Author: murrayof

Therapeutic Program Community: Where Is Everybody?

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This is the last in a series of 10 opinion articles about inclusion and mental health in schools.


By my estimation, there are thousands of programs in school districts across the United States for students with significant social, emotional, and behavioral challenges. Many programs are segregated from general education, while others practice inclusion models. Due to budget imperatives and least restrictive environment rules, this has been true for many years. These programs exist internationally as well, which is even more difficult to enumerate.

Laura Balogh and I had significant experience to draw on when we were tasked with designing a new therapeutic inclusion program in 2019. On top of our experience, we looked for published resources we could use to draw inspiration and to reference in support of our ideas.

But, having looked for relevant resources before, I knew there were very few. The lack of professional discourse about our work was, and continues to be, a subject of great puzzlement for me. In the early days of our program Laura and I decided to write The Therapeutic Inclusion Program so that there would be at least one reference specific to therapeutic inclusion programming for others to use, and hopefully prompt further conversation and writing in the community.

So, where is everybody? I have found I am more likely to meet and have a conversation with someone who works in a therapeutic education program at a random event like a concert than I am in seeking professional exchanges online.

There are vibrant and active professional communities and conversations around psychology, and education, taking place online and in the publishing world. Why is it that in these same arenas, people do not want to talk about the important work of educating students with significant social, emotional, and behavioral challenges?

The work of inclusive therapeutic education is endlessly interesting and deeply important. Furthermore, significant budgetary resources are at stake. To me, these factors and others indicate that inclusive therapeutic education is well worth talking about, and in fact needs to be talked about. 

The work of inclusive education for this group of students is deeply interesting. In school, our students must grow their way through academics, social demands/opportunities, their orientation toward authority, and that’s just scratching the surface. The challenges and opportunities of being employed in inclusive therapeutic education are no less dynamic and interesting. 

The work of educating students with significant social, emotional, and behavioral challenges could hardly be more important! In our roles as inclusive educators we have a tremendous and exciting opportunity to have a positive impact on students and families that are struggling. This opportunity has always been the most energizing part for me. We meet students and families at a critical juncture in their lives, where it is possible through our work to support a more positive trajectory. The impact of our efforts potentially resonate far into the future. The work is as rewarding as it is challenging, and well suited to those of us who thrive under these conditions with the right support. 

Regarding the budgetary concerns, school districts are spending a lot of money on out-of-district placements, and in-district programming for our population of students. The expense of out-of-district-placements, in Massachusetts for example, easily average over $100,000 per year, per student (Murray & Balogh, 2023, p.136). Creating programming in-district is also expensive, as far as hiring and maintaining staff. The well-being of program children, staff, and families are more than enough reason for robust professional conversation. However, if anyone needs something more measurable, how about dollars? While districts spend big money on programming for students with significant social, emotional, and behavioral challenges, they have almost no idea and very few resources to draw on regarding what actually works.

We need to talk about what works and what doesn’t seem to work in inclusive education for students with significant social, emotional, and behavioral challenges. What should we measure? What is the value of our measures? And, what is immeasurable? Like any arena of work, we should be developing and revising best practices in robust conversation in person, online, and in published material. 

Tell me, what do you think?

References 
Murray, M.A. & Balogh, L. (2023) The therapeutic inclusion program: Establishment and maintenance in public schools. Routledge.

What Happened to Therapeutic Work In Schools?

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Given that you are reading this, the term “school counseling” is probably familiar. What about “school therapy”? This is not a term that people use. Why not?

Our word choices signal cultural concerns and priorities. While counseling and therapy are not clearly distinguishable, “counseling” connotes a goal-oriented, problem-solving approach with a relatively predictable arc, while “therapy” connotes deeper, exploratory, holistic, and less predictable mental health care.

Our culture has chosen the word “therapy” when we want to communicate depth in areas where some underappreciate the seriousness of the work: speech and language therapy, occupational therapy, physical therapy. 

