation. (p. 44)

Sanders and Lyon (1976) view professionalization as a process of

self-labeling. Within this process there is little value in listing

stages of professionalization or degrees of professionalism; profes-

sions are simply those occupational groups that can convince the pub-

lic that their skills are necessary for the societal good and that

their authority to control access to and utilization of these essen-

tial skills should be publicly sanctioned.

Tabachnik (1976) believes that the recent sanction of profession-

alism by politicians and by the public is due, in part, to several

basic beliefs. Among these are




their training is no more, in Goode's words, "than a lower-level
medical education."







1. the general belief that professionalism protects the public
from irresponsible and incompetent practitioners, and there-
fore contributes to the virtual elimination of quackery.

2. the related belief that by raising the level of competency,
political corruption will also disappear.

3. the belief that professionalism, via specialization, adds
to a growing body of knowledge, resulting in the long term
advancement of science. (p. 25)

Abrams (In Turner and Hodge, 1970) makes the point that as pro-

fessions emerge, they may also recede.2 He cites scribes, pharisees,

and alchemists as cases in point. These processes of professionali-

zation, de-professionalization, and re-professionalization, according

to Gerstl and Jacobs (1976) are cyclical. He conjectures that we are

now at what he calls "the point of advanced elitist professionaliza-

tion" (p. 1) and, should history repeat itself, on the brink of a

de-professionalization cycle. Gartner and Riessman (1972) assert




The process of de-professionalization as discussed by Abrams,
Gerstl and Jacobs, Gartner and Riessman, and others relates to entire
professions. A study of the various "sub-cycles" of professionalization,
de-professionalization, and re-professionalization within a given
discipline may well allow one to anticipate changes in the profession-
alization cycle of the entire profession. Over a period of time it is
possible that specialized areas or sub-sets of a profession may
experience a professionalizing or de-professionalizing trend.
In the field of speech pathology, the decreased incidence of dis-
orders of rhythm such as cluttering and stuttering (Van Riper, 1971,
p. 51) may, over time, lead to some degree of de-professionalization
of specialists in that area of concern. Conversely, advances in medi-
cine now allow many stroke victims to survive who in previous years
would have died soon after receiving the cerebral insult. The new
medical technology responsible for keeping stroke victims alive has
also created the need for increased numbers of well-trained specialists
in the area of aphasia rehabilitation. One may assume a defensible
position that this area of concern within the discipline of speech
pathology is undergoing a gradual process of professionalization. One
now hears quite frequently the unifying term "aphasiologist;" however
this writer knows of no such encompassing term which unifies those
interested in disorders of rhythm.







that this de-professionalization cycle has already begun, primarily

because of distortions and limitations imposed on the idea of what the

term "professionalism" means.

Large numbers of professionals are functioning at a very
low level. Teachers spend time helping children on with
their boots, taking attendance, keeping order, filling
out forms. . In essence, the professional is
underutilized. He mechanically performs routine tasks;
he has little initiative and he is bureaucratically
controlled by the rules. His skills are wasted, and
he becomes stultified and apathetic. (p. 271)3




3This concept has broad applicability to the discipline of speech
pathology. The advent of "programmed" therapy, the increased need for
accountability which is often reflected in time-consuming administra-
tive detail, and the specialization into which those trained under a
generalized orientation are forced to go, often require that a speech
pathologist use only a very small percentage of his training in service
to his clientele. Perhaps a reevaluation of our training methods needs
to be undertaken. As Hughes (1958) remarks:
From all of this there flows the question common to all
new professions and by no means uncommon among older ones:
for what are the people being trained, anyway? A recent study
of librarians gives the impression that the most successful
librarian is no longer a librarian but an administrator.
(p. 137)
The two primary bases for specialization within a profession are
1. the substantive field of knowledge which the specialist
professes to command, and
2. the technique of production or application of knowledge
over which the specialist claims mastery. (Moore, 1970,
p. 141)
It is becoming increasingly necessary for speech pathology to evaluate
the training and professionalization of its new careerists with regard
to the increasing administrative responsibilities of each professional,
and with regard to more effective utilization of specialized skills
within realistically viewed specialized work environments.







The Profit Motive and Additional Elements of the Professional/
Nonprofessional Schism: Differences That Make a Difference

"The professional man, it has been said, does not work in order to

be paid: he is paid in order that he may work" (Marshall, 1964,

p. 145). This question of incentives and motivation is of primary

importance in attempting to realize those characteristics which

dichotomize professionals and nonprofessionals.

Thorner (1942) asserts that the question of the profit motive is

not between business people who want to earn money and professional

people who don't, as both are equally interested in earning money as a

generalized goal. The contrast is, in Thorner's words, "between the

two institutionalized patterns controlling the manner in which money

ought to be made" (p. 323).

Thorner continues by indicating that the manner of remuneration

for professionals is not made indirectly in the guise of a profit

incident to a transaction involving material goods. The exceptions to

this statement prove the rule, as occupations such as pharmacy and

optometry rest on the fringes of professionalism as compared with

teaching, law, or medicine.

Many professionals assert that they are engaged in a non-profit

endeavor. Since the basic charge is for a professional's time, and

since there is no raw material on which to show a markup, no profit

can be visible (Lieberman, 1970). Of course it is to be understood

that although many would contend that the monetary incentive is a

relatively unimportant one for professionals, professions generally

can only maintain respectability if they succeed in receiving a

favorable monetary return. Marshall (1964) states the professional








viewpoint well when he asserts that professionals believe that,

"money must flow in as an almost unsolicited recognition of their

[the professionals'] inestimable services" (p. 145).

May (1976) stresses that most professionals serving consumer

clients do not receive monetary incentives to increase their produc-

tivity. She reports that some research is currently being conducted

to ascertain whether monetary incentives do in fact increase a profes-

sional's effectiveness in working with clients.

Barber (1965), in writing of professional behavior, lists as one

of his attributes of such behavior a system of monetary and honorary

rewards which acts primarily as a set of symbols for professional

achievement. These symbols are ends in themselves, and not simply a

means to some end of individual self-interest.

Seldon (1972) and Gilb (1966) write of the role that professional

associations play in guarding the economic interests of their members.




In the practice of speech pathology it is entirely probable that
some aspects of a desirable performance may not be measurable. How
does one measure motivation to use a learned phoneme or the alleviation
of gross misconceptions concerning one's problem? How does one weigh
the efforts of a speech pathologist who has almost "cured" a stutterer
of his mild problem with the efforts of a speech pathologist who has
enabled a severe stutterer to make an excellent adjustment to living
with his problem, while not necessarily effecting a great reduction in
the number of dysfluencies per unit of time? Awarding monetary incen-
tives based on client satisfaction is not an answer either, for many
clients are unaware of "how far they have come" in addition to the fact
that it may be necessary with certain types of therapies to provoke
client dissatisfaction with himself (which may be transferred to the
therapist) before any real progress can be realized. Moreover, many
of those who would generally be thought of as a profession's rost
unprofessional practitioners (i.e., the charlatans) are quite adept at
securing client satisfaction. Hughes' (1958) definition of a quack as
"the man who continues through time to please his customers [clients]
but not his colleagues" (p. 98) is very appropriate in this regard.








Seldon laments what he sees as a general retreat on the part of profes-

sional associations in health related fields from their traditional

emphases upon educational, ethical, and scientific concerns. He

writes, . when at the same time the profession exerts pressures

to increase the economic, political, and social benefits of its mem-

bers, it can no longer be considered to be operating on the basis of

altruism or as an unprejudiced party" (p. 27). Gilb views the profes-

sional association as a vehicle for gaining prestige and status for

the profession as well as the individual professional. If this pres-

tige and status are reflected in increased monetary rewards while

concurrently giving the profession the reputation of rendering service

rather than seeking profit, states Gilb, so much the better for the

individual practitioner.

If differences in viewing the profit motive are one critical

aspect in distinguishing professionals from nonprofessionals, certainly

the nature of the work performed may act as another element to bifur-

cate these two groups.

Elliott (1972), in writing of the minimum standards that an occu-

pation must meet to develop toward professional status, asserts that

"one of the most important of these is that it should be non-manual

. or only manual in so far as it is necessary to perform personal

services" (p. 114). With the same line of thought, Lieberman (1970)

writes that "first among equals in the professionals' claim to unique-

ness is preoccupation with a specialized skill premised on an under-

lying theory" (p. 55). This is not the type of skill that may be

mastered at a week long training course, but rather a skill which is








measured by the probability that the unitiated would not succeed at

the assigned task with varying degrees of patience.




5"Professionals," according to Hughes (1965), "profess" (p. 2).
In the case of emerging professions, professionals often find them-
selves either performing functions which were previously performed
for free or, as Goode (1960) points out, claiming the right to "solve"
a problem which was formerly solved by another (p. 902). In the for-
mer case, the lay public will be extremely hesitant to pay for
previously free services unless the emerging profession can convince
the public as to the superiority of their services over the free
services received. In the latter case, cries of "encroachment" from
other more established professions may well be heard. An emerging
profession such as speech pathology must be careful not to give the
impression that the special skill which they possess is one which,
as Lieberman states, "a housewife may learn at a one week training
course" (p. 55). Intensive training programs, professional jargon,
codes of ethics and so forth help in this regard. However, newer
technologies often do, in fact, place previously "sanctified" areas
of the profession within the reach of those with limited education and
training. In more established professions, for example in medicine,
technology is so complex, community sanction is so pervasive, and
authority and status are so elevated that the profession need not
worry in this regard. In a discipline such as speech pathology,
however, an interesting paradox can emerge. This is seen clearly in
an area such as remediation of articulatory difficulties. While the
profession strives to reduce therapy time, to make therapy more
efficient, and to standardize certain procedures, such "programming"
of the therapy process can eliminate to a large degree the need for
subjective "professional" decisions and leave administration of therapy
to those possessing relatively limited training. Three possibilities
are then presented. Professionals may continue to perform "programmed"
tasks which fail to make use of their full training, professionals may
abdicate responsibility in such areas (with the possible erosion of
their professional base) or professionals may evolve to higher level
competencies and expand the horizons of their profession while, at the
same time, expanding their professional status and authority.







Professional Services: The Ethic, the Expectation, the Reality

The service orientation which a professional possesses is yet

another factor which must be considered in a discussion of the profes-

sional/nonprofessional schism. Lieberman (1970) maintains that the

professional preserves his neutrality against encroachment by taking

the fundamental position that the skills he has to offer are actually,

or at least potentially, of benefit to all. The professional contends

that he desires to serve all to the maximum of his ability and that

his desire is not mitigated by the size of his compensation.

Thorner (1942), in writing about the tenuous position which phar-

macy occupies with regard to being a profession, asserts that the

ambivalence of pharmacy's position rests in the juxtaposition of

viewing the pharmacist as a skilled professional with a strong service

orientation toward mankind and viewing him as a seller of commodities

for profit. This "compromise" of the service ethic continues to be a

matter of debate in professions considering whether to allow their

members to sell therapeutic equipment in addition to offering services.

While the professional is quick to assert that service is fore-

most in his mind, even to the point where, as Greenwood (1957) points

out, "the work life invades the after-work life, and the sharp

demarcation between the work hours and the leisure hours disappears"

(p. 53), one should look to those receiving services for an opinion.

Business Week ("How Licensing Hurts Consumers," 1977) quotes two

economists, J. Gaston and S. L. Carroll, with regard to the fact that

high quality service is available from professionals, but only for

high income individuals. This "Cadillac effect" requires those on low







incomes, who cannot afford the price of service, to go without or

rely on low priced, unlicensed, "quacks."

May (1976) pursues the question of differences in client, profes-

sional, and bureaucrat service expectations. If these three groups

share common expectations as to how professional service should be

performed, May feels professionals will be responsive to clients. If

they do not, then the responsiveness shown by a professional toward

a client will vary with the professional's autonomy and the extent to

which he and his client share expectations.

Lieberman (1970) believes that the "primary" motivation is one of

service. He lists three separate motivations that blend to energize

the professional: the service goal, the profit goal, and the desire

for autonomy (p. 68).

Johnson (1972) indicates that one reason government mediation is

often essential is to stress social service. Professionals may have a

personal service commitment but may lack adequate perspective on the

broad social consequences of the provision of services in general.

While agreeing in principle that government mediation with regard

to service allocation may be practical, Moore (1970) does cite one

advantage of leaving resource allocation to the vagaries of the open

market.

Reliance on the market as a way of allocating professional
and related services has the dual disadvantage that the
need for services may not coincide with the ability to pay
and the prospective client may not be able to judge among
competing alternatives. Yet a somewhat open market and
somewhat accessible and decentralized legal system has the
distinct advantage of permitting new specialties to get
established. (p. 185)







May (1976) contends that public bureaucracies are better equipped

to redistribute advantages, so one might assume that the state bureau-

cracy is the best place to redistribute professionals. Finally,

Lebell (1973) specifies a number of recent trends with regard to

professionals and the services they provide. One such trend, he

indicates, is a growing public sentiment that the needs of society

are not being fulfilled by the various professions to the extent

claimed feasible.




If one prerequisite to becoming a licensed (or certified, regis-
tered, etc.) speech pathologist was to have the state "place you" for
your first year of work, certain advantages might accrue. Among these:
1. Resources would be allocated more evenly, giving credence
to the claims of "service" as a prime motivator for speech
pathologists.
2. Compliance with public laws, such as PL 94-142, would be
enhanced.
3. Fewer people might enter the profession (which, depending
on one's perspective, is an advantage or a disadvantage).
4. Neonate speech pathologists might be required to work with
speech, hearing, or language disorders to which they would
otherwise have very little exposure.
5. Instead of isolated rural positions offering lower salaries
than more popular urban positions, the state could supple-
ment rural salaries to make them potentially more attractive.
Obvious cries of "socialization" and "abridgement of 14th Amend-
ment rights to life, liberty, and the pursuit of happiness" would be
heard. Thus, the age old question of society's right (or obligation)
to subjugate individual freedoms for the common good is again brought
to the forefront. Or rephrased, do we have to limit professional
autonomy to provide better allocation of resources? Johnson (1972),
in writing of various forms of mediative control in England, states
that
the state may attempt to ensure a desired distribution of
occupational services through the medium of the state agency
which is the effective employer of all practitioners who have
a statutory obligation to provide a given service. . The
effect of state mediation has been to extend services to con-
sumers who are defined on the basis of "citizenship" rather
than social origin or the ability to pay fees. . How-
ever, the major significance of this form of control lies not
in the social composition of the consumers but in the creation
of a guaranteed "clientele." (p. 77)








The Professional Culture:
Values, Norms, Standards, and the Career Concept

The professional culture, according to Greenwood (1957), is

another characteristic which sets the professional apart from his

nonprofessional counterpart. The professional's commitment, or

calling, requires that he accept the appropriate norms and standards

of his profession so that he can identify with his professional peers

and the profession collectively. Greenwood states that if one were

to choose the single attribute that most effectively differentiates

the professions from the nonprofessions, the acquisition of a profes-

sional culture would be that attribute (p. 52). He goes on to affirm

that the culture of a profession consists of its values, norms, and

symbols. These terms are explained below.

