Supporting Teachers and The Work They are Doing. As a mental health therapist who has worked many years alongside teachers within the school system, I have a deep appreciate for the work that they do
Dr. Andrea Hutchinson’s drive to improve mental health providers’ lives has quickly established her as a leader
in the mental health community. Dr. Hutchinson’s practice, Care Counseling, fights for therapists by providing
support and training necessary to say things like CARE has 7x less clinician turnover than the national average.
When Cathy Moen’s son, Elijah, was in first grade, he was diagnosed with attention deficit hyperactivity disorder. She took him to the pediatrician, who put him on medication and suggested therapy.
The medication part was easy. But getting him therapy proved more difficult — not because Moen couldn’t find a therapist or didn’t have insurance, but because of logistics.
The appointments were always during the day, and between her work schedule and the traffic, it was nearly impossible for them to make it.
But she soon learned Elijah was able to see a therapist in his Bloomington school. More than 15 years ago, Minneapolis Public Schools helped pioneer a national model of bringing community mental health care directly to its students. Today, most of the public schools in Minneapolis — more than 50 of them — have a therapist on site, and many other districts, like Elijah’s, have followed suit.
These days, Elijah’s therapist simply walks down the hall and pulls him from class.
“This is like a godsend,” said Moen.
The family’s health insurance pays for the care the same way it would if the student were being seen in the clinic. The school program was designed so that no student in need will be turned away for lack of insurance.
The Minneapolis program has also provided a road map for schools across the country as more administrators realize that mental health is as important to students’ future success as academics. Studies have shown that students are more likely to show up for appointments when the therapists are on-site.
More and more states are making mental health care in schools a priority. At least two states have recently passed laws that require schools to teach mental health. And more are considering it.
But the benefit of having a therapist on-site goes beyond just getting students to see a therapist. In Minneapolis, it’s also helped make mental health a school-wide priority — and helped get counselors, teachers and others more involved, said Mark Sander, who helped start the district program.
“Those teachers start learning more and more [about mental health],” said Sander, who directs school mental health for the district and the county.
He said as they learn more about mental health, teachers are feeling like, “‘OK, I get it. And now, you know, I’ve got this other student who’s not diagnosed with anxiety but has some of those anxiety features. And now I know how to better support them.”
At South High School in Minneapolis, the therapists sit in the school clinic, the same one where students go if they feel sick during the day or to get a physical so they can play sports.
The issues the students bring to the therapist run the gamut from stress about grades and colleges to anxiety related to a bad situation at home.
Farah Hussein is a therapist at South. She said it’s hard being a teenager, and she tries to help.
“There’s a lot of conversations about, ‘Who am I? Where do I fit in the world? Where do I belong?’ and just a lot of distress in exploring that,” she said.
All of this has important implications for the students’ well-being beyond just their mental health.
Sharon Hoover, who co-directs the National Center for School Mental Health at the University of Maryland School of Medicine, said more schools are collecting data on outcomes of in-school mental health programs, and the results are clear.
“They are more likely to have good attendance and to graduate and to get improved grades. We even have documentation of having better standardized test scores when you put universal systems in place like classroom-wide social emotional learning,” she said, all of which makes for happier, better adjusted students.
Cathy Moen, the mother whose son, Elijah, is in therapy in school, said she doesn’t know if it’s the medicine, or the therapy, or just that he’s growing up, but she — and his teachers — are already seeing a difference.
By: Bridget Eickhoff, MA, Alison Dolan, Psy.D., LP, and Andrea Hutchinson, Psy.D., LP
Being a therapist can be a fulfilling and rewarding career. However, it can be hard to remember that therapists are humans who also experience anxiety, stress, and burnout. We took a survey of 30 clinicians at CARE Counseling asking what makes them feel successful and balanced at work. Here are the main points our amazing clinicians found that help them find balance when working with a full caseload.
- Create Boundaries and Stick to Them
- Let your clients know your boundaries for cancellations and follow through with the boundaries you’ve set or are set by your agency. Therapy should be a flexible time for the client to address topics that are important to them; however, aspects of structure are important in therapy to keep both your clients and yourself accountable.
- Start and end sessions on time so that you have time to complete documentation, grab something to eat or drink, use the restroom, consult with a colleague, and/or take a moment to regroup.