We don’t say “occupational counseling.” We have physical therapists, occupational therapists, and speech and language therapists. Using the word “therapy” reinforces for practitioners, students, and families that the work at hand is significant. 

“Psychotherapy” is therapy for the psyche. But generally, we don’t call therapy in schools “psychotherapy,” and we don’t refer to school counselors as therapists.

We know the psyche is powerful, complicated, and of great consequence to our development and lives. However, we don’t understand it as confidently as speech and language, or the mechanical workings of the body. So, we use the word “counsel” to reassure the fearful that we won’t be venturing too deeply into this unknown territory from school.

This same fear drives the types of mental health and behavior interventions prevalent in schools. Behaviorism dominates, -an explicitly and intentionally surface-level approach. After that, we find “strategies and toolboxes”, with their bases in cognitive behavioral therapy (CBT). 

Behaviorism addressed behavior (unsurprisingly). CBT can help a student try different ways of thinking, but only if the student cooperates with the therapist sufficiently to perceive the same issues and is willing to try what the counselor suggests.

Outside of schools, we find a wider array of mainstream mental health therapies. Among the important differences, we find therapists and therapies that acknowledge the importance of the unconscious in individuals, families, and groups. And, we find therapists and therapies supported by the long and mainstream tradition of ongoing supervision for mental health clinicians. 

Our schools imagine that they can address the complex and deep mental health issues and crises in schools without core concepts and supports from mainstream mental health care. As you probably are aware, this isn’t going well.

I can’t confidently account for why school’s responses to mental health concerns have diverged so significantly from mainstream approaches in mental health care. But, I can identify some of the forces at work. 

One is budgetary. The cyclical nature of school budget growth and cuts pushes relentlessly for efficiency. Despite clinical supervision being a core component of mainstream mental health care, it was cut from the budget for school counselors long ago, and no clinical supervision for school counselors has long been the norm. With no supervision, the scope of work that is possible narrowed toward simpler and more surface-level interventions.

There is also the economics of working on a large human scale. To be efficient, the schools must find the smallest interventions that are effective for the largest number of students. This naturally steers schools toward surface interventions and away from more sophisticated work.

Additionally, there is the force of fear on which this article opened. 

There are benefits to these tensions. Minimal effective interventions are a good thing, and preserve time and resources for other learning concerns, from both the school and student perspectives.

The problem is that school mental health has developed over decades under these forces, and has diverged from mainstream psychotherapies to the point where schools no longer have the knowledge reservoir or practice familiarity needed to effectively address many mental health presentations. 

CBT is a valuable approach and helpful to many people. Regarding behaviorism, it’s crucial to understand and apply the lessons of behaviorism in interventions concerned with behavior. However, the insights of behaviorism should be integrated into a larger relational and humane approach.

To better provide support for student’s mental health, we must provide clinical supervision for counselors and introduce concepts and approaches from mainstream and effective mental health care. This will benefit the school population at large, and especially those students with significant mental health concerns for whom CBT and behaviorist approaches are often ineffective. 

Frequently, these students are removed from their familiar home school communities and sent to much smaller private therapeutic schools that do not have the breadth of resources of larger public schools. These private therapeutic school placements are extremely expensive for the school district.

What do these private therapeutic schools offer? Many have a clinical supervision structure, and familiarity and comfort with more sophisticated mainstream mental health concepts and interventions. If school districts want to expand their capacity to serve students effectively in their home communities, and avoid expensive private therapeutic school placements, naturally they will have to build their capacity to do similar therapeutic work.

References 

Murray, M.A. & Balogh, L. (2023) The therapeutic inclusion program: Establishment and maintenance in public schools. Routledge.

Stone, M. (2023). Why America has a youth mental health crisis, and how schools can help. Education Week, https://www.edweek.org/leadership/why-america-has-a-youth-mental-health-crisis-and-how-schools-can-help/2023/10.