The social values of a professional group are its
basic and fundamental beliefs, the unquestioned premises
upon which its very existence rests. Foremost among
these values is the essential worth of the service which
the professional group extends to the community. . .
The norms of a professional group are the guides to
behavior in social situations. Every profession develops
an elaborate system of these role definitions. There is
a range of appropriate behaviors for seeking admittance
into the profession, for gaining entry into its formal
and informal groups, and for progressing within the
occupation's hierarchy. . .
The symbols of a profession are its meaning-laden
items. These may include such things as: its insignias,
emblems, and distinctive dress; its history, folklore,
and argot; its heroes and its villains; and its stereo-
types of the professional, the client, and the layman.
(p. 52)

Least one believe that each of these sociological terms is

operationally defined in a similar manner by different authors, Becker

(1962) writes of the symbols for a profession with a totally different

perspective. His interpretation of symbols includes







1. recruitment of new members being tightly controlled,

2. entrance to the profession being strictly in the hands
of the profession,

3. responsibility for approval and/or accreditation of
the educational preparatory programs resting with
members of the profession,

4. consideration of any member of the profession as being
fully competent because of the dictums outlined in
one, two, and three above (p. 36).

Another important idea with regard to the professional culture

which is discussed by many authors is that of the "career" concept.

The term "career," in its general usage, is employed only in refer-

ence to a professional occupation. Thus,one can talk about the career

of a lawyer or physician, but one does not speak of the career of a

plumber or carpenter. Most authors agree that the essence of the

career concept is a distinctly professional attitude toward work which

encompasses many of the notions previously discussed in this chapter.

However, Wilensky (1960) defines a career as more than simply a pro-

fessional attitude. Viewed structurally, he sees a career as, "a

succession of related jobs, arranged in a hierarchy of prestige,

through which persons move in an ordered, predictable sequence"

(p. 554).7 It is possible that this microcosmic interpretation of

the career concept may eliminate a number of important considerations.




If one does, indeed, view a career as "a succession of related
jobs, arranged in a hierarchy of prestige, through which persons move
in an ordered, predictable sequence," then one may find it very
difficult to defend speech pathology as a career. The "typical"
speech pathologist may move through a succession of related jobs,
but often the "hierarchy of prestige" concept is lacking. This
prestige factor may assume a relatively low priority when compared
with factors such as geographical location, proximity of work to one's








Professional Goals: Sanction, Control,
Authority, Autonomy, Mandate, and Monopoly

Community sanction may be viewed as another key determinant in

defining the parameters of a profession or of a professional. Related

to this, of course, are the concepts of professional control,




residence, work schedule (availability of half-time positions, etc.),
and type of disordered population serviced. In fact, the Occupational
Outlook Handbook (U. S. Dept. of Labor, Bureau of Labor Statistics,
1974) states quite clearly that "opportunity for advancement, as in
most health service occupations, is generally not an important consid-
eration for speech pathologists and audiologists" (p. 517).
While the origin of the word "career" is from the French "carri-
ere," meaning a racing course, thus Webster's (Webster's New World
Dictionary, 1957) definition of a "career" as
1. originally, a racing course; hence, 2. a swift course,
as of the sun through the sky; hence, 3. full speed,
4. one's progress through life. (p. 221)
modern usage has somewhat altered both Wilensky's and Webster's defi-
nition. Today when one asks, "Is he going to make it his career?"
one is often asking more about an investment of time, effort, or
money than about the new careerist's desire to proceed swiftly to the
zenith of his profession. One might even question the efficacy of
speaking in terms of a "zenith" for many service professions, con-
tending that each service professional has his own personal goals and
aspirations within the profession; goals and aspirations which may
never fit the traditionalist's notion of "progress in one's profes-
sion." Marshall (1964) illuminates the problem more fully.
In the church or the army, in law or medicine, a man
at the head of his profession is on top of the world. He
admits no superiors. But many of these new semi-professions
are really subordinate grades placed in the middle of the
hierarchy of modern business organization. The educational
ladder leads into them but there is no ladder leading out.
The grade above is entered by a different road starting at
a different level of the educational system. . Mobility
between generations is increased, but mobility during the
working life of one generation is diminished. That appears
to be the direction in which things are moving today, towards
the transfer of individual competitiveness from the economic
to the educational world, from the office and workshop to
the school and university. (p. 161)







professional mandate, professional autonomy, and professional monopoly.

The interrelationship of these ideas is so complete as to make it

virtually impossible to discuss one without discussing the others.

Greenwood (1957) writes that every profession "strives to

persuade the community to sanction its authority within certain spheres

by conferring upon the profession a series of powers and privileges"

(p. 48). Some of the powers which a profession seeks to control are

the power of control over its training schools and the power of con-

trol over admission into the profession. Comparable control, states

Greenwood, is not to be found in a nonprofessional occupation.

Often a profession is not strong enough at the outset to gain

from the community a full set of professional controls. It may then

begin to circumspectly attempt to achieve a modest measure of public

recognition via public dissemination of information regarding the

profession and by attempting to prove to the community just how

zealously the profession wants to protect it from fraud, menaces to

the public health and, in some instances, itself. From a relatively

weak grant of public power, the professional group may ultimately be

able to push for state licensure by convincing the community that it

is in the community's best interest to license the profession. Licen-

sure as a form of control will be discussed at length in the next

chapter.

Gilb (1966) summarizes well the professional's desire for control.

Gilb views the professional as an individual who wants to create an

abstract standard which is enforced by his peers (code of ethics) or

by the state (licensure) which will stand between the individual







professional and those who might have arbitrary power over him.

Goode (1972) believes that one response to the threat of the

community controlling the profession is the social control which the

professional community exerts over its members. Failure to discipline

one's own would result in both a loss of societal prestige and a loss

of community autonomy.

Barber (1965), while affirming the importance of societal control

and colleague control, stresses the need for self-controls.

. the requisite understanding is available in full
measure only to those who have themselves been trained
in and apply that knowledge. It follows that some kind
of self-control, by means of internalized codes of ethics
and voluntary in groups, is necessary. . Further
controls on professional behavior exist, of course, in
the informal agencies of public opinion and in govern-
mental legal agencies. But these forms of social control
are less important than in nonprofessional areas. (p. 18)

Gilb (1966) discusses the role of the professional association in

attempting to achieve professional cohesion and gain control over the

profession. The professional association, according to Gilb, desires

this control in order to "make the profession's work more uniform and

predictable and to check excessive intraprofessional competition"

(p. 53). Professionals desire colleague control, as opposed to public,

client, or employer control, not only over the profession but also

over the conditions and the standards of the profession's work.8




Employer control, as referred to by Gilb, is generally not
considered by authors with the same intensity as are peer controls,
community controls, legal controls, client controls, and self-controls.
However, for the speech pathologist, employer control is often of
considerable consequence. With approximately two-thirds of the
currently employed speech pathologists working in the public schools,
it is not surprising that many speech pathologists feel rather








Clients may exercise market controls directly by deciding whether

to buy particular professional services and by selecting the services

of particular professionals. Professionals, needless to say, feel

great dismay at their vulnerability to these controls. May (1976), in

a discussion of client control, makes the following observations.

1. Employer clients have more control over salaried
professionals than consumer clients do.

2. Employer clients exercise less market control over
professionals when the supply of professionals is
smaller than the demand for their services.
(p. 13-14)

Moore (1970) affirms that professionals in strictly independent

practice respond only to initiatives taken by clients. Thus clients




confused concerning the chain of command. Does one take orders from
the chief speech pathologist or from the principal who directs the
school in which the speech pathologist works? What orders does one
accept from an "employer" (i.e., principal) who is not a member of
one's own profession and whose primary concerns may not always be
those of the speech pathologist and those he serves? Questions such
as these need to be answered or at least discussed prior to actual
confrontation. Moreover, the principle of unity of command, as
discussed by Haimann (1973) and others, should be applied to the type
of situation described above.
The uninterrupted line of authority from the adminis-
trator to the team leader assures that each superior exer-
cises direct command over his subordinate and that each
subordinate has only one superior to obey. This is known
as the principle of unity of command. It is a principle
which every administrator should follow while arranging
line authority relationships. Unity of command means that
there is one person in each organizational unit who has the
authority to make the decisions appropriate to his position.
(p. 98)








have more control over professionals who perform services for a fee

than over salaried professionals.

How does a professional counter client controls and seek to

extend his professional authority over the client? One means of doing

so, suggested by Moore (1970), might be to have the professional con-

vince the client that his particular problem is in need of a "team"

approach. Thus the professional may form a dossier on the client

based on the belief that the client's problem is properly contextual

and not an isolated one. In this way, according to Moore, the pro-

fessional can begin to counter the control of the employing client

and establish a professional control of his own.

It is apparent that many forces interact in the establishment of

professional controls. Licensing is simply one of them. Lieberman

attempts to take an overview of the problem, but the role of laymen

today is, with regard to the regulation of some professions, vastly

different from that described by Lieberman in 1970.

We seem to be at an impasse in the conduct of our
public affairs. The people are not economically motivated
to contest the market power of professionals; the legis-
latures are not politically disposed to establish necessary
controls; the courts declare themselves constitutionally
powerless to regulate often outrageous conduct. And the




There is great potential for abuse here. At times, a speech
pathologist in the employ of a client may become so overly sensitive
and responsive to the wishes of the client that he violates profes-
sional ethics. For example, a speech pathologist may acquiesce to
a client's demand for "stuttering" therapy although no problem
exists. If, after counseling, the client continues to demand a
formalized therapeutic program, the speech pathologist may rationalize
his decision to proceed with unnecessary therapy by stating that if
he doesn't provide the service, the client will look elsewhere.







general impotence is a psychological phenomenon, the fear of
expertise being sufficient to deter laymen from accepting
responsibility for modern problems. (p. 220)

Professional autonomy and professional authority are two prime

considerations of those practicing professions. Autonomy, according

to May (1976), refers to the institutional component of a profes-

sional's authority. It is quite different from authority which is

legitimized by his training. The professional's authority comes

forth in a one-to-one relationship with the client and Freidson (1968)

asserts that when the professional clientele is unorganized and the

number of professionals is small in relation to demand, professional

authority is at its highest. It is fair to say that professionals

working in private practice exercise their individual authority under

conditions of increased autonomy. May (1976) makes the following

statements relative to professional autonomy.

1. When an organization's goal achievement requires their
full cooperation, professionals will enjoy more
autonomy.

2. Managers who are professionals may be more sympathetic
to the professionals' desire for autonomy and may permit
them more self-determination.

3. Professionals who are in demand have more autonomy than
those who are not.

4. . professional autonomy is not a function of the
amount of control. Rather, as professional autonomy
increases, so does the professionals' ability to
determine the content of the administrative controls.
(pp. 17-21)

Moore (1970) notes that while autonomy may be reduced by licensing

in other areas, such is not the case with professions. Generally,

among professionals, judgment tends to remain within the professional

fraternity.







Lieberman (1970) believes that the extension of professional

autonomy is a dynamic act. The professional promotes the assertion

that all within his realm belongs to him. This belief is generally

promulgated through the professional association with the results

that the dominion of the profession is increasingly expanded to

encompass the social aspects of the discipline.

Allied very closely with the concept of professional autonomy is

that of professional mandate. Hughes (1958) comments frequently on

this concept.

Many new and some old occupations have sought for
themselves the envied status of profession; some of them
succeed in gaining that esteem, that broad license to
control their work and that social mandate over affairs
pertaining to it that the term profession connotes.
(1958, p. 7)

An occupation consists, in part, of a successful claim
of some people to license to carry out certain activities
which others may not, and to do so in exchange for money,
goods, or services. Those who have such license will, if
they have any sense of self-consciousness and solidarity,
also claim a mandate to define what is proper conduct of
others toward the matters concerned with their work.
(1958, p. 78)

License, as an attribute of an occupation, is ordinar-
ily thought of as legal permission to carry on a kind of
work. . Professions also, perhaps more than other
types of occupations, claim a legal, moral, and intellec-
tual mandate. Not merely do the practitioners, by virtue
of gaining admission to the charmed circle of colleagues,
individually exercise the license to do things others do
not do, but collectively they presume to tell society what
is good and right for the individual and for society at
large in some aspect of life. (1958, p. 79)

Thus.a profession seeks to insure its collective authority and

autonomy by convincing society as to the validity of its mandate and

the benefits of internal control (even if such control appears to be

issuing from without). Once a profession successfully exercises a








mandate, once a profession can claim to monopolize expertise in a

particular area, then, as Lieberman (1970) points out, professionals

can achieve by indirection what anti-trust laws prohibit.

Professionals cannot privately get together to limit the
number of competitors by refusing to employ them or by
making it difficult for the competitor to compete, so
they provide laws from state legislatures which authorize
them to achieve remarkably similar effects by quasi-public
regulation. To this end they are aided even by the
federal government. (p. 138)

When this right to practice a particular profession depends on the

approval of some agency, and when official approval is based on

factors related to the occupation, Lieberman believes that the

profession has established the foundation for the exercise of monopoly

power. Moore (1970), however, states that not one of the older, more

established professions has been able to command a complete monopoly

with regard to its claimed field of competence.

Greenwood (1957) writes of the "monopoly of judgment" which is

achieved by client subordination to professional authority. When an

occupation is undergoing the process of professionalization, one of

its primary aspirations is to acquire this monopoly. Many authors feel

that when this monopoly of judgment is achieved, the professional has

a license to deviate from lay conduct in action and in thought with

regard to the matter which he professes.

Barron (1966) elaborates on two cases in which the acquisition of

monopoly powers may be beneficial to both the buyer and the seller.

One of these situations is the "natural monopoly" case while the other

is referred to by Barron as "the case of no second chance." In the

first instance, it becomes apparent that one producer can supply the








entire market with a product or service at a lower real cost, using

fewer resources, than can several producers. In a "natural monopoly"

situation, Barron feels the existence of more than one producer will

have the effect of

1. providing each seller with excess capacity and/or,

2. providing ruinous competition to the point where
sellers, attempting to cut costs, may reduce the
quality of the product or service (p. 642).

