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  • Writer's pictureTobias Kroll

Self-advocacy and overwhelm in school SLPs

An exercise in listening


Sometimes profound insights start out as a hunch. Phương Liên Palafox, speech-language advocate, has been close up to the world of school-based speech-language pathology for years, as a school-based speech language pathologist (SLP), district and regional SLP Lead, and educational consultant for school districts. And from those vantage points, she saw some disconcerting changes. Overwhelm and burnout, long a concern for SLPs in the schools, seemed to increase over the years (and that's before the pandemic). Curious about what was driving this, she contacted me to do some research on it, and I was happy to oblige.


We decided to run focus groups to get a sense whether there were shared concerns among school-based SLPs. We ran one group of seven elementary-based SLPs and one of five secondary-based SLPs. And then we spent a lot of time - a lot of time! - analyzing our data using line-by-line coding, chunking, and memoing. Relentlessly supported by my fantabulous grad assistant, Makinna Morgan. And we got some real insights that I wanted to share with y'all on this forum. So, here we go.


When we got started, we were harboring the following assumptions:


Assumption 1: School-based SLPs are overwhelmed (at least some of them).

Assumption 2: Their overwhelm stems from an excessive workload, and from a lack of support by leadership and organizations.

Assumption 3: The overwhelming workload consists mainly of paperwork and other issues around regulation and billing procedures.

Assumption 4: SLPs do not advocate for themselves, or do not know how to do so - or are afraid to.


Number 1 was our starting point, of course: we deliberately recruited clinicians who said they were overwhelmed. Then, to test our assumptions 2 to 4 against reality, we had our focus groupers talk about the following research questions:


  1. How are you advocating for your needs as an SLP?

  2. Do you know how to advocate for yourself in the following areas:

    1. mental health needs?

    2. resources and materials?

    3. decreased workload?

    4. implementation of service delivery models?

  3. How confident are you in advocating for your needs?

  4. Do you feel safe to advocate for your needs?


So, what did we find? Let me give you the big picture first. As it turned out, we were mostly right in our assumption 2: SLPs do have too much on their plates, and leadership issues do play a role in that. But, we were mostly wrong in our assumptions 3 and 4. SLPs do advocate for themselves, but are up against some serious obstacles. And their overwhelming workload doesn't come from paperwork but - wait for it - the constant need to advocate for themselves.


Mic drop. Yeah, I know.


 

Overwhelm: a story told by codes


Our first impression, after the focus groups were over, was a sense of two very, very different groups. The secondary school group, whom we interviewed first, was characterized by a defeated, aching mood: a quality of hurt. Several participants mentioned they were getting ready to quit their job. The elementary group, by contrast, was struggling with overwhelm but in good spirits all the same. They talked about ways to improve their situation, and they even mentioned the fun that can be had on the job. That term was not used a single time in the secondary group.


The main reason for this, we found, are the stark differences between the two settings. The code we gave most often in the secondary group was special populations. By that our participants meant students with severe conditions and extensive needs. As school clinicians know, that's a big chunk of the kids we work with in middle and high school, a much bigger one than in elementary. For by the time they enter middle school, most students with communication disorders will have gotten intervention. As the years pass by, the less severe cases get dismissed, and the more intense ones remain.


And that comes with issues. That story is told in the codes. Secondary school SLPs were constantly negotiating their roles and responsibilities - with leadership, parents, and student advocates who don't understand what SLPs do and with whom they found themselves at odds. They knew what their students needed but were unable to provide it - because leadership, parents and advocates all had their own ideas of what students needed, or because clinicians didn't even have the resources to schedule an ethical amount and intensity of service. And all their advocating got them nowhere - over and over, they reported finding advocacy to be ineffectual, and even feeling ineffectual as clinicians!


Also, as students' needs weren't met, some kids on their caseload communicated through physical means. These SLPs found themselves having physical altercations with their students. One of them described it this way: “a lot of times we’re taking down students like it’s a juvenile jail at times. And when I'm doing speech therapy, a lot of times, you have to be aware of where your body's positioned. You have to have your back against the wall.” No wonder this group mentioned being done with the job eighteen times.