The Importance of “We’re All In This Together”

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When you hear “that’s not in my job description” it’s a discouraging indication regarding staff morale and staff’s ability to work as a team.

I’m writing from a place centered on inclusive school programming for students with significant social, emotional, and behavioral difficulties. These programs are sometimes called “therapeutic programs.”

What our students need most from staff is reliability and adults who work together. The best way to provide this dependably is through the overlap of staff functions. When the abilities of staff members largely overlap, a resilient and flexible net is created, with the security provided by redundancy. By “redundancy” I mean that if one staff member is out sick or otherwise unavailable, other staff members are capable of doing the same work.

I visualize this as overlapping circles of ability and responsibility. This is what we want, as opposed to unique staff abilities and responsibility gaps that make a program rigid and unreliable.

So, what does healthy staff overlap look like in more specific school situations? Here’s a concrete example of what I mean: If a therapeutic program has a counselor and a special education teacher, the special education teacher will be doing plenty of counseling, and the counselor will be educating. They will often work side by side. I advocate for referring to them both as “therapeutic educators.” 

Naturally, over the course of their time and experience, they will both become better teachers and counselors. We should continue to respect their individual expertise and leadership within their unique roles, while adopting a flexible approach toward responding to the needs presented by the students.

Supervision is an important part of the program model I advocate for, which is an essential support to anyone doing therapeutic work – counselor, teacher, and paraprofessional included.

Similarly, when therapeutic program staff supports inclusion in a general education classroom, the ‘all in this together’ mentality makes all the difference. The general education teacher is responsible for educating all the students in the room. The therapeutic program staff member is responsible for providing needed support and accommodations to program students so that the general education teacher can deliver instruction.

Without losing sight of these clear priorities, there is room for overlap and flexibility, making for a much richer and more collaborative experience. The therapeutic program staff member can be supportive of the entire classroom. If the general education teacher and therapeutic program staff member are both sufficiently skilled they may trade roles at times, with the general education teacher providing specialized support while the program staff member holds and teaches the classroom group. In practice, this can be quite fluid. (If you’ve ever played basketball, it’s a lot like switching your defense assignment on the fly in person-to-person defense.)

Every staff member in the school is ultimately responsible for doing what they can to make the whole school function the best that it can. This mindset mutually supports the inclusive mindset we must have with the students. Alternately, when program staff has a siloed mindset, the program students experience siloing as well.

As a staff member of a therapeutic program, helping students and staff during the random opportunities that come up in a school day supports your prime responsibility of helping your program students receive non-stigmatizing, appropriate, inclusive education. I suggest seizing any opportunity that doesn’t actively interfere with your ability to attend to your primary responsibilities. 

As far as your job description/contract goes – I do think it’s important to maintain your lunches and preps, and to keep your work within your paid hours. That is part of avoiding burnout, staying with the work long-term, and building program stability.

When you’re ‘on the clock’, and not in your prep or lunch times, just do whatever you can to help the school. It will pay off in a better experience for your students and your school community.

References
Murray, M.A. & Balogh, L. (2023) The therapeutic inclusion program: Establishment and maintenance in public schools. Routledge.

New group psychotherapy offering

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I have a new group psychotherapy offering.

Group psychotherapy is an extremely valuable, rewarding, and powerful therapy modality. Depending on the individual, it can be an alternative or complement to individual therapy.

Details:

-in person: Porter Square in Cambridge

-Thursdays 10am – 11:15am

-Begins on Thursday September 5th

-It will be a general adult interpersonal group

-Fee will be $80 per session. There will also be two individual sessions to determine fit and prepare for the group. I will not be accepting insurance for group, though I will provide you with invoices to submit to your insurer upon request. If cost is prohibitive to receiving care, please let me know.

Contact me if you are interested, have questions, and feel free to send someone my way.