The "no second chance" monopoly is applicable in situations where the

assumption that a consumer will learn from his mistakes is not a

valid one. In some situations, errors cannot be rectified because the

consumer may not be around to correct them. Such may be the case from

eating adulterated foods or drinking methyl alcohol sold as grain

alcohol. Barron believes that the public licensing of businesses and

professions contains elements of both "natural monopoly" reasoning and

"no second chance" reasoning (p. 642).


Professional Abuses and Conflict of Interest:
No Wonder the Public Is Angry

Without client confidence, the profession could not maintain its

monopoly. A monopoly can be abused.

The professional group could peg the price of its services
at an unreasonably high level; it could restrict the num-
bers entering the occupation to create a scarcity of
personnel; it could dilute the caliber of its performance
without community awareness. . (Greenwood, 1957, p. 50)

If the profession, in the eyes of the community, abuses its monopoly,

then the monopoly may be revoked or at the very least reviewed. Just

what constitutes "abuse" is often unclear, and this topic will be

discussed at length with regard to professional licensing in Chapter 2.








However, to briefly illustrate that the potential abuses cited by

Greenwood in the above quotation are indeed realistic, further elab-

oration will be undertaken at this time.

Greenwood's first point, that the professional group may peg the

price of its services at an unreasonably high level, is expanded upon

by Consumer Reports ("Consumers Seek Public Voice," 1976). Writing

with regard to the Virginia State Board of Examiners in Optometry

enforcing a statute prohibiting optometrists from working for, or

leasing space in, commercial establishments, Consumer Reports

concludes:

The powers of licensing boards are so far-reaching that
there's a clear potential for abuse. Whenever a board
restricts entry into a trade or profession, competition
is reduced and existing practitioners can command higher
prices for their scarce services. Strict curbs on pro-
fessional advertising serve to reduce price competition.
(p. 372)

Greenwood's second point, that the professional group could

restrict the numbers entering the occupation to create a scarcity of

personnel, is addressed in an article published in the January 8, 1975,

Wall Street Journal. In 1973, 2,149 aspiring general contractors took

the Florida Construction Industry Licensing Board's examination to

test their competence. Each of the 2,149 examinees failed the exam-

ination, with the resulting effect that some Florida state legislators

suggested that "the total failure had been a calculated effort by the

board to limit competition by barring new entrants to the field"

(Montgomery, 1975, p. 1).

Larson (1977) also views the manipulation of licensing exami-

nations and the artificially stringent standards for admission to







training with suspicion. Since professionals with vested interests

in maintaining the price of services and the prestige of their profes-

sion are the very individuals who develop the standards for both

training schools and licensing boards, such abuses are likely to

continue. The primary question generated by Larson, however, is for

how long this reduction of supply can be publicly justified by the

"pure objectivity" of meritocratic standards, especially when the cost

of training also tends to increase (p. 52).

The fact that a profession can dilute the caliber of its perform-

ance without community awareness, Greenwood's third point, can be

reflected in numerous ways. "Grandfathering" and continuing education

are but two.

"Grandfathering," as used here, refers to establishing a way in

which all persons who were practicing a profession prior to enactment

of a law can obtain a license without having to meet the requirements

which are specified in the law. Goode (1972) illustrates the effect

of grandfathering on the caliber of professional service.

S. when the standards for entrance are raised substan-
tially. This is, in effect, an announcement that certain
older members of the professional community have not been
adequately trained. However, allegiance to the professional
collectivity outweighs the service obligation to the public
and grandfatheringg clauses" lessen the severity of that
indictment. (p. 25)

Street (1977), writing about lay participation on state licensing

boards, quotes California Department of Consumer Affairs Deputy

Director Michael Krisman.

They [California marriage and family counselors] go to the
legislature saying "You've got to regulate us, you've got to
protect the public from all these quacks." Then they
grandfather in all the quacks they complain about. (p. 310)








Johnson (1972) goes one step further when he comments:


Charlatanism and quackery are . a creation of pro-
fessionalism and not the cause of it. That is to say
that periods in which it is claimed charlatanism is
rife and needs to be stamped out are just those periods
when an occupation is attempting to establish or
struggling to maintain a monopolistic position. (p. 57)

The lack of a plan for continuing education can certainly adverse-

ly affect the performance of a professional, generally without the

community's knowledge. Although individuals often must meet rigid

requirements to acquire a license, licensed professionals may not have

to indicate that they have maintained their skills at a satisfactory

level or show an understanding of new technology.10




W1 while the issue of continuing education in the disciplines of
speech pathology and audiology will be discussed in a subsequent
chapter, it is of interest to note here that continuing education is
not required to maintain one's ASHA certification, nor is it required
to renew one's license in the vast majority of those states licensing
speech pathologists and audiologists. As long ago as May 1973, the
American Speech and Hearing Association concluded:
There is a strong feeling among many in the profession that
there should be an inclusion in the licensure bill of a
continuing education clause. The desirability of having
licensed professionals update their level of knowledge and
their clinical skills is obvious to both the CGR [Committee
on Governmental Regulations] and to most legislators.
However, the question of what constitutes adequate continuing
education for our profession is presently being considered by
several ASHA committees. (ASHA, 1973a, p. 20)
Apparently the "jury" is still deliberating, and comments such as the
following are unlikely to aid in bringing about a positive verdict.
To change from continuously respected certification to
mandatory recertification with imposition of life-long
requirements may connote the same impact of dishonor to the
offended graduate or professional as would a university that
imposed lifelong requirements on all its graduates with the
threat of withdrawing recognition of its awarded degrees.
After years of costly preparation coercion by one's
professional organization -- or by any governmental or other
body -- to matriculate in any manner with threat of loss of
professional livelihood may be interpreted as a form of
extortion. Therefore, for ASHA to withdraw its commitments







Such abuses or potential abuses are often epitomized in the

conflict of self-interest versus community interest. Barber (1965)

writes that since knowledge provides powerful control over nature and

society, and since a profession evolves around a systematized body of

abstract knowledge, that knowledge should be used primarily in the

community interest. Hughes (1958) does not believe that individual

self-interest should be wholly neglected in professional dealings,

but rather should be subserved indirectly.

However, critics are increasingly coming to view the profession

as a group of individuals whose primary function is one of self-

interest, namely self-perpetuation. Lieberman (1970) contends that,

while the professional will publicly proclaim that his only function

is to perform a service, the service function is incidental to the

primary purpose of the profession. This primary purpose is to main-

tain the system which supports the profession. Lieberman states:

Maintenance of the legal system as construed by lawyers is
the principal function of the lawyer. . What degrades
the profession degrades the legal system. . What is
not good for lawyers is bad for law. In short, lawyers
are the legal system, and doctors the public health.
Professionals might deny this, but they take actions based
on it, and the contradiction is serious. (p. 5)

In a latter portion of his book, Lieberman further decries the

idea of the public interest notion.




and prerogatives of certification may pose a genuine threat to
its integrity and the integrity of the profession. (Becker,
1974, p. 352)
Such a comment indicates an acute awareness of the need for integrity
on the part of the professional association, and an appalling lack of
awareness of the need for integrity on the part of each professional
toward those whom he serves.








When a highly specialized group speaks out in a matter
that directly concerns its economic well-being by saying
that it has the public's interest at heart, it is engaging
in the highly developed American art of bombast -- a
subject worthy of more serious study than it has been
given. (p. 146)

Finally, Barron (1966), with regard to self-interest and commu-

nity interest, indicates that community interest is often compromised

because the profession being licensed controls its own licensing

function. Moreover, if the court is of the opinion that the state

legislature believes a licensing law will have any relation to the

public interest, the court will generally not overturn it (p. 657).

It is not surprising, then, that public sentiment has turned

somewhat against professionals within the last several decades.

Lieberman (1970) comments on this widespread ambivalence toward the

professional in our country by indicating the paradox which exists

between the desperate need for specialists and the "uneasy belief in

the stupidity, inefficiency, even cupidity of professionals" (p. 62).

Hughes (1958) contends that in the hearts of many laymen is an

aggressive suspicion of all professionals which can occasionally flare

into fanatical anger. Some professions are engaging the services of

public relations firms to help eradicate not only the obvious mani-

festations of suspicion and anger, but also to locate and dispose of

the more latent and perhaps more chronic feelings of suspicion against

those who are licensed to perform services for them.


Codes of Ethics: The Professions State Their Case

While the retention of public relations firms to protect and pro-

mote the public image of a profession may be fairly recent, the promul-

gation of professional codes of ethics is not. These codes allow the







profession simultaneously to retain power and to present a collective

image of dignity and honor. They serve to protect the profession

from the pervasive fear that the public will lose confidence in the

profession. This fear is a very real one, for professions are not

simply discarded by a suspicious public; rather they are subjected to

"outside" controls which will assure the public that they are per-

forming their functions more capably.

Furthermore, such codes tend to reinforce the homogeneity which

follows from uniform training within a profession and from licensing

laws (Gilb, 1966). Such codes were developed in many professions

toward the beginning of the twentieth century with the explicit

rationale that an honest community of professional practitioners could

be fashioned. It was felt that professionals would not abuse their

positions of public trust if they knew that suspension or expulsion

from their professional association was a means of sanctioning them.

Thus, professional associations devised codes of ethics which

amounted to private systems of law. Moore (1970) affirms that these

are characteristic of all formally constituted organizations with the

exception of two notable features which are not prominent in the admin-

istrative regulations of public or private bureaucracies.

1. The codes highlight proper relations with clients
or others outside the organization rather than
procedural rules for organizational behavior.

2. Codes are also commonly understood as not self-
enforcing. In the bureaucratic setting, regu-
lations are supposed to be monitored, and
discipline imposed, by hierarchical superiors.
The professional association, being nominally
a society of equals, must adopt other procedures;
normally these will rest primarily on an internal,
quasi-judicial body commonly known as a "committee
on ethics" which will review complaints and, if
necessary, recommend disciplinary action. (p. 116)








Professional codes of ethics are generally based on a dedication

to truth, justice, or some other abstraction that aids the profession

in its attempt to justify the power and autonomy granted it by the lay

community. Such codes retain the notion of an inherent morality.

Unethical behavior is not simply improper for practical reasons, but

for basic moral reasons as well. However, Lieberman (1970) contends

that morality is more likely to be legislated by majority vote (p. 83).

Turner and Hodge (1970) believe that ethical codes, whether

written or unwritten, allow for a substantial area of equivocation out-

side of the ethical rules. Because codes of ethics include relatively

few prescriptions and/or proscriptions, and because such codes have

generally high levels of abstraction, there is often a great deal of

ambiguity at the level of action (p. 29).

Marshall (1964) writes that ethical codes are centered on the

conviction that a relationship of trust is present between the pro-

fessional and the client which is not evident in dealings between a

buyer and a seller. Such codes are necessary due to the impossibility

of drawing up and enforcing a contract which would stipulate just what

the client is to receive from the professional. Marshall specifies

two reasons for this.

1. One is that professional service is not standardized.
It is unique and personal.11




The veracity of Marshall's statement regarding the unique and
personalized nature of professional service has been challenged by a
number of authors. Moore (1970) states:
Marshall asserts that professional service is "unique and
personal." That is a very interesting and conspicuously
false notion. If every professional problem were in all








2. [The second reason] is the ignorance of the client. He
hardly knows what to ask for, let alone how it can be
provided. He must surrender all initiative and put
himself in his lawyer's hands or under his doctor's
orders. (p. 148)

Greenwood (1957) bifurcates a code of ethics into its formal and

informal parts. He views the formal portion as the written code to

which the professional usually swears allegiance as he is admitted to

practice. The informal portion consists of an unwritten code which,

according to Greenwood, nevertheless carries the weight of the more

formal pronouncements in the written code. Discipline consists of

subtle and not-so-subtle colleague pressures which may be reflected in

consultation and referral practices. Greenwood comments that "the

consultation-referral custom involves professional colleagues in a

system of reciprocity which fosters mutual interdependence. Inter-

dependence facilitates social control . (p. 51).

More extreme forms of discipline can occur via professional




respects unique, solutions would be at best accidental, and
therefore have nothing to do with expert knowledge. (p. 55)
In the practice of speech pathology, as well as the practice of many
other professions, it would seem fair to say that the practitioner
amalgamates general principles of the discipline with unique aspects
of his own training and personality to provide personalized service.
All problems are unique, but just to what degree depends on one's
viewpoint. The client believes his problem to be truly unique. He
suffers, and from his perspective the professional treats his unique
emergency with callous routine procedures. However, the professional's
ability to deal adequately with the situation may be the result of
having dealt with thousands of similar cases. Perhaps the enlightened
professional is one who can ascertain and investigate what is unique
in the client, even if the problem which presents itself is routine.








association censure or, in extreme cases, barring of the offender.

Goode (1960) notes that as an occupation becomes more professionalized,

the norms of practice (code of ethics) enforced by the profession are

more stringent than legal controls. Wilensky (1964) contends that in

some cases a formal code of ethics may appear during the initial

stages of the push for professional status. However, his research,

which examined a total of 13 established professions or professions in

process, indicates that in ten of the professions under consideration

the formal code of ethics came in the final stages of professionali-

zation (p. 145).


The Professional: Relationships with Clients,
Colleagues, and Trends of the Future

The professional's relationship with his clients and colleagues

deserves further elaboration than can be given solely in a discussion

of codes of ethics. The intermix of these relationships is at the

very heart of the licensing question, a question which will be

explored in subsequent chapters.

Greenwood (1957) calls attention to the need for emotional

neutrality which provides yet another disparity in the services

offered by professionals as opposed to those offered by nonprofes-

sionals. Whereas a nonprofessional may withhold services to customers

for a number of reasons, the professional is obligated to provide

service to whomever requests it. The professional is motivated to a

greater extent by what Greenwood terms "the impulse to perform

maximally" (p. 50) and to a lesser extent by tangible reinforcements.

The nonprofessional can compromise with the customer, diluting the







quality of that which he offers the customer in order to correspond

to that which the customer will pay. Theoretically, such is not the

case in professional/client relationships.

A nonprofessional occupation has customers; a professional occu-

pation deals with clients. The difference, according to Greenwood,

lies in the fact that the customer shops until he finds the quality

and quantity of services and/or commodities he desires at the price he

is willing to pay. His freedom of decision lies in the fact that he

has the capacity to view his own needs and the ability to judge the

worth of competing services or commodities which will satisfy them.