- Manage your Schedule Proactively
- Make your life easier by scheduling clients as recurring appointments and practice confirming the next appointment at the end of the session.
- You probably enjoy seeing clients and it can be heartbreaking to refer them out. However, back to that accountability point, close your clients who are not following the attendance policy (or use supervision and consultation if you need guidance) and give them referrals to help with barriers (e.g., closer to home, different hours, attending to a different piece of their difficulties, etc).
- Proactively reach out and ask for more clients if you start to notice your caseload looking low or you have inconsistent clients.
- Keep in mind, being proactive will help keep the number of intakes in the same week lower and documentation will likely feel more manageable.
- Take advantage of cancellations and catch up on documentation or check-in with a co-worker. If you are finding yourself racing towards burnout remember:
- You can use PTO and take a day or more to feel grounded again
- Ask if you can have a temporary block off time in your schedule to help you gain some extra time to feel like things are more manageable again
- Talk to management to see if there are ways to contribute to the team without as many client appointments.
- Try to NOT Take this Very Personal Job, Personally (easier said than done)
- For both you and your clients, use your intuition for goodness of fit. As you know, a healthy therapeutic alliance is a key factor for the overall success of therapy. At times, especially as a new clinician, it can be difficult to decipher between your intuition and anxiety. Clinicians should utilize supervision and consultation to explore types of clients who are and are not a good fit. Supervision and consultation are also helpful when you feel stuck.
- Sometimes, it can feel pretty personal when a client cancels often or ghosts us. Keep in mind, clients will cancel appointments for a multitude of reasons ranging from weather, illness, moving, and symptoms and this happens to the best of us.
- You’re Not Alone
- Consult with your peers and use supervision to feel balanced and confident with your caseload.
- While you are likely a compassionate person, remember you too may have times when you need to check-in on your own mental health. Remember everyone can benefit from therapy!
When Dr. Jeff Hardwig started his job as a psychiatrist in his hometown near the Canadian border, he wasn’t sure there was enough work for him.
Pretty soon, it became clear that there was, in fact, plenty of work in International Falls, Minn., a town of 6,000 people. He split his time between a group family practice and community mental health center and also saw patients in nearby communities.
“Within two or three years, it was clear I was too busy to go out of town anymore,” he said.
After nearly 30 years working as the town’s sole psychiatrist, Hardwig retired in September, leaving no psychiatrists for more than 100 miles around. His departure underscores a difficult reality: A national shortage of psychiatrists is much more acute in rural and remote areas, which leaves many people without access to the kind of services they need.
And the demand for Hardwig’s services has never let up.
Wendy Dougherty, the nurse who worked with him at the clinic, said his calendar was always full.
“He never ever … in the five years I worked with him, ever had an empty slot,” she said. “And one thing about his patients, if they called and canceled, that empty slot was filled by somebody that had been waiting two months to get in.”
But, she said, he was also the kind of doctor who would always find a way to squeeze in somebody in a crisis, even if it meant missing lunch or canceling his own meetings.
‘You take all comers’
The clinic where Hardwig worked is a primary care center on the outskirts of town, part of the Duluth-based Essentia Health system. It’s a low-slung building across the street from a Menards and a Dollar Tree that offers all the basic services, including annual checkups and mammograms.
Hardwig and others agree that the need for a psychiatrist in town was there, but until he arrived, people mostly counted on their primary care doctors to handle it.
His patients’ diagnoses over the years ran the spectrum of diseases, including anxiety, depression, bipolar disorder and schizophrenia.
“I had to take care of people of all ages — all the way through to the nursing home,” he said. “You can’t really specialize if you’re in a small town. You take all comers.”
And working in a small town, he also couldn’t avoid running into his patients frequently. It might have been hard for some doctors — psychiatry is a profession that particularly prizes its discretion — but Hardwig says he didn’t mind.
“I just had sort of an agreement with my patients if they say ‘hi’ to me, I’ll say ‘hi’ back, but I won’t otherwise out them. And my wife knew not to ask, ‘How do you know that person?’” he said.
He said his patients were respectful of him, too, and didn’t try to squeeze in consultations in line at the grocery store or when he was out to dinner.
One of his longtime patients was a man named Daniel Carr, whom I met at a clubhouse run by a community mental health center where people with serious mental illness can spend their time. The cozy house has battered couches and an armchair in the living room. A Christmas tree sparkles near the front window.