Process as Counterweight to Reactivity in Schools

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A blog entry about why organization, structure, and process is so important – without mention of Tolkien’s ents. 

Think of process as the antidote to reactivity. 

Reactivity is always available. It doesn’t require any planning or preparation. The student’s habitual stress response is set off. They act out. This sets off the teacher’s habitual stress response. The teacher’s reaction could be an in-the-moment response that they later regret. Or, maybe their reaction is deciding that this student simply can’t be educated in this setting.

A meeting is called. -Teachers, counselors, and administrators gather in some combination. The gathering is a reaction, so the reactivity continues.

This is meeting student reactivity with staff reactivity. This is the opposite of meeting reactivity with process. Reactivity is logistically easy, emotionally difficult, and ineffective at improving any student’s or teacher’s school experience.

Process receives reactivity and slows it down. Process moves at its own pace. The process receives the intense initial distress, slows it down, and disperses it amongst the collaborative adult team. Reactivity arrives at any time, and this uncertainty fuels anxiety. Process is predictable, and your staff’s consistency will earn a sense of security.

What does process look like? 

Process in this context consists primarily of three things:

  1. Regular, scheduled meetings.
  2. Clear expectations about communication.
  3. Clear decision-making processes.

We do see some of these structures taking root in school districts, with regular data meetings and processes for determining interventions for students. However, I don’t reliably see these structures where they are needed most – in programs designed to support students with significant social, emotional, and behavioral challenges.

The elements listed above are all worth talking about at length and in detail. Here, I will touch upon each very briefly.

Regular, scheduled meetings – These dictate the pace. Knowing there is a regular time to discuss and sort out challenges has a tremendous stabilizing effect on the staff. A staff member may be in a reactive space and feel that an issue needs to be resolved right away. With a dependable meeting time, -say, on a Tuesday – they will just have to hold tight until Tuesday, when everyone will get together and talk about the issue along with other concerns. In the meantime, everyone involved has a little time to stop, think, and adjust to the pace of the process.

Clear expectations about communication – The way that information is shared should be routine, clear, and understood by everyone on staff. There should not be any guesswork in determining whether and whom to share information with. Leaving these routines and expectations unclear is a recipe for interpersonal trouble. A lack of clarity adds extra burdens on staff who must not only confront a difficult situation, but also figure out whether, and whom with, to share information about it.

Clear decision-making processes – Disagreement among staff is inevitable. Disagreement among staff is also functional. A staff in constant agreement is not much use to each other in terms of deepening understanding, seeing from multiple perspectives, and rich collaboration. But disagreement is also uncomfortable. We have varying degrees of tolerance for it. Having a process for decision-making is a relief to interpersonal discomfort. When everyone has had a chance to say their piece and the conversation has stopped developing, we can move on to the decision-making process, and then on to the next concern.

Reactivity lives at the core of human nature while establishing and maintaining these structures and processes goes against some basic human tendencies, and there lies the challenge.

If we meet regularly, we will have more difficult conversations and disagreements. People tend to avoid difficult conversations and disagreements. So, many people would prefer not to meet. You may find that meetings are regularly missed, and people start to arrive late, or that meetings end early. If someone does not assume the role of maintaining the meeting and holding expectations about attendance and timeliness, these phenomena will almost certainly develop.

Similarly, staff may avoid communicating about something that they know will be contentious and difficult to talk about. The temptation may be to keep it to one’s self, or to tell only the most sympathetic ear. And lastly, people don’t naturally rely on established processes to make decisions. People tend to revert to more habitual and less organized group patterns, and groups often get stuck there.

The effort required to establish and maintain organized processes is worthwhile. Regular meetings and processes will provide practice in confronting challenges and lead to a greater sense of predictability and security, which will reduce anxiety. This predictability and increased security will infuse the staff’s work with students, and create a better learning environment. It will also decrease staff burnout and turnover, greatly benefiting program staff and students.