This is not true in the professional relationship. As Moore (1970)

states:

The client is in no position to judge competence, except,
possibly, at the extremes, and even there his view may
differ from that of the expert; what appears to be extreme
competence may appear to colleagues as mere showmanship,
and what appears as extreme incompetence may appear to
colleagues as reasonable conduct in a situation fraught
with difficulties and possibly bad luck. (p. 111)

The viewpoint shared by Greenwood and Moore is not a universally

accepted one. More recently, a number of authors have attacked the

efficacy of occupational licensure on a number of fronts. One argu-

ment used by those favoring delicensure or alternative forms of

occupational/professional control is that the client is not in the

rather helpless state described by Moore. Barger (1975) contends:

The customer himself should be the supreme judge of who
is competent to perform the service he requires. If the
members of a trade or profession believe that certain
standards or practices are considered desirable in their
field, they ought to have the right to publicize this
fact and even to urge customers to accept such standards








and practices before making service commitments.
(p. 198)12

May (1976) ascertains three properties of the professional/client

relationship. These are

1. the extent to which colleagues supervise a
professional's performance,

2. the extent to which clients exercise market
controls over the professional,

3. the extent to which an agency exercises
administrative (hierarchical) controls over
the professional-client relationship. (p. 7)

With regard to colleague control and the professional client

relationship, May writes that collegial control is greater with

salaried professionals working in a bureaucratic setting than with

fee-for-service professionals working in isolation. Professionals

working under greater collegial control will generally tend to keep

abreast of new technical advances in their field to a greater extent




12
It is interesting to note that Barger uses the term "customer"
throughout, although talking about consumers of professional as well as
nonprofessional services or commodities. Such viewpoints seem to
assume that if professions educate the public as to the standards that
they (the collective profession) expect from their members, the public
will be able to separate "the wheat from the chaff" with regard to
those practicing the profession who can adequately fill the require-
ments of the customer/client. It is difficult to visualize the
individual with an excruciating toothache, an emotionally-laden
stuttering disorder, or a prescription for a drug to remedy a severe
bleeding ulcer as taking the time to study the "standards or practices
[that] are considered desirable in [a given] field" and to decide
whether or not a given professional meets such standards before "making
service commitments." The profession as a collectivity can urge the
public to accept only a high level of practice, but those in pain,
those in grief, those with low intelligence, those who are illiterate,
and those who are apathetic are, most likely, going to receive an
acceptable level of service only if standards of service are controlled
at some level above that of the consumer. Public education as an
alternative to licensing will be discussed more fully in Chapter 2.







than more isolated professionals (p. 11). Moreover, May sees the

balance between a professional's loyalties to his client and to his

profession as being affected by the nature and amount of experienced

colleague interaction.

Wilensky (1964), in order to focus upon the relationship between

colleague and client control, constructed an index of client orien-

tation. The results of his research confirm the conflict between

client and colleague orientations, and his findings imply that "a

client orientation will be an increasing threat to professionalism"

(p. 155). However, insofar as self-employment fosters a client

orientation, the professional segments of the service sector are

becoming less vulnerable as they become more salaried.

Greenwood (1957) discusses colleague relationships in terms of

behavior that is cooperative, equalitarian, and supportive. Out of

place are the blatant competition for clients and the "in-house"

attitudes toward discovery and invention found in the industrial and

business world. Gilb (1966) writes:

Unity requires that competition be curtailed. Among
these rules a cardinal principle has been "Thou shalt
not compete unduly with thy fellow professionals."
The rules pertaining to advertising are quite
specific. . (p. 67)

Rueschemeyer (1972) contends that all professions have norms

restricting or prohibiting advertising. He outlines four ways in which

these ncrnms relate to the structure of social controls in the pro-

f s7Sit'n t ; h:,-,' a.i., Fojrti" po',: be0 t'in.3 heaviiy on the question

e a' 'e j c --h- a r '<-czh;D








1. The restriction of advertising serves to emphasize
symbolically the subcultural distinction between the
professions and the business world .

2. Advertising would presuppose that the customer can
legitimately make up his mind about the qualities of
the various members of the profession.

3. Advertising would increase competition among the
professionals who under pressure might give in to
temptations to deviate from professional norms.

4. The restriction of advertising serves to make the
members of the profession concerned with the
performance of their "brethren" since it limits
the possibilities to excel individually. (p. 28)

Another facet of the collegial relationship is that of peer

review. Hughes (1958) asks:

Who has the right to say what a mistake or failure is?
The findings on this point are fairly clear; a colleague-
group (the people who consider themselves subject to the
same work risks) will stubbornly defend its own right to
define mistakes, and to say in the given case whether one
has been made. (p. 93)

Several rather recent trends have developed in the area of a pro-

fessional's relationship with his colleagues and with his clients.

Lebell (1973) writes of the increasing incidence of professionals

joining together to form firms (p. X). Hughes (1958), foreseeing the

same trend developing, finds that although professions are apparently

prospering under this arrangement, there is the possibility of

endangering the supposedly simple relationship of professional with

client (p. 132).

Another seemingly undeterrable trend is that toward the use of the

paraprofessional. Gartner and Riessman (1972) write:

Contact with paraprofessional co-workers generally tends
to increase the sensitivity of the professional to the
demands of the community. In addition, the paraprofes-
sional brings the values and needs of the consumer directly








into professional practice. Of necessity, the professional
becomes reoriented to the consumer in new and significant
ways. The paraprofessional also affects the professional
by raising new and constructive questions about how the
various agencies operate. In this sense, the paraprofes-
sional functions as an observer/monitor of the professional
within the work system. He also embodies new styles of
work and new ways of relating to people, which to some
extent may rub off on the professional. (p. 273)

A third major trend in the professional's relationships with those

whom he serves and with whom he works is the trend toward client organ-

ization. Lebell (1973) believes that the client tends to feel that

the only time the practitioner spends concerned with his problem is

that time spent directly with him. The consumer does not take into

account practitioner time involved in searching, learning, examination

of "dead ends," and what Lebell refers to as "subconscious percolation"

(p. 178). Thus, clients are increasingly demanding that professionals

be held accountable for their time. This call for professional account-

ability as to how services are performed and time spent, and the

desire on the part of clients to share with the professional the respon-

sibility for resource allocation, are the two chief factors May (1976)

sees in the move toward client organization (p. 24).

Certainly the three trends discussed briefly above are not

inclusive of the current trends taking place in professional-client-

colleague relationships. For example, the trend toward specialization

of professional services constitutes another broad area of investi-

gation. The discussion presented herein is provided solely to give

the reader some insight into a few of the factors involved in the

complex of relationships that emerge when professionals deal with

clients and/or fellow professionals. Some of these relationships








will be discussed with increased specificity as they relate to the

licensing of professionals in general and the licensing of speech

pathologists and audiologists in particular.


Professional Associations: Their Inception, Relationships
with Government, and Rationale for Existence

The phenomenal growth of professional associations, both in terms

of numbers and influence, has had a profound impact on the professional

and those he serves. Moore (1970) asserts that such mundane matters

as the terms and conditions of employment often led to the formation

of a self-styled professional association, but that more strategic

considerations such as exclusion of incompetents, protection of the

honorable monopoly, criteria for admission to the occupation, and

maintenance of performance standards also prompted the birth of many

such associations.

Gilb (1966) reports that many national organizations were founded

by only a handful of men, with memberships remaining small for years.

She continues:

Limited membership of professional associations at all
geographical levels was partially due to their deliberately
exclusive character. Although all associations wished to
have enough members to operate successfully and to sub-
stantiate a claim to represent the whole profession, most
were organizations of the "elite" who wished to "elevate"
their respective professions and felt they could do so
only if they confined association membership to the
"better" members of the profession. (p. 31)

Gilb also notes that, within their self-imposed limits, early assoc-

iations laid the foundations for much of what was to be accomplished

in the future. They established professional libraries, pursued the

problems of professional education and professional standards, and







created standards and channels of communication that would later pro-

vide a unifying force for the profession.

Hoore (1970) believes that the early formation of professional

associations provided"the lever with which the gap between the ideal

and the actual could be narrowed" (p. 59). This lever, according to

Moore, was government cooperation by means of the various licensing

statutes, statutes which would aid in the effort to standardize

performance.

However, government cooperation and aid were sometimes slow in

coming. In the early portion of the twentieth century, the profes-

sional organizations' ties with government actually lessened to some

extent, and it was becoming apparent that professional associations

were, in Gilb's (1966) words, "mobilizing independently to influence

state government from the outside" (p. 41). Yet professions began

to realize that it was becoming increasingly necessary to use the

sanctions of the state to accomplish such tasks as screening, dis-

ciplining, and presenting the proper public image. It is important

to note, according to Gilb, that "they [the professional associations]

turned to state action willingly, not reluctantly, because they could

not control purely through private sanctions either their own members

. or their rivals and competitors" (p. 41).

Today professional associations tend to rely to a great extent on

government -- primarily that of the state -- to provide them with the

recognition, tools, and sanctions to control the circumstances of their

work. Gilb (1966) contends that when professionals seek governmental

aid, they do so with the following aims in mind:








1. to control preparation, entry, and practice;

2. to maximize favorable public opinion and so obtain
guarantees of freedom on the job;

3. to rationalize work;

4. to maximize economic returns;

5. to facilitate their work. (p. 135)

Professional associations have however, in the eyes of some,

become appendages of state government. The problem, as viewed by many

writers, has become not one of "How can government help the profes-

sions?" but one of "How can government control the professions?"

Professions, often through their professional associations, have been

allowed to govern themselves and, as Lieberman (1970) states, "where

the state ends and the 'private' association begins is increasingly

difficult to determine" (p. 233).

While it is convenient to blame the professional and his

association for corrupting the lofty ideals which they promulgate, the

blame for controlling themselves to their own advantage (and not to

that of the public) may not reside solely in the private sector. It

is true that when the sellers are given power to decide what is in the

buyers' best interest, a situation occurs which is untenable to many

in the lay community. However, it may be that the attitude of state

governments toward control has fostered a series of abuses. This

laissez-faire posture is reviewed by Lieberman (1970).

We are seeing laissez-faire at its last outpost.
That wispy "principle" is applied to private associations
and the government is deterred. Not only is there
economic justification for leaving the professions to
themselves, there is a political one, they say, and
nothing is rore sacred in America than that combination.
But it is a short step from piety to blasphemy and it







has already been taken. For laissez-faire was always
grounded on the belief that no one man or group could
significantly influence price or production in the
economic realm. That this assumption is untenable in
the professional sphere is manifest. And the right to
be free from political intervention by public govern-
ment similarly rests on the premise that the group
does not have governmental power. This power the pro-
fessionals do hold. (p. 177)

Lieberman, in a later portion of his book, indicates that it is imper-

ative a line between public and private be drawn to impose responsi-

bilities on those who wield power over the lay community through

control of the professions.

The professional association, needless to say, is quite capable

of justifying its existence. As Marshall (1364) points out, profes-

sional associations attempt to guarantee the expertise of their mem-

bers, impose a code of ethics which, among other things, requires that

the professional give only his best at all times, and protect their

field from encroachment by "outsiders." While "protecting their

field from encroachment" may be viewed by some as a euphemism for

"creating an artificial scarcity of personnel," nevertheless such

associations undoubtedly serve the public interest to some degree even

if such service is auxiliary to the achievement of less humanistic

goals.

Gilb (1966) sees a primary goal of the professional association

as achieving cohesion. Cohesion is necessary for control, and control

is necessary for cohesion. At the same time the professional associ-

ation is attempting to define the profession's boundaries and

establish the profession as a distinct entity, separate from the

rest of the work force, it is also attempting to integrate the pro-

fession into the work force and into the pattern of community life.








Moore (1970) states that perhaps the major rationale for the

professional organization is "precisely in dealing with various

interests and publics outside the professional group, as distinct from

maintaining communications within a self-contained community" (p. 160).

When one realizes the extent to which professional associations have

attempted to exert political pressure and the extent to which they

"have gradually turned from a naive and indirect to a realistic and

direct approach to power, and . have turned from irregular,

amateur lobbying to lobbying on a year-in, year-out, professionalized

basis" (Gilb, 1966, p. 143), one is most tempted to agree whole-

heartedly with Moore's statement. Moore (1970) himself writes about

the efforts of many professional associations to directly influence the

course of legislation, stressing that such associations are generally

tax-exempt and, as such, are not supposed to devote a sizable amount

of their resources toward endeavoring to affect the outcome of legis-

lation (p. 165).

Lebell (1973) asserts that the tax-free status enjoyed by such

associations helps to preserve the status quo. However, this point

alone does not adequately convey the nature of Lebell's view of the

professional association.

Professional societies tend to become hydra-headed
monsters in grappling with the variety of functions they
assume. Consequently they have difficulty keeping pace
with the need for constantly changing interaction between
the profession and society. A large, multi-tiered
committee structure provides a title for any member
willing to serve but such a structure thereby precludes
dynamic response to new needs. Revenue from advertisers
in the professional journal and from "trade-show"
participants in technical meetings has a not incon-
siderable impact on society's policies. Finally, there








is the constraint of preserving the society's tax-free
status, which practically provides a blanket
rationalization for avoiding change or even controversy.
(p. 23)

The role of the professional association, and more specifically

the role of the American Speech-Language-Hearing Association, with

regard to licensure and other forms of control will be discussed

throughout the remainder of this text. The foregoing discussion has

provided an overview of the variety of activities which are carried

on by these associations and, more importantly, the varying perspec-

tives from which these activities can be viewed. Once the complexity

of the issues is understood, one can form a base from which to examine

the professional association and its role in the control of the

profession it represents.


Emerging Professions and New Careerists:
Nobody Said It Was Going to Be Easy

While the general discussion presented earlier relating to the

"process of professionalization" attempted to delineate some of the

essential attributes of this process, more needs to be said at this

point with regard to the emerging professions and the professionals

who serve in them. Barber (1965) defines the emerging or marginal

profession as "an occupation which is not so clearly high or so clearly

low on both the first two attributes of professionalism -- generalized

knowledge and community orientation -- that its status is clearly

defined by itself and others" (p. 22). Such an occupation is conceived,

according to Moore (1970), when the value placed on certain work tasks

or activities becomes separated from other, similar tasks, and the

distinction or separation becomes publicly recognizable. Rules to








regularize these activities soon follow, and with the genesis of

differential activities and normative patterns, a new occupational

role is formed. While there is a lack of homogeneity with regard to

community orientation and the amount of knowledge possessed by

members, the "elite" are clearly professional and these individuals

take the responsibility for the advancement of professionalism in

the discipline. Inadequacies in the profession are noted by those at

the forefront; however such inadequacies are often compared with

those experienced in the formative years of what are now well

established professions.