Carr, who has paranoid schizophrenia, was Hardwig’s patient for 25 years. He says he misses Hardwig.
“He knew exactly about how to treat me,” Carr said.
“I had some trouble with my medicine changing a little one way or the other, but he usually knew what was best. I’d tell him what I was experiencing and he knew what to do.”
Hardwig wouldn’t talk about specific patients, including Carr. Carr said his psychiatric care has been transferred back to his primary care doctor, and that it’s been going OK so far.
But Wendy Dougherty, the nurse who worked with Hardwig, said some of the primary care doctors have been less than enthusiastic about taking on the psychiatrist role.
“Jeff took care of the hard ones,” she said. “The schizophrenics, the bipolars … these docs kind of put up their hands and say, ‘Oh, my God, I don’t know what meds to give them.’”
The psychiatric nurse practitioner Hardwig worked with is still at the clinic and handles some of the harder cases, but she’s planning to retire soon, too.
A shortage in nearly every county
International Falls is hardly alone in not having a psychiatrist — particularly in remote areas.
More than 90 percent of psychiatrists only work in urban areas, even though more than 20 percent of Americans live in rural areas. In Minnesota, nearly every county — aside from the Twin Cities metro and Rochester area — is considered to have a shortage of mental-health professionals as determined by federal guidelines.
Hardwig said the hardest part of working in such a remote area was that he didn’t have a continuum of care to work with.
“There just isn’t that inpatient bed when you need it. We have only one crisis bed and we haven’t had that the whole time I’ve lived here. We don’t have residential treatment,” he said.
And International Falls is luckier than some places because there’s a community mental health clinic in town. (Hardwig partnered with it until his retirement, and the nurse practitioner still does.) The clinic is looking to expand in the near future. There’s also a mobile crisis team in town that can help with emergencies.
Still, recruiting mental-health care providers, even those who aren’t psychiatrists, to remote areas is challenging. Paul Mackie, a professor at Minnesota State University, Mankato, has studied the problem. And he said the only way to recruit and retain people in remote areas is to grow them from scratch. That is how Hardwig, who grew up in International Falls, ended up there.
Mackie said there are already physical medicine programs that train people for practice in rural areas. And he said now we need to do the same for mental health, too.
“We need to be a lot more thoughtful about who we’re recruiting and how we’re recruiting them,” he said. “We can have that conversation around what does a rural practitioner look like and look for that person and encourage them.”
But that takes time. People who graduated from high school this year won’t be done with medical school until 2027. And then they still have to complete their residency and any other specialty training.
So in the meantime, International Falls — and communities like it — are doing what they can. Hardwig’s old clinic has hired a child psychiatrist who sees her patients remotely over Skype-like technology.
Finding people to work on-site is proving much trickier, though. It was two years ago that Hardwig told the clinic he was planning to retire. It’s been looking for a replacement since then. But nobody has applied for the job.
I love teaching writing; it’s where revelations happen, where children plumb the dark corners, nudge the sleeping dogs, and work out solutions to their most convoluted dilemmas. As much as I adore reading student work, I still get a little nervous about what I’ll find there. Among the stories of what my teenage students did last summer and what they want to be when they grow up are the more emotionally loaded accounts: firsts (periods, kisses, or failures), transitions (moves, their parents’ divorces, or custody disputes), and departures (dropouts, graduations, or suicide attempts).
Over the years, my students have entrusted me with their most harrowing moments: psychotic hallucinations, sexual molestation, physical abuse, substance abuse, HIV exposures, and all sorts of self-injurious behavior ranging from cutting to starvation to trichotillomania. When students write about delicate and dangerous experiences, there are decisions to be made and judgments to be called. And yet, for much of my career, I have been horribly unprepared and have failed to secure the services my students needed as a result.
Teachers are often the first person children turn to when they are in crisis, and yet they are, as a profession, woefully unprepared to identify students’ mental-health issues and connect them with the services they need—even when those services are provided by schools. Aside from the obligatory professional-development session on mandatory reporting laws for child abuse and neglect we have to attend during new faculty orientation, teachers receive little or no education in evidence-based mental-health interventions. According to Darcy Gruttadaro, Director of Advocacy and Public Policy at the National Alliance on Mental Illness, “Most teachers are not trained about mental health in their formal education and degree programs, and yet an unidentified mental-health condition often interferes with a student’s ability to learn and reach their full academic potential.”