Wilensky (1964) notes that, in general, university training

schools have appeared before the creation of national professional

associations in the more established professions. The reverse pattern

is more typical of newer emerging professions (p. 144). Wilensky also

indicates that at some point the emerging profession is likely to

change the name of the occupation. This change may help to reduce

identification with the previous, less professional occupation.13




Wilensky's point is well taken, although other reasons than
simply reducing an emerging profession's identification with a previous
less professional occupation may precipitate the change. A profession
may attempt to secure public acceptance of a name change that tacitly
implies that the profession has expanded its horizons, that it now
has assumed additional status or come to the point where it sees itself
as involved in a process rather than a simple act or series of acts.
The term "correct" suggests the commission of an act or number of
acts which makes something wrong into something right. Thus,the term
"speech correction" indicates that one who performs this task sees
something wrong and makes it right. Not only is the term "correction"
rather static, but it also brings to mind such synonyms as "repara-
tion," "reprimand," and "punishment." The term "therapy" is much more
dynamic, bringing to mind a process or system. Therefore the speech
therapist is seen as engaging in the healing arts, as being interested








Elliott (1972) believes that professional titles indicate that

new careerists are members of a distinct occupational group which is

associated with the performance of some set of services or tasks.

Elliott sees such titles as being relatively specific and he asserts

that around these titles a definite set of expectations and stereotypes

develops. Barber (1965) writes that rather early in the development




in the rehabilitation of those with speech/language disorders and not
with simply "fixing" the speech of the disordered person, much as a
mechanic "fixes" a flat tire. People who "fix" are not professionals.
While the term "speech therapy" expands, the term "speech path-
ology" further expands and also elevates. "Pathology" encompasses a
professional interest in more than just rehabilitation. Few would
dispute that speech therapy involves a process or systematized approach
to help those with speech/language difficulties. However, speech
pathology is cerebral. It implies long study and minute examination.
Like the term "therapy," it implies a process, but a much higher level
process. The therapeutic process is seen as distinctly practical, the
process or processes involved in pathology are viewed as abstract, and
this sense of abstraction tends to further elevate the professional in
the eyes of his client. That the term "pathology" is most often
associated with medicine, one of the most prestigious professions,
certainly cannot help but give many the idea that the speech pathologist
is, in reality, a "speech doctor."
Today, some within the field assert that further expansion is
necessary. The term "communicologist," some believe, would indicate
that the speech pathologist is not simply interested in the study of
"disease" processes and their reversal, but rather is an expert in the
entire field of communication. Conversely, others within the field
are advocating labels which are much more specific as to one's area of
specialization. Thus, the "aphasiologist" is more interested that one
know he is an expert in aphasia than that his knowledge encompasses the
whole spectrum of communication. Likewise with the "language patholo-
gist," although it would appear that a reading specialist could also
lay claim to this label.
For the reader who is interested in a more complete listing of
suggested names for professionals who function within the realm of
speech-language pathology and audiology. Asha magazine ("Speech
Language Pathologist," 1978) has almost 100 such titles, ranging from
aphasiologist to voxologist. For the practicing speech pathologist,
such a listing may be indispensable for learning who one's colleagues
are.








of the emerging professions the leaders of the profession establish

titles, such as "fellow," as an incentive for the less professional

to become more so.

However, this takes time because, as Hughes (1958) states,

many people in the occupation do not have the full new
training, and because those who have power of appointment
to places do not fully accept the occupational group's
right to say who can be hired for the work. The profes-
sional group will go through a process of self-consciously
studying its work and deciding what functions are really
professional and what can be delegated to nonprofessional
or less-than-professional people. (p. 135)

Not only is the question of what to delegate important to the new

careerist, but so also is the question of professional role boundaries

important. This question involves the acceptance of work delegated

from above. May (1976) points out that new careerists may become

"specialists in dirty work" (p. 35) if professionals are allowed to

use them in that capacity. One of the more easily identifiable sources

of antagonism in hospitals, according to May, is the feeling among many

new careerists that the physician constantly calls upon them to do his

"dirty work" in the name of the role of healing the sick, although none

of the prestige, autonomy, or monetary benefits filters down to their

level. However, when new careerists are in short supply, they tend to

redefine their functions upward while at the same time passing their

dirty work on to a lower echelon (Wilensky, 1964, p. 144). Hughes

(1958) comments in this regard.

Actually in the medical world there are two contrary
trends operating simultaneously. As medical technology
develops and changes, particular tasks are constantly
downgraded; that is, they are delegated by the physician
to the nurse. The nurse in turn passes them on to the
maid. But people and occupations are being upgraded
within certain limits. The nurse moves up nearer the








doctor in techniques and devotes more of her time to
supervision of other workers. . New workers [new
careerists] come in at the bottom of the hierarchy to
take over the tasks abandoned by those occupations
which are ascending the mobility ladder. Others come
in outside the hierarchy as new kinds of technology
find a place in the medical effort. Satisfactory
definitions of role for these new people are notori-
ously lacking, and that in a system in which rigidly
defined roles and ranks are the rule. (p. 73)14




1Defining the role of the speech pathologist in such a rigid
system as described by Hughes can be particularly difficult. Speech
pathology is one emerging profession with at least three distinct
systems into which it must be integrated: the medical system, the
educational system, and the lay community. It is not surprising,
then, that speech pathologists working in hospitals and those working
in schools often appear to the lay community to have little in common.
This conception, plus the tremendous pressure to specialize brought
about by the information boom, may tend to fragment this emerging
profession at the very time unity is needed to demonstrate that speech
pathology is a separate complex of skills.
Least one believe that speech pathology has already "emerged,"
the International Standards Classification of Occupations (Inter-
national Labor Office, 1958) does not list speech pathology as an
occupation, despite boasting a rather inclusive list which contains
such occupations as whale harpooner, beam warper, umbrella maker, wine
taster, and putty-less skylight glazier.
The International Standards Classification of Occupations for 1968
(International Labor Office, 1969) lists "speech pathology" under the
category of "Other Medical, Dental, Veterinary and Related Workers."
The single paragraph under this heading, quoted below, hardly gives one
insight into the field of speech pathology or the functions of a speech
pathologist.
This group includes medical, dental, veterinary, and
related workers not elsewhere classified, for example
those treating sickness through the application of various
herbs and medicinal plants; those treating patients with
a system of physical culture and drugless treatment of
disease by methods aimed to stimulate and assist nature;
those treating body ailments and nervous disorders through
mental influence and suggestion; those diagnosing and
treating rinor ailments of the human foot such as corns,
callouses, deformed toenails, flat feet and other disorders
and advising patients on further treatment, proper feet
care, and suitable footwear. (p. 67)








Just where does this leave the new careerist in an emerging

profession? Gross and Osterman (1972) write of disillusioned high

school and college students who have examined many of the established

professions and found them to be severely lacking with regard to

honesty, humanism, and the service ethic. These students have

extended their beliefs about the nature of professionalism as

currently practiced to include all professional practice, old or new.

Students are taught that one enters a profession to serve ideals such

as teaching, healing, or justice, but these students realize from

their life experiences that one does not simply heal, teach, or

serve justice -- one becomes a doctor, teacher, or lawyer. In their

minds the professions have become "established, institutionalized,

and rigid" (p. 11). This attitude, usually formed from experiences

with more established professions, may be every bit as strong when

emerging professions are the topic of discussion.

However, Gross and Osterman are not pessimistic about the fate of

the new professional in the emerging profession.

In short, a national movement of new professionals
is growing, united by a network of publications and new
organizations. This movement, devoted to social change,
client control, and anti-credentialism, has already
performed important services and is growing with each
graduating class. (p. 23)

Thus, the new careerist in an emerging profession asks to be

judged on his competency, rather than the impressiveness of his creden-

tials, in performing what he believes to be a unique service. However,

no emerging profession attains the respected position it so desperately

covets without a struggle. As Goode (1960) points out, the larger

patterns of professionalism consist of "innumerable smaller








encroachments, attacks, retreats, and absorptions" (p. 902). Whether

the emerging profession will attach and encroach, or retreat and be

absorbed, is chiefly related to the status it is able to achieve

with colleagues and clients and to its ability to achieve a signifi-

cant measure of upward mobility for the individual practitioner and

for the profession as a whole.


Status and Mobility: Can Licensing be Far Behind?

The status of a profession changes. It changes in relation to

its own past, to other professions that are ascending or descending the

status scale, to its clients, and to its public. Changes, according to

Hughes (1965), include more independence, more recognition, a higher

place, a clearer distinction between those in the profession and those

outside, and a larger measure of autonomy in choosing colleagues and

successors (p. 7).

Moore (1970) has delineated a subscale of organization with

respect to achievement of, or approximation to, professional status.

His order is as follows:

I. recognition of common occupational interests, with
some priority over all other simultaneously competing
Interests;

2. some mechanism of control to maintain standards of
performance;

3. control of access to the occupation, so that qualifi-
cations for inclusion are essentially under the control
and jurisdiction of current practitioners. (p. 10)

Moore continues by indicating that formal education qualifications

are the general rule for many occupations in our society, especially

those that strive for and are accorded the status of professions.







Hughes (1965) believes that a necessary validation of alterations

in professional status is that the profession in question be introduced

for study into the universities. One way in which an occupation can

document its elevated status is by being able to take its choice of the

individuals preparing to enter the labor market and then requiring a

long period of academic training before allowing them admittance to the

"charmed circle." Thus, the competition for status is accompanied by

prolonging professional training at the outset by multiplying prerequi-

sites for entry to professional school, and prolonging professional

training at the finish by extending the course of study and requiring

students to undergo various apprentice or internship programs (p. 8).

That professions appear doomed to constantly increase the quantity of

training without ever elevating the quality of training is a point that

has been made by many writers.

Gilb (1966) contends that a profession with a weak power base may

sometimes attempt to elevate its status via employer persuasion. When

a profession lacks homogeneity or does not possess the requisite power

to secure passage of a state licensure bill, the professional associ-

ation itself may begin examining and issuing certificates. Gilb

believes the next step toward acquiring control over a profession is

"certifying by the state of all those with a certain level of profes-

sional training and attainment, while not precluding others from using

the title or trying to gain employment in the field" (p. 61). Status

may be further reflected in requiring licensure for individuals who

wish to engage only in certain areas of the profession. Thus, Gilb

sees a profession as passing through a number of stages of self








consciousness, beginning with voluntary certification and concluding

with stringent, mandatory licensing.

Status and licensing seem inseparable. When asked if teachers

need licensing, Thomas Holcomb, legislator and former teacher sponsoring

a licensing bill in Michigan, replied:

Teaching is one of the few professions that does not have
the recognizable and automatic recognition that a license
carries with it. I think that when you can produce a
license in a profession, others realize that that
person has achieved certain standards [status] and has
been recognized by the state as having done so. (Heisner,
1976, p. 184)

If a profession's status can be reduced by lack of a licensure law,

its status can further be reduced by a "competing" profession's ability

to secure such a law. Sweeney and Sturdevant (1974), writing of an

Ohio licensing law for psychologists and school psychologists, reflect

on the effect that this law will have on school counselors.

The real threat to school counselors under the new
law is directed by inference at their comparative status
in the professional order rather than their right to
practice. The school counselor is certified as a teacher;
the school psychologist is now explicit certified under
the same section of the Revised Code as the school counselor
and licensed by the State of Ohio Board of Psychology. This
latter distinction not only affords the school psychologist
a professional posture unavailable to the school counselor
but also allows the school psychologist's constituents
privileged communication -- a protection not available
through the school counselor. (p. 578)

As school counselors find themselves in the shadow of school psy-

chologists, so too do many quasi-professions in the medical realm find

themselves unable to expand their status because of the physician's

omnipotence. Wilensky (1964) points out that while the physician is

still officially a guest at the hospital, he wields a great deal of

power and, upon occasion, takes complete control with regard to the








management of daily hospital affairs. Medicine, using both legal and

nonlegal means, maintains its status and authority and steadfastly

resists encroachment into what it considers its dominion.

Professionals engaging in professions where upward mobility of

the profession as a collectivity is effectively blocked (as with

school counselors and the medical quasi-professions mentioned above)

may seek upward and/or lateral mobility on an individual basis. Roemer

(1974), writing with attention to trends in the regulation of health

manpower, believes that although general agreement exists that

opportunities for the professional to move laterally to related

occupations and upward to more highly skilled jobs are necessary, the

mechanisms for engendering these types of mobility are still poorly

defined (p. 31).

The foundation which has been laid in this chapter will enable the

reader to understand the reasons for the multitude of often incongruous

viewpoints concerning professional control which will be discussed in

the following chapter. Chapter 2 will focus upon traditional controls,

occupational barriers, trends in licensure, alternate forms of control,

and various legislative considerations, as well as attempt to briefly

examine licensing in a number of professions. With this background,

a consideration of state licensure laws in speech pathology and audi-

ology will be initiated in a subsequent chapter.













CHAPTER 2

LICENSURE AND ALTERNATE FORMS OF CONTROL:
REGULATING THE PROFESSIONS

Within the last 150 years there has been an extraordinary increase

in state legislation dealing with professional and occupational licens-

ing. The trend in the decade just completed has been to regulate more

and more occupations, a trend which nevertheless has encountered strong

opposition from a number of sources. An example of such opposition

can be seen in a 1970 position paper of the American Medical Associa-

tion (AMA, 1970). Due to the fact that the American Medical Associa-

tion's Council on Health Manpower viewed with alarm the increasing

proliferation of what they termed "narrowly defined, legally circum-

scribed health service roles" (p. 8), the following recommendation was

made by the Council to the House of Delegates of the American Medical

Association.

That the louse of Delegates call for a nationwide
moratorium on licensure of any additional health
occupations, and that the American Hospital Associa-
tion and the American Public Health Association be
encouraged to join in supporting such a moratorium. (p. 8)

This resolution was adopted by the House of Delegates, and subsequently

received the support of both the American Hospital Association and the

American Public Health Service, as well as the support of a number of

other influential organizations.

Despite attempts such as that described above, "one occupational

group after another has sought legislative and administrative support








for enactment and enforcement of legislation . to provide for

issuance of a state license as [a] prior condition for entrance into

the occupation" (Council of State Governments, 1952, p. 2).

Statistics confirm the magnitude of the increase. The Council of

State Governments (1952) reported that in 1951 there were over 75

different professions, skill trades, or other occupations which

required differing combinations of qualifications, examination, and

license in order to practice. The Council noted that there were more

than 1,200 occupational licensing laws in the states at that time

(p. 2). Angel, in 1970, indicated that almost 500 professional and

nonprofessional occupations were currently licensed by one or more

states (p. 15), and Mackin (1976) found that there were almost 2,800

statutory provisions that required occupational licensing in 1976

(p. 507). Business Week ("How Licensing Hurts Consumers"), in a 1977

article, revealed that United States Labor Department statistics

indicated that licensed workers made up 25% of the employed labor force

in some states (p. 127). In view of such statistics, it is apparent

why the question of licensing and alternate forms of control assumed

prominence in the decade of the 1970's and will continue to provoke

heated debate in the decade to come.


A Brief History of Individual Licensure

The first attempt to regulate the practice of medicine in America

took place in Virginia in 1639. This effort was not motivated by a

wish to eliminate the unskilled from the colony, but rather resulted

from claims of excessive charges. Except for such additional statutes

as those passed in Massachusetts (1649) and New York (1665), the








colonies did not endeavor to regulate the practice of medicine until

late in the eighteenth century. The revision of the 1639 Virginia

statute in 1736, however, did clearly benefit those with university

training. It attempted to differentiate between the charges of sur-

geons, apothecaries, and those who had only served an apprenticeship

to a physician (Council of State Governments, 1952, p. 15).

Tabachnik (1976) points out that in the early nineteenth century

(1820-1860), legislators began to believe that licensing laws actually

hindered the development of the professions by granting monopolistic

powers. Some states, partially because they felt such laws offered no

protection to the consumer, began to repeal medical and legal licensing

statutes with the result that by 1840, "only 11 of 30 states maintained

regulations for admission to the bar; and by 1845 only eight of 30

states had effective medical legislation" (p. 26).

Prior to the Civil War the practice of a profession was considered

a right and not a privilege. The consumer was solely responsible for

determining the qualifications and abilities of the professional who

served him. With the advent of the Civil War came a revival of the

idea that to practice a profession was a privilege rather than a right,

and that the consumer was entitled to some degree of protection

(Gilb, 1966, p. 60).

This belief was partially responsible for the fact that occupa-

tional groups began to organize themselves into associations in the

late 1840's and early 1850's. The American Medical Association (1847),

the American Pharmaceutical Association (1852), the American Dental

Association (1859), and the American Veterinary Medical Association








(1863) were among the earlier associations to be founded. These

associations were given the opportunity to control or assume repre-

sentation on state licensing boards, and they promoted legislation

designed to protect their ethical codes and their standards of com-

petence and to aid them in the establishment of lists of qualified

practitioners (Angel, 1970, p. 15). Nevertheless, by the outbreak of

the Civil War "no effective state licensing system was in operation and

standards of professional competence were badly in need of reform"

(Council of State Governments, 1952, p. 19).

The efforts of local, state, and national associations began to

slowly upgrade these standards of training and competence in the late

1800's. These attempts were led by the American Medical Association

and the American Bar Association; they often had to overcome strong

opposition from respected members of both professions who felt that

regulation via licensing was an infringement of their personal rights.

As Tabachnik (1976) states:

The argument appears to be that those competent in their
fields favored higher standards and strict licensing in
order to eliminate quackery, while the incompetent wished
no regulation so that they could peddle their wares without
interference. According to these official accounts, under
the enlightened leadership of the A.B.A. and A.t'.A., after
a long struggle standards were slowly restored. (p. 26)

As other emerging professions viewed the struggle and sensed the

outcome, they began to contemplate the benefits and drawbacks of

launching an effort to upgrade training, competence, and performance in

their own realm. It soon became apparent to many such professions that

the consumers of their services would concede autonomy to the profession

only if, in Goode's (1960) words,







its members are able and willing to police themselves;
will grant higher fees or prestige only when both its
competence and its area of competence seem to merit
them; or will grant an effective monopoly to the
profession through licensure boards only when it has
persuasively shown that it is the sole master of its
special craft and that its decisions are not to be
reviewed by other professions. (p. 903)

Professional associations likewise came to realize that once

licensing legislation was achieved, and the status of the profession

was confirmed both internally and externally, the association was

likely not only to achieve increased prestige but also to undergo a

substantial increase in membership. The rapid advancements in com-

munication in the early 1900's made it possible for state associations

across the country to learn quickly that a particular state associa-

tion in their discipline had succeeded in its sponsorship of licensing

legislation. "Model laws" were soon constructed and distributed, and

state associations representing many diverse professions, occupations,

and trades decided they had little to lose and much to gain by con-

vincing state legislators of the need for licensure in their areas.

Of course, the critical reason the professions always tendered in their

legislative struggle was that licensure was necessary "to protect an

unwary public from charlatans and from well-meaning but poorly prepared

practitioners" (Gross, 1977, p. 586).

Hence, the early years of the twentieth century saw a frenzy of

licensure activity unequaled to this day. The Council of State Govern-

ments (1952) found that the five year span from 1911 to 1915 was the

period of greatest activity, with the passage of 110 state statutes

licensing 24 occupations (p. 22). Gilb (1966) writes that the first

state licensing of accountants took place in 1896 (p. 61), with the







initial licensing of architects and engineers occurring shortly after

the turn of the century. Angel (1970) indicates that the first

successful statutes licensing nurses were adopted in 1903 by New York

and Virginia, and that by 1910, 25 states had enacted licensure laws

in this area (p. 15). Levine (1978) gives a capsulated account of the

history of licensure for nurses in the twentieth century.

Between 1900 and 1938 there was a period of voluntary or
permissive licensing, during which only persons holding
a license were permitted to use a particular title or
designation, while unlicensed individuals would not use
the protected title, but could work in the field. In
1938, a push for mandatory or compulsory licensure began
whereby only individuals with a license were permitted
to practice the occupation and unlicensed persons were
prohibited from working. The 1969 statute requiring
licensing of the Child Health Associate in Colorado
initiated the third phase -- that of expanding function.
(p. 9)

Although, as previously pointed out, the initial licensing of many

professions and occupations occurred during the last decade of the

nineteenth century and the first decade of the twentieth century,

Lieberman (1970) affirms that it was not until the 1920's that doctors,

dentists, pharmacists, accountants, beauticians, and others were

licensed on an extensive basis. "Always," states Lieberman, "these

regulations were justified by an appeal to the precarious position of

the public health in an unregulated, but nevertheless complex, modern

society" (p. 189). When such regulations were imposed, the profession

or occupation lost a measure of its independence. However, when that

loss was viewed against the gain of the right to legal monopoly along

with the right to seek and obtain legal action to protect the profes-

sion, the loss of independence assumed diminutive proportions.

Professional associations had long realized that private, associational







sanctions were often wholly inadequate, and the right to use the legal

system to their advantage outweighed the possibility that this same

legal system might be used against them.

Consequently, profession after profession inundated the state

legislatures (often comprised of legislators who were totally ignorant

with regard to the functions, services, or actual needs of the lobbying

profession) with requests or demands for the imposition of legal

controls. With no definite guidelines to follow, the choice of whether

to grant licensure or to withhold licensure was often arbitrary. This

point is clearly illustrated by Freund who, writing in 1928, states

that "a view of the entire field of legislation operating with the aid

of licensing or certification requirements fails to reveal a clear

principle determining the choice between granting or withholding

discretion" (p. 70).

The period from 1930-1960 saw an abundance of emerging professions

seeking and obtaining legal controls. The Council of State Governments

(1952) viewed five trends as influencing this licensing process:

1. the organization of occupational groups into national
societies and associations,

2. the increase in the number of occupations licensed,

3. the increasing centralization of the control of
licensing,

4. the trend from occupational certification to
compulsory licensing,

5. the continued demand for raising and tightening
of license qualifications. (pp. 20-25)

Although the earliest statutes licensing physical therapists were

enacted prior to 1930, the majority of states ratified licensure laws








related to the practice of physical therapy in the 1940's, 1950's,

and 1960's. While only ten states licensed physical therapists in

1952 (Council of State Governments, 1952, p. 22), all 50 states and

Puerto Rico had licensing laws regulating physical therapists by

1970 (Angel, 1970, p. 37). Dental hygienists, nurses, midwives,

chiropractors, and medical laboratory technicians were among the

emerging professions which sought and often obtained state licensing

during the 1960's (Gilb, 1966, p. 62), while the first statute regu-

lating speech pathologists and audiologists took effect in 1970.

The decade of the 1970's has witnessed a revival of consumer

interest in licensing activities, and this interest has led to a

reassessment of the principles upon which state control was founded.

Questions related to the efficacy of individual licensure, the value

of institutional licensure, lay participation on state licensing

boards, and the effect of increased specialization on the licensing

process have constantly been referred to in the literature. These

questions appear to be especially acute in the area of health related

occupations.


The Philosophy of Licensing

Why regulate the professions? Moore (1970) contends that "the

rationale for regulation is precisely the opposite of an open market

for services, on the grounds that an open market will cause harm to the

ill-advised and ill-informed" (p. 112). Angel (1970) believes that

"occupational and professional licenses are issued to safeguard the

life, health, safety, welfare and property of the citizen. . to

shield the public from incompetent practitioners and from fraud" (p. 15),







while Occupational Outlook Quarterly ("Occupational Licensing: Help or

Hindrance?" 1973) indicates that "the purpose of occupational and

professional licensing is to insure that only qualified persons perform

tasks that might endanger the public health and safety" (p. 32).

Barger (1975), viewing regulation in a less humanitarian light, states

that "any kind of certification program that eventually calls upon the

power of the state to control access to a field is occupational licensing

and usually is an attempt to win a favored position for the people

already in the field" (p. 200).

While agreeing that the explanations presented above are essen-

tially correct, Behavior Today ("Pressure Builds to Improve," 1976)

writes of mounting complaints concerning restrictions upon competition

and the soaring costs of obtaining services. Among questions being

asked are the following.

1. Is licensing really needed?

2. Does it improve standards?

3. Is it worth the cost?

4. Are requirements really related to the job?

5. Are licensing boards responsive to public interest?

6. Are there other ways to achieve the same ends? (p. 1)

Before attempting to discover how researchers have attempted to answer

these and other related questions, a consideration of traditional state

controls is a necessity.








Traditional Means of Control

While the trend in occupational and professional licensure has

been in the direction of compulsory licensing, nevertheless the

licensing of a particular trade or discipline often commences with

the prohibition of a particular title rather than of the practice.

This is sometimes referred to as optional or voluntary certification

or registration (Council of State Governments, 1952, p. 24). Such

registration does not restrict the practice of the profession, but

rather allows those who have met certain qualifications to use the

title if they so choose. For example, under these conditions, the

title "registered speech pathologist" could be used only by individuals

meeting predetermined criteria, although anyone could legally engage in

the practice of speech pathology. Gilb (1966) writes of much the same

thing under the rubric of "mandatory title licensing" (p. 62). Again,

it is the title rather than the right to work at a profession which is

being regulated. Barron (1966) refers to such a system as "optional

licensing." Under this arrangement the right to practice an occupation

or profession is not dependent upon being licensed, however regulatory

agencies could establish guidelines to aid potential entrants in

meeting standards for the use of the term "licensed" or "state

approved" (p. 663).

It is apparent by this time that many authors refer to essentially

similar types of control with the use of differing designations. For

example, Gilb chooses to view the mandatory aspect of title licensing.

Hence, it is mandatory that one meet a particular set of standards

to call oneself "licensed," "state-approved," "certified," or







"registered." Barron chooses to regard the optional aspect of title

regulation. Accordingly, it is optional for the person who wishes to

practice a profession as to whether he wishes to pursue those estab-

lished standards which would allow him the use of a particular title.

Roemer (1974) attempts to alleviate some of the confusion which

may exist between the terms "certification" and "registration."

Certification, the process of granting recognition
to an individual who has met certain standards, may apply
either to basic or to specialty qualifications. Regis-
tration, a term often used interchangeably with certifi-
cation, is actually listing a name in a register of an
agency if a person has completed certain training. Both
certification and registration are intertwined with
accreditation of educational programs. . The basic
requirement for certification is the completion of an
approved educational program. . (p. 29)

Barron (1966) sees registration as a system wherein all members of

a profession who provide services would be required to register with

the state. Each professional would take an examination, with no

minimum score required, and be issued a registration certificate which

would attest to his experience, education, and examination gradess.

Prospective consumers would assume responsibility for reading and

evaluating each professional's qualifications. As will be seen later,

this type of "public disclosure" is often offered as an alternative to

professional and/or occupational licensure.

Sweeney and Sturdevant (1974) endeavor to compare certification

laws with licensure laws. A certification law, according to these

authors, regulates the use of a professional title while licensure

regulates not only the title but the practice of a profession as

well (p. 575). However, Roemer (1974) views the distinction as one of

voluntary versus legal rather than one of regulation of title versus








regulation of practice. Certification, as viewed by Roemer, is a

"voluntary mechanism by which a non-governmental agency or association

grants recognition to an individual who has met certain predetermined

qualifications specified by that agency or association" (p. 26). On

the other hand, licensure is considered to be "a legal mechanism by

which a governmental agency authorizes persons who have met minimal

standards of competency to engage in a given profession or occupation"

(p. 26). The fact that licensure laws have behind them the police

power of the state, whereas certification generally is a much weaker

form of nongovernmental control, makes such licensure laws much coveted.

This is despite the fact that, as Wilensky (1964) points out, licensing

and certification in the battle for professional authority are

relatively unimportant events (p. 145).

A differentiation between voluntary licensing and compulsory

licensing must also be established. Under voluntary licensing (that

which Barron [1966] refers to as "optional licensing," and Sweeney and

Sturdevant [1974] designate as "certification") those who are unlicensed

are prohibited from the use of a given title or designation; however

their right to practice in the occupation or profession is not affected.

An example of a voluntary law is the one that permits optional regis-

tration for practical nurses. In a number of states, an individual may

offer herself for employment as a practical nurse as long as she does

not use the title "licensed practical nurse" (Angel, 1970, p. 18).

Compulsory licensing, on the other hand, allows those holding a

valid license to practice in the profession or occupation while

unlicensed individuals are prohibited from practicing. The licensing







of physicians is typical of the compulsory type of licensing. Angel

(1970) indicates a number of exceptions to compulsory licensing

requirements.

Exclusions and exceptions from licensing requirements
are always made for federal employees, and often for state
and municipal workers as well. Sometimes those engaged in
research or educational pursuits are exempt from license
requirements, as are students and auxiliary personnel
working under the supervision of an individual who is
licensed. Out-of-state licensed practitioners who render
occasional services may also be exempt from licensure. . .
(p. 17)

While licensing acts as a traditional form of control, some

writers believe that the control which initial licensing produces is

reduced by "automatic" renewal policies. Angel (1970) suggests that

usually the only information required for renewal of a license is the

present name and address of the practitioner (p. 26). Occupational

Outlook Quarterly ("Occupational Licensing: Help or Hindrance?"