According to the National Institute of Mental Health, approximately one in five children currently have or will experience a severe mental disorder. For some disorders, such as anxiety, the rates are even higher. For people who do experience mental-health disorders, most experienced their first symptoms before young adulthood. Half of all people with mental disorders experienced the onset of symptoms by age of 14; 75 percent by age 24. Half of these students will drop out of school. As suicide is the second-leading cause of death among adolescents and young adults, lack of appropriate mental-health interventions and treatment can mean the difference between life and death. Given the amount of time children spend at school, teachers are likely be the ones to identify and refer children for mental-health services. For children fortunate enough to be identified and given access to those services, treatment will mostly likely take place at school, as schools serve as the primary providers of mental services for children in this country.
However, all the mental-health services in the world won’t help if teachers don’t understand the nature of the services available in school and can’t identify the students in need of intervention.
In 2011, researchers at the University of Missouri looked at whether teachers understood the 10 evidence-based mental-health interventions or resources their schools employed. The results were disheartening, to say the least. While two-thirds of the surveyed teachers held graduate degrees, and the remaining third had earned undergraduate degrees, more than 80 percent had never heard of some of the interventions or strategies their own school utilized. Half of the teachers surveyed did not know if their schools provided functional behavioral assessment or intervention planning at all. Given that the response rate for this study was only 50 percent—and it’s likely that teachers with a heightened interest in student mental health would be more likely to respond to the survey—these results probably overstate teachers’ understanding of the tools their own school districts use to support students’ mental and emotional health.
As an increasing number of schools roll out evidence-based mental-health programs such as Positive Behavioral Interventions and Supports (PBIS), teaching that promotes appropriate student behavior by proactively defining, teaching, and supporting positive student conduct, and Trauma-Sensitive Schools, programs aimed at reducing the effects of trauma on children’s emotional and academic well-being, educators need to be at least minimally conversant in the terminology, methods, and thinking behind these strategies. These programs provide strategies that can be highly effective, but only if the teachers tasked with implementing them are sufficiently trained in the basics of mental-health interventions and treatment.
Teachers routinely receive first-aid training in CPR, EpiPen use, and safe body fluid cleanup, but it’s rare for schools to offer training in mental health, said Todd Giszack, Academic Dean of Fork Union Military Academy in Fork Union, Virginia. Recognizing that schools are responsible for their students’ mental, as well as physical health, Fork Union Military Academy designed and implemented its own curriculum with the help of two mental-health professionals, and now offers eight-hour certification programs in Mental Health First Aid. “It has taken two years, but nearly all of our faculty and staff has become certified in Mental Health First Aid. This has allowed our school community to become familiar with trends and warning signs associated with adolescent emotional and mental health” Giszack said.
Dr. Michael Hollander, Assistant Professor in Psychology at Harvard Medical School and director of Training and Consultations on the 3East Dialectical Behavioral Therapy program at McLean Hospital in Belmont, Massachusetts, urges teachers to use caution when intervening in students’ mental-health crises. “In my experience, teacher response tends to be bi-modal; either they get solicitous, over-involved, and in over their head, or they mistake mental health issues for behavioral problems that require in-class discipline.”
Programs such as NAMI’s Parents and Teachers as Allies presentation are beneficial, Dr. Hollander said, because they help teachers understand both the benefits and limitations of in-class interventions. Despite his worries about teacher-facilitated mental health interventions, he’s grateful for the trend toward a greater understanding of students’ mental health. “We have arrived at a place where we finally understand that teaching is not just about educating someone’s rational mind, but also educating their heart,” he said.
Children with untreated mental-health issues can get by. They can limp along toward adulthood until an inevitable, eventual mental-health crisis lands them in the hospital, in jail, or even at an inpatient drug and alcohol rehabilitation facility for adolescents, where I teach. But by then, a lot of damage has been done to their young minds and hearts—damage that could have been prevented if they had received support when their symptoms first appeared.
As I read their essays about crippling childhood anxiety, alcoholic parents, and/or domestic violence, I can’t help but mourn for all the lost opportunities and squandered potential that was wasted on the way.
I recently saw a meme on social media that said “It’s almost time for my normal anxiety to turn into my fancy holiday anxiety.” I had to chuckle when picturing anxiety showing up in a glittery ugly sweater or draped in all things sparkly. Humor aside, it shows that during the holidays, our existing anxiety (or depression) does not just “take a holiday” but rather increases due to stress and societal pressures.
This time of year can be an incredibly stressful and frustrating time. On one hand, we fill our days to the brim with spending time with family and friends, social events, potlucks, baking, preparing meals, finding the right present within your means, and many other tasks guised in the name of the holidays. All of this “fun” can turn to chaotic quickly. Then on the other hand, some of us may have unwelcome reminders or memories associated with the holidays or feel more alone during this time as we watch others join together and celebrate. Whatever the reason for your distress, here are some helpful strategies to help manage the rise of our fancy anxiety (or depression) in finding ways to relax during the busy time of year or help with our perspective on the season.
- Self-soothe – Using all 5 senses, focus on what you notice. Cast any judgments away and focus on the experience in the moment. Here are some examples.
- Taste – slowly eat and notice different flavors in a favorite holiday treat or dish
- Smell – light a candle or smell a pine tree or cup of tea
- Sound – listen to your favorite holiday music, point our different instruments or lyrics you might have over looked
- Sight – watch the fireplace flicker with light or notice the holiday lights all around
- Touch – when baking or wrapping gifts, bring attention to the different textures you feel
- Pay it forward – doing something kind for others or contributing can make us feel good about ourselves and give perspective. This could be anything from holding a door open for someone, greeting someone with a smile, adopting a family for the holiday, or volunteering. It does not need to be a large act to bring a sense of contribution to your holiday.
- Be intentional about breaks – Set aside 15 minutes to check in with yourself and pause from all of the holiday excitement. Read a favorite book, do a meditation, sit in silence, or snuggle up with someone you love.
- Simplify and slow down – With your to-do list growing, it may feel like you need to be in multiple places at once; however, what we know about the brain is that it cannot think 2 things at once. So, focus your entire attention to the task at hand rather than jumping from task to task (aka multitasking).
- Follow traditions (or make your own new ones) – Partake in something that brings you meaning for the season, whether this be a family tradition, baking Grandma’s cookies, or finding something new to do this time of year (i.e., sledding, ice skating, driving around to see holiday lights, etc).
- Put down the phones – I know, I said it. Just hear me out. Often times social media can impact our level of stress by comparing ourselves to others, especially when those others seem to have it all together. They have the catalog ready decorations, Martha Stewarts holiday food spread, or gifts we cannot afford. This can lead us into a down spiral. So, try to limit your access to your phone and engage with those around you.
- Reach out to someone– The holidays can be a lonely time for some. Sometimes we can still feel lonely in a room full of people, feel so far away and disconnected from others, or feel forgotten. Use all of your willingness to reach out to someone or connect. Whether that be grabbing a cup of hot cocoa with a friend, attending a service, volunteering, or making a phone call to someone you have lost touch with in the past. We are social creatures and need human connection.
- Be real with yourself – This includes preparing to spend time with family or friends. You likely already know who is going to be the Grinch, who is going to over indulge in the holiday punch, who is going to bring up politics, and who is going to ask about your love life. Just because it is the holidays, does not mean we are going to change who we are or the roles we play. Have an action plan for how you are going to deal with the likely interactions or dynamics.
- Life in moderation – Life is about balance. Enjoy the holidays by partaking in the indulgences and socialization. Moderation is key. Listen to your body and the signals it is giving you.
- Gratitude– Research is growing on the importance and efficacy of practicing gratitude in daily life. Our brains are inherently negative so being intentional about shifting out of the holiday stress (and negativity) can help bring perspective and renew our enjoyment of the season.
- Write down things you are thankful for in life. Focus on the small things (i.e., clean water, fresh air, etc). Nothing is too small to be grateful for in life.
- Reflect one thing you believe you did well over the past year.
- Compare yourself to a time in your past when you might have handled the holiday stress less effectively.
- Permission grant yourself – The holidays are not always candy canes and sprinkles. Often times we hold ourselves to high expectations and forget we are in control of our own actions. Grant yourself permission to: take time outs/breaks, have fun, do things “out of order”, celebrate differently than family/friends/the past, start a project and stop, be honest with people (and yourself), or have days that are “humbug” or just okay.
Feel free to make these tips your own by adding your own personal flair to them. It is important to find what works for you and your fancy holiday distress.
Dr. Alison Dolan