1973) states categorically that "the public is deluded by licensing

laws which do not require re-examination or evidence of continued

competency" (p. 33). The article continues:

Although persons who wish to enter licensed occu-
pations may need to meet rigid requirements, licensed
practitioners seldom have to show that they have
maintained their skills or kept up with changing
technology within the occupation. Usually licenses may
be renewed indefinitely on payment of the appropriate
fee. (p. 33)

Thomas Holcomb, quoted by Heisner (1976), indicates that many

teachers are opposing the passage of a law that would license teachers

in Michigan on the grounds that they would be subject to examination

for license renewal (p. 184). The threat of having to update their

knowledge to maintain their licensed status apparently offsets the

benefits of licensing for many of Michigan's public school teachers.







Thomas (1974) believes emphatically that "the notion of one-time

licensure for practice of any of the healing arts is an idea whose

time has passed" (p. 80). She points out that in 1974 the half-life

of health care knowledge was 2.5 years, and that by 1980 the estimated

half-life of health care knowledge will be only 18 months. Thus,

health care personnel should be required to give evidence that they

have fulfilled current requirements for those jobs which they occupy.

Certainly the question of license renewal bears heavily on contin-

uing education, a topic which will be further developed in this text.

It is sufficient to note at this point that a number of critics are

extremely dubious of a professional's ability to serve the public

effectively when his authority is vested in a license issued 20 or 30

years ago and automatically renewed periodically.


The Role of the University, Professional, or
Training School and the Question of Accreditation

Barber (1965) believes that "university professional schools are

the leading, though not the sole, innovators and systematizers of ideas

for their professions" (p. 21). Barber continues by stating that the

university professional school attends to the ethical training of its

students by explicitly teaching professional codes, by intermixing such

ethical training with what apparently is only the teaching of sub-

stantive knowledge, and by presenting appropriate staff behavior that

serves to act as a model for the student. Thus, Barber sees the role

of the university professional school as one of "moral watchdog" for

the profession, and he believes that the relative insulation of such

schools has the advantage that it enables them to be "freer of those







commitments to other organizations and other interests that practicing

professionals have, and therefore . more nearly able to maintain

the highest intellectual and moral standards" (p. 21).

It is this image of high intellectual and moral standards which

the emerging profession wishes to convey to the lay community. As

Goode (1960) points out, occupations undergoing the process of pro-

fessionalization tend to gain in income, power, and prestige and can

therefore demand and obtain students of a higher caliber (p. 903).

Once licensure is secured, added leverage is achieved for the profes-

sional schools. Kimball (1965) reflects that, since a compulsory

degree generally acts as a prerequisite for licensure, "the educators

for the licensed professions have first crack at the future practitioner"

(p. 246).

This process of professionalization, encompassing a move from

registration or certification to compulsory licensing, generally is

accompanied by a raising or tightening of standards. This trend has

two noteworthy aspects:

1. The greater degree of training now required, especially
in approved institutions accredited by the occupation,
makes the licensed practitioner a more competent
individual than his counterpart of a generation ago.

2. The increased emphasis upon educational qualifications
and in some instances additional supervised
experience (apprenticeship) has increased the over-all
time and experience involved in gaining the require-
ments necessary for certification or licensing. (Council
of State Governments, 1952, p. 27)

Kasper (1977), viewing this second trend with dismay, writes of

the increased prices which consumers must pay to finance higher licens-

ing standards in the field of medicine. He believes this increased






emphasis upon educational qualifications referred to by the Council of

State Governments "inevitably prevents some needy patients from

obtaining physician services and thereby tends to lower the average

quality of care for the population as a whole" (p. 169). Kasper uses

this argument to help support a case for the use of less qualified

M.D.'s, paramedics, midwives, and allied health professionals.

Kinsinger (1973) warns, however, that the cost of many separate

technical curriculums is too high. Writing with regard to health care

programs, Kinsinger contends that many new educational and technical

programs are developed at educational institutions having little or

no previous experience in the health field. He posits the inauguration

of a new curriculum emphasis, or "core curriculum," for all technical

level personnel in allied health fields. Although recognizing the

need to begin with the basic work force of physicians, dentists, and

nurses, Kinsinger believes

extending and modifying the services they provide will
require technicians with a "career base" -- that is,
technical health workers who have a broad background
in both acute-care and in health maintenance problems
when applied to individuals and their life style and a
grounding in health-care fundamentals that will make them
valuable as extenders for many of the professionals who
must continue to provide leadership. (p. 13)

Educators in the professional and training schools would, of necessity,

abandon a great many of their traditional time-consuming activities as

lecturers and examiners and concentrate on their roles as health

delivery system analysts within this framework. They would pay

particular attention to the means by which the students under their

leadership could be utilized most effectively to serve public health

needs.







Pellegrino (1977) likewise affirms that it is critical for all

health care workers to be given "some generic form of education which

they can use as the base for amplification later if a career change is

indicated" (p. 28). He views the regionalized academic health center

as a multischool cooperative venture which will help eliminate the

problems of fragmentation, proliferation, isolation, overspecialization,

and duplication of services.

Whether one is speaking of a regionalized academic health center,

a university school of mechanical engineering, or a one room night

school for prospective journalists, the question of accreditation

invariably assumes tremendous import. Certification, registration, and

accreditation are frequently tied together. The United States

Department of Health, Education, and Welfare (1971) defines accredi-

tation as "the process by which an agency or organization evaluates

and recognizes an institution or program of study as meeting certain

predetermined criteria or standards" (p. 7). Kelly (1977) states that

accreditation is a part of the credentialing system and, as such,

generates as much controversy as the other mechanisms. She points out

that accreditation is voluntary, presumably indicates excellence in a

particular program and, most significantly, allows for crucial federal

funding (p. 568). Roemer (1974) defines accreditation as, "a volun-

tary mechanism by which an agency or organization (unfortunately a

multiplicity of agencies and organizations) recognizes a program of

study or an institution as meeting certain predetermined qualifications

or standards" (p. 26). She continues by identifying the key issues

related to accreditation in the area of health educational programs.








These issues, which will be briefly discussed, are

1. accountability of accreditation,

2. structure of accreditation,

3. financing of accreditation,

4. expansion of accreditation,

5. research in accreditation,

6. relationship of accreditation to licensure and
certification. (p. 29)

The question of accountability is vital due to the fact that

private agencies (such as professional associations) are functioning

in a public role. Wilensky (1964) believes that it is somewhat of a

misconception that professional associations generally form a training

school and then establish accreditation. "Where professionalization

has gone farthest," contends Wilensky, "the occupational association

does not typically set up the training school; the schools usually

promote an effective professional association" (p. 144).

The structure of accreditation is similarly important to a profes-

sion. Statutes usually specify that those applying for licensure must

receive their training in schools approved by state licensing agencies.

Often licensing boards accept the/a national association's list of

accredited schools; however they may also accept the approval of

appropriate regional college accrediting bodies. The state department

of education in some states is the state agency which has the responsi-

bility to inspect and accredit schools within the state (Angel, 1970,

p. 32).

The financing of accreditation may be borne largely by profes-

sionals who pay dues to professional accrediting associations or through








fees for licensure or renewal paid to state licensing agencies.

Roemer (1974) contends that since the cost of accreditation of health

educational programs has been sustained largely by the health

professional organizations, a sufficiently broad financial base has

not been established with regard to financing accreditation in this

area (p. 29).

The expansion of accreditation, the fourth issue delineated by

Roemer, deals with the rapid proliferation of accrediting programs

and agencies. Fields (1978), writing about the problem of determining

who should be considered psychologists and what programs actually

train them, expounds upon one way this discipline is attempting to cope

with the expansion of accrediting agencies and the lack of consistency

in evaluating credentials. Because of confusion partially brought

about by the expansion of accreditation, a steering committee comprised

of representatives from a number of influential associations and

organizations recommended the establishment of a national commission,

to be called the National Commission on Education and Credentialing in

Psychology, which would operate similarly to an accrediting agency.

College and university programs would pay to have their programs

evaluated, and a positive evaluation by the commission would designate

a program as a "certified psychology program."

Defenders of the commission refer to the absence of a national

definition for "psychologist" which has caused some individual state

boards of examiners in psychology to license applicants who would not

qualify in another state. Many psychologists, however, fear forced

evaluations. Fields states that








some psychologists believe that even though institutions
would voluntarily decide whether to try to have their
programs designated by the proposed commission, the
existence of such a body would force almost all admin-
istrators to pay to have their programs evaluated.
Others believe the commission could lead some states
to tighten their licensing laws, so that only graduates
of designated programs could be licensed.
Supporters of the proposed commission counter that
state licensing authorities could still evaluate indivi-
dually the educational backgrounds of graduates of
undesignated programs, just as they do now. The desig-
nation system simply would reduce the number of applicants
for whom that would be necessary, they say. (p. 9)

Roemer's (1974) definition of accreditation as "a voluntary mechanism,"

it would seem, might well be in danger. A commission similar to the

National Commission on Education and Credentialing in Psychology, the

National Commission for Health Certifying Agencies, was formally

organized at its constitutional convention in December 1977.

The primary purpose of the Commission is to assure
the health and safety of the public by the development and
encouragement of high standards of professional conduct
among the health certifying agencies. To achieve this
the Commission will establish national standards for
certifying bodies that attest to the competency of
individuals who participate in the health care delivery
system. The Commission will grant recognition to
certifying bodies that apply for and meet the established
standards. It also will monitor the adherence to these
standards by the certifying body which it has recognized,
thereby assuring public accountability. The membership
in the Commission is voluntary. ("National Commission for
Health Certifying Agencies," 1978, p. 1)

Roemer's (1974) fifth issue in health care accreditation, that of

research in accreditation, will not be elaborated upon here. However,

Roemer's sixth and final issue, that of the relationship of accredi-

tation to licensure and certification, is a key issue since graduation

from an accredited school is often a prerequisite under state statutes

for licensing or certification. Cottingham (1978) illustrates the








difficulties that counselors are facing with this relationship of

accreditation to certification or licensure.

Currently, counselor preparation programs are not
officially accredited, validating skills provided for
trainees, as is the case with APA-approved programs
in psychology. Hence, program accreditation as a basis
for professional counselor certification or licensure
is not available. Credentialing eventually must link
program approval and counselor certification or
licensure. (p. 334)


Occupational Entry and Licensing:
Requirements, Limitations, and Barriers

The desire to maintain control over entry into an occupation is

nothing new. Lieberman (1970) states that as early as 1321, London

guilds were attempting to curb membership by charging exorbitant

fees for entrance, establishing long apprenticeship periods, dismissing

apprentices just prior to the completion of their training period, and

putting severe limitations upon the number of apprentices who might

legally be associated with a given trade (p. 39).

Whether one views entry qualifications as safeguards in the public

interest or as artificial restrictions upon the freedom of one wishing

to enter an occupation is largely a matter of perspective and is in-

timately related to one's value system. Some, like Barron (1966),

believe that "entry requirements in excess of those necessary to protect

the public are apparently absent in the professions for which recog-

nized curriculums have been developed in major colleges and univer-

sities" (p. 651). Others, for example Montgomery (1975), contend

"it isn't uncommon for [state licensing] boards to try to limit access

to a given occupation in apparent disregard for the public interest"

(p. 1). Since Montgomery continues by elaborating upon perceived







injustices perpetrated by medical and dental boards, apparently the

fact that both medicine and dentistry have recognized college and

university curriculums is not a primary consideration for Montgomery

in the reduction of overly stringent entry requirements.

Although specific qualifications for occupational entry and

licensing vary greatly, some general requirements or qualifications

can be postulated. Angel (1970) states that applicants for occupa-

tional licenses may have to meet four different types of qualifications.

These are

1. personal qualifications,

2. educational qualifications,

3. experience qualifications,

4. examination qualifications. (p. 23)

Personal requirements traditionally include moral character,

minimum age, minimum state residency, and in some cases, health status.

However, the minimum requirement in each of these areas, according to

Angel, "generally seems to have slight effect, or none at all, on the

actual ability of technically competent applicants to secure licenses"

(p. 29). Thus, such matters assume relative unimportance in a dis-

cussion of occupational limitations and barriers.

Educational requirements doubtless assume more importance. Gilb

(1966) points out that "for some professions . a certificate or

license is issued to anyone of good moral character who has completed

the specified education in approved schools or colleges" (p. 62). This

is becoming less and less true with regard to the professions: however

the various professions have placed an ever increasing emphasis upon







formal education as a prerequisite for licensure. Some believe this

emphasis is often extreme, and as such constitutes a barrier to occu-

pational entry and licensing. Since the professional association is

often the accrediting agency that imposes more stringent educational

and apprenticeship requirements, it is not surprising that it has

received the brunt of the criticism in this area. Goode (1972) states

quite candidly that "typically a profession, through its association

and its members, controls admission to training and requires far more

education from its trainees than the containing community demands"

(p. 19). Johnson (1972) writes that the professional association will

also endeavor to impose a uni-portal system of entry into the occu-

pation or profession (p. 54). Such a system recognizes the completion

of arduous education prerequisites, but does not allow that competence

can be achieved in any but this manner. Roemer (1974) indicates that

"it is becoming increasingly clear that all educational programs are

being called on to provide multiple entry points" (p. 32). She

recommends that individuals with experience or other nonacademic

qualifications begin to receive recognition in the licensing process.

Levine (1978) stresses the need for equivalency and proficiency

examinations.

This might be a means of making the career-ladder concept
a reality by providing alternative routes for entry into
professional schools and/or credentialing systems. It
could also help to minimize what is perceived as rigid
categorization of health care personnel. With the massive
amount of information now necessary to render safe care,
it is doubtful that categories will ever be totally
eliminated; but if mobility is increased between the cate-
gories, this might suffice. (p. 113)







Kinsinger (1973) criticizes an educational system which he views as

inflexible and unfair for health care workers. He writes emphatically

of the need to review the present educational system as it relates to

the allied health professions to prevent "dead-ended health workers

caught by career barriers built into the present educational system"

(p. 15).

In addition to formal education requirements, those who wish to

enter and be licensed in many professions must fulfill apprenticeship

or internship requirements. In other occupations, a clinical experi-

ence constitutes a portion of the formal education program, while some

professions require both a formal clinical experience and an apprentice-

ship or internship. Angel (1970) reports that many licensing statutes

provide for various combinations of education and experience, and that

applicants can qualify for licensure by fulfilling any of these

combinations.

At the opposite extreme from those professions requiring completion

of a rigorous educational curriculum are those occupations or trades

wherein experience constitutes a prime determinant of licensure. While

such occupations may escape criticisms leveled at those professions

which are viewed as requiring overly stringent academic prerequisites

which are above-and-beyond those needed to protect the public welfare,

they nevertheless are not without their own difficulties. Consumer

Reports ("Should Mechanics Be Licensed?" 1?76) details one such

difficulty related to limiting entry of auto mechanics into this newly

licensed field.

A second problem with licensing is that it must
somehow provide for those already practicing the trade.
If they are automatically licensed( under a "grandfather







clause") and if the apprenticeship requirements are
used to limit the number of people entering the field,
the result could be a shortage of trained licensees.
That could push up the cost of repairs without
guaranteeing more competent work. . (p. 204)

Hence, it is apparent that occupational entry limitations are not

imposed solely by requiring a tremendous investment of time and money

for a formal education. Goode (1960) states it succinctly when he

writes that "any plan to raise standards defines some practitioners

as incompetent" (p. 904). That a profession or occupation must

grandfather individuals who would be classified as incompetent under

less strict standards, a procedure which might well limit entry into

the field for potentially competent practitioners, is a problem that

is not easily resolved. So too, an artificially prolonged apprentice-

ship requirement can constitute an unnecessary barrier which is unfair

to those wishing to enter the occupation and unfair to those having to

pay inflated prices to purchase services from the relatively few

practitioners.

A fourth category of entry qualifications, those related to

examinations of competency, has received a good deal of attention.

Angel (1970) writes that written examinations are a usual requirement

for all occupations in the health field, while oral examinations are

generally mandatory for those wishing to be licensed in the fields

of chiropractic and veterinary medicine. Disciplines requiring

practical or clinical examinations include dental hygiene, dentistry,

optics, optometry, pharmacy, podiatry, and veterinary medicine (p. 25).

Such exams are usually constructed by either the state licensing board

or by the state licensing board in cooperation with the national

association.








Mackin (1976), writing with regard to licensing and counselors,

contends that an individual may possess the experience, understanding,

and empathy necessary to become a successful counselor, but may fail

in this ambition because of the inability to pass an examination as a

prerequisite for licensure. He writes of the frequent misuse of exam-

inations and the overdependence on test scores. Mackin comments:

One alternative is to create valid licensing tests. A
truly valid licensing test would not. . discriminate
against a student who does not perform well on traditional
tests but who is nevertheless competent to perform a
given job. . A second alternative is to abolish
licensing tests altogether. This alternative would per-
haps prevent the increased governmental social control
suggested by the first alternative. It may also be a
more realistic alternative. Few employers have been able
to validate tests challenged as discriminatory, and it is
doubtful that development of valid licensing tests will be
any more than an abstract goal unobtainable for years to
come. (p. 510)

Occupational Outlook Quarterly ("Occupational Licensing: Help or

Hindrance? 1973), in reviewing a number of conclusions reached by the

Educational Testing Service's intensive research into occupational

licensing in four fields, asserts that

licensing tests are often substandard, and testing
procedures and policies create difficulties for some
applicants. . For example, written examinations
often contain multiple-choice questions which are
ambiguous or which deal with inconsequential matters.
Essay questions are widely used, but few boards have
devised procedures for grading such exams in an
objective way. Performance tests may fail to test
crucial job skills and are likely to be evaluated by
judges who do not have objective evaluation guidelines.
(p. 33)

Barron (1966) gives several examples of seemingly irrelevant questions

which have been asked on the written examination for cosmetologists.







Which one of the following is not a muscle of the mouth:
1. Quardatus Labii superioris; 2. Zygomaticus;
3. Obicularis oculi; 4. Obicularis oris.

Attachment of the muscle to the bone is known as the:
1. Aponeurosis; 2. Origin; 3. Insertion; 4. Fascia.

Oxygen is carried to the body cells by the:
1. White corpuscles; 2. Leucocytes; 3. Red corpuscles;
4. Platelets. (p. 654)

Montgomery (1975) makes mention of physicians and dentists in

Florida who organized to challenge what they viewed as restrictive state

licensing regulations. Some of these regulations related to the exam-

ination question, for although all of the physicians and dentists

challenging these regulations were licensed in other states, they had

been unable to obtain a license to practice in the state of Florida.

In contrast to many other states, Florida did not grant automatic

reciprocity to licensed doctors and dentists from other states. Prior

to receiving licensure in Florida, new residents were required to

successfully complete a comprehensive examination in general medicine

or dentistry, as well as one in their specialty (p. 1). Such examina-

tions were viewed as intentional, measured attempts at exclusion by

what one member of the group, Dr. Norris C. Elvin, called Florida's

"arrogant, overworked, overpaid" physicians (p. 1). The situation in

1979 is apparently unchanged. Mr. Fred Varn, Executive Director of the

Florida State Board of Dentistry in Tallahassee, Florida, relates that

reciprocity is still denied to licensed physicians and dentists from

other states. According to Mr. Varn, a bill related to endorsement of

physicians from other states failed to gain passage in the Florida







Legislature in 1978, and it is possible such a measure will again be

introduced in 1979.

Reciprocity, endorsement, and waiver constitute important concepts

in any discussion of occupational entry requirements, limitations, or

barriers. As noted above, the inability of one competent in his field

to practice in another state without re-examination may constitute an

unreasonable barrier to license acquisition in the practitioner's new

state. However, the use of reciprocity, endorsement, and waiver may

facilitate the provision of services from state to state and, as such,

help to eliminate what the Educational Testing Service ("Occupational

Licensing: Help or Hindrance? 1973) calls, "a near chaotic situation

insofar as skilled worker mobility is concerned" (p. 33).

Angel (1970) indicates that the term reciprocity has come to

acquire many different meanings to the various state licensing agencies.

Angel believes the term "reciprocity" is intended to mean, "the actual

value accorded an out-of-state license when an accredited person from

one state seeks licensure in another" (p. 27), and that there is more

uniformity with respect to reciprocal agreements among the states

whenever national professional organizations exercise a powerful influ-

ence. Angel describes the process of licensing by reciprocity.

In licensing by reciprocity, for a given occupation,
a licensing board in one state will recognize licensees
of a second state if the board in the latter will extend
the same recognition to licensees of the former. In
addition, licensing requirements must be equivalent in
the two states before formal or informal reciprocal
agreements are made. Applicants for reciprocal licensure
must generally meet the same requirements as those
seeking licensure by endorsement. (p. 28)



Varn, F. Personal communication. March 13, 1979.







The terms "reciprocity" and "endorsement" are sometimes used inter-

changeably by state licensing agencies; however Angel (1970) specifies

that

in licensing by endorsement, the members of the state
board in the state where the license is being sought,
determine whether the qualifications of the applicant
were equivalent to those required in their state at
the time the applicant was initially licensed. Most
states also specify that initial licensure must have
been by an examination which was comparable to theirs.
(p. 28)

State Licensing of Health Occupations (1976) reports that while reci-

procity and endorsement provisions generally are applied only to out-

of-state licensees, some states have begun licensing Canadian and

foreign-trained health care practitioners by reciprocity. This

eliminates the need for the establishment of a third system of licensing

these applicants (p. 16).

Licensure is also possible by waiver, a condition in which appli-

cants not meeting one or more of the state board's requirements are

licensed if they possess other qualifications which the state board

judges to be equivalent. Professional recognition is often cited as a

reason for waiving certain education requirements, but it should be

understood that licensure by waiver occurs infrequently.

It appears clear that licensing requirements may, indeed, act as

occupational barriers and limitations. Moreover, such barriers have

existed for many years, it being the state of public enlightenment that

has undergone a transformation rather than the barriers or limitations

themselves. The professions use the same rationale, only the lay

community no longer accepts it without questioning its validity.

Kidder (1976) explains this rationale.







Legal requirements indicate a second feature of pro-
fessionalization -- the use of licensing as a barrier.
The theory of expertise justifies the use of legal
restrictions so that the public will be protected from
"quacks" -- i.e., those whose skills have not been proven
against prevailing methods of evaluation and/or those whose
practice violates the paradigms of expertise of the dominant
professional community. Licensing can, of course, be
responsive to norms other than expertise (e.g., considera-
tions of supply and demand for the service), but in the
licensing of professionals, expertise is the sole "up
front" justification. (p. 153)

This "up front" justification is proving to be increasingly inadequate

as critics review the activities of professional associations and

licensing boards in this area. Barron (1966) affirms that "any restric-

tion upon the freedom of individuals to enter an occupation, whether

publicly or privately imposed, is a 'monopolistic' restriction on the

operation of the market. . Thus, licensing results in higher

prices than would exist in its absence" (p. 643). Kasper (1977)

contends that "those excluded by licensure's restrictions are forced

into lower-preference occupations. There is strong evidence that such

restrictions tend to fall on minorities. . (p. 170) while Asha

magazine ("Congress, FTC Probe Professional Associations," 1977)

reports concern about the "future direction of professional associations

amid growing interest on the part of Congress and the Federal Trade

Commission in enforcing antitrust legislation. The activities of pro-

fessional associations in controlling qualifications, numbers and scope

or practice of their members have recently come under scrutiny ."

(p. 673).

Such comments and reports dealing with the exercise of artificial

and possibly harmful restrictions to occupational entry constitute a

portion of a more generalized attack on professional and occupational








licensure. This assault will be more fully documented later in this

chapter, and alternatives to licensure will be briefly discussed.


Legislative and Judicial Considerations

As has been documented previously, many professional practitioners

are quite willing to forego their traditional political conservatism

to seek governmental intervention when they believe that such intrusion

best serves their interests. Licensing serves as a conspicuous example.

Kelly (1977) states that licensure is the police power of the

state and that "it is through the state legislative process that the

decision is made as to what group is licensed and with what limits

(p. 563). The Council of State Governments (1952) specifies a

number of legislative considerations to be contemplated when licensure

is at issue. Initially, the Council sees the need to establish a

clear definition of the area to be licensed and a delineation of the

area of prohibition (p. 60). Lieberman (1970) states that often the

legislature defaults on this "threshold question" of defining the

profession which will subsequently be given rule making power (p. 169).

Roemer (1974) writes of the legal repercussions which can emanate from

the definition of a discipline's scope of functions in a formal

licensing law regulating an emerging health profession.

The physician's scope of functions is all inclusive, but
other licensed personnel are authorized to perform only
a segment of those functions. Fortunately, these
definitions are usually couched in quite general terms,
but nevertheless they specify the bounds of allowable
practice. The legal effect is that liability can be
imposed for overstepping these bounds, particularly if
harm should result to the patient. (p. 27)

Cottingham (1978) points out that when the scope of a profession has







not been adequately delineated, the courts may create their own

definition of the profession. Thus, professionals may have their areas

of expertise prescribed for them (p. 331).

A second legislative consideration discussed by the Council of

State Governments (1952) deals with the problem of establishing a

regulatory agency and granting to it a degree of discretion. The

Council lists five kinds of public agencies which have received licens-

ing authority. These are

1. completely independent licensing boards,

2. departments of education or public instruction,

3. departments of health,

4. offices of the Secretary of the State,

5. central licensing departments. (p. 61)

Moore (1970) comments upon the extremes which may be the outcome of

legislative discussion in the area of assigning regulatory agencies and

granting power to these agencies.

At one extreme is the uncommon situation in which a state
board of examiners is authorized, to be appointed normally
by state officials. These examiners then set the kinds of
knowledge or demonstrated competence that they consider
important for admission to an occupation. . At the
other extreme is the situation in which the license is pro
Co~a, being granted upon presentation of "credentials,"
the most important of which is successful completion of
the training approved by an accredited school. (p. 124)

A third legislative consideration indicated by the Council of State

Governments (1952) revolves around the need for state legislatures to

assess the role to be assumed by private professional associations.

Lieberman (1970), highly critical of the laissez-faire attitude of state

legislatures toward professional associations, affirms:








When legislatures become agencies for ratifying
policies of separate groups, there is reason to expect
that private groups will seek at some point to impose
their own policies on the public directly. . .
Overt legislative delegation of authority to private
groups combines with the acquiescence of legislatures
and courts in the customary power of other groups to
enforce private standards; in either case, traditional
controls . are unavailing. Laymen do not have
access to the decision-making process of "private"
groups. (p. 168)

Hence, Lieberman accuses the state legislatures and the courts of

neglecting consideration of the proper role and function for profes-

sional associations, with the result that, in the author's words,

"traditional controls . are unavailing." Goode (1972) contends

that part of the problem may reside in the fact that the professions

generally occupy a disproportionate number of seats in state and

national legislative houses. Consequently, any legislation which

pertains to the professions is shaped by the professions (p. 19).

Sweeney and Sturdevant (1974), writing with regard to licensing and

school counselors, assess the effects on Ohio counselors of legis-

lation passed in 1972 which "follows closely the recommendations of

the APA [American Psychological Association] Committee on Legislation"

(p. 576). This legislation, brought about to a great extent by the

power of the APA in the Ohio legislature, has resulted in what the

authors believe are a number of deleterious effects upon school

counselors in that state. The authors enumerate a number of these,

not the least of which is that "membership in psychological

associations -- previously considered a voluntary professionally

responsible choice -- may seem an economical and professional requisite

for job mobility and credibility" (p. 577). Lieberman (1970) believes







that professional associations have succeeded in avoiding public regu-

lation because the lay community has accepted the associations'

contentions that, while the Fifth and Fourteenth Amendments prohibit

federal and state governments from depriving individuals of life,

liberty, and property without the due process of law, these amendments

do not prohibit "private" associations or members thereof from

operating in such a manner (p.199).

A fourth legislative consideration specified by the Council of

State Governments (1952) relates to legislative decisions with regard

to violations and sanctions. Angel (1970) writes of the difficulty in

determining violations of particular sections of licensing statutes

because of the fact that standards of performance are expressed in

broad terms. State Licensing of Health Occupations (1976) indicates

that generally licensing agencies investigate a practitioner's com-

pliance with statutory provisions only when a complaint is filed. Thus,

the extent to which licensing laws are enforced is based upon the

voluntary compliance of each professional and the willingness of the

professional association and the consumer to monitor the behavior of

individual practitioners (p. 10). Of course, offenses may be committed

by those who are not in the profession. Kelly (1977), commenting on

violations of licensure laws in the field of nursing, contends that

"violation of the law by nonlicensed individuals results in such

ridiculously low fines (and seldom imprisonment) that it is no real

deterrent" (p. 563).

Finally, the Council of State Governments (1952) points out that

the legislature may want to ponder the question of whether or not to

permit reciprocity in occupational and professional licensing and, if




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