So far, so bad. Now contrast this to the elementary group.


This group faced similar needs - they, too, mentioned roles and responsibilities, special populations, and leadership who didn't understand what SLPs do. But their top codes were much more upbeat: our elementary clinicians spoke at length about setting boundaries to protect themselves from overwhelm. That looked e.g. like not taking work home, not helping teachers in the classroom, not meeting deadlines, or even not seeing students (which tended to make them feel guilty - and also opens up whole buckets of ethical and legal issues, obviously).


Most boundaries were set by individual clinicians, but group members explicitly mentioned the importance of collective action. Elementary SLPs felt they could always ask a fellow clinician for help to take on work they couldn't handle, and where clinicians banded together and advocated as a group, advocacy tended to be successful.


It's not just that strength is in numbers. This group also mentioned that they felt safe advocating. That's partly because they knew they couldn't be easily replaced, and partly because they had good leadership.


Elementary SLPs also offered an eye opening insight into our professional culture. Over and over they mentioned how we are perfectionists and tend to go at it alone. No wonder, then, that SLPs tend to have trouble setting boundaries and banding together to advocate - those go directly against our self-understanding!


All that said, the elementary group, too, found themselves bumping up against issues no amount of advocacy seemed to help with. Like the secondary group, they mentioned lacking a dedicated therapy room. Like the secondary group, they had to deal with all the folks around them - leaders, teachers, parents, advocates - who simply don't understand what we do but still have an opinion about it, so SLPs found themselves at odds with them. They too were constantly advocating for their time, their needs, and their students, and they too were overwhelmed as a result - not to the degree the secondary group was, but still painfully enough to sign up for our study.


 

Our theory of what's going on


The goal of our research was to come up with an explanation of why school-based SLPs are overwhelmed. We thought we had some pretty good ideas to start with (that's our assumptions above). Most prominently, we thought SLPs don't advocate for themselves - and boy, were we wrong. Turns out the main problem is that they have to advocate for themselves constantly - that's what gets them overwhelmed.


As serious researchers, we therefore drafted what's called a grounded theory: a data-based explanation of a problem. We call it the invisible workload theory of SLP overwhelm. Check out our neat visual.



As you can see, the central problem in SLP overwhelm seems to be, not the typical suspects - workload, paperwork, etc. - but something deeper than those (yet intimately related to them). We call it the invisible workload of being a school-based SLP, and by that we mean the constant need to advocate for ourselves, and to juggle external and internal expectations, without anyone acknowledging this part of our work.


Let's look at the top bubble, roles and responsibilities. Our participants told us that most people around them do not understand what SLPs do. As a result, they have to explain themselves constantly: to teachers, parents, administrators, and advocates. Which by itself is exhausting. And it's made worse by leadership issues. Obviously, if leadership (principals, admins, Leads) doesn't understand what we do, but tell us what they want us to do, a mismatch ensues: between our roles and responsibilities on the one hand, and expectations on the other. (This is one of the definitions of burnout, btw!) Which the SLP then has to explain to leadership; come up with a better way forward; and argue for that better way. All of which adds to their workload.


Part of that has to do with the issue of expectations vs. reality. This is mainly for secondary settings. Admins and parents, teachers and advocates all have their own ideas about what young people of a certain age should know and do, and fail to understand how disabilities impact that. One participant told us about a 20-year old who is cognitively around kindergarten age (he likes Elmo, for example) but all the non-SLPs in his life want him to have a Facebook account because they think that's age-appropriate. And then it's the SLPs job to explain that any intervention needs to be tailored to the individual's actual abilities. Over. And over. And over.


These problems don't just happen randomly, at the face-to-face level. They are built into the organizational structure. (That's the next bubble, clockwise. And I have to credit Phương for these insights - as an academic, I wouldn't have known!) SLPs have issues with their leaders because those are typically not SLPs. Not only do they not quite get what we do, there is also a kink in the accountability structure: we get hired by people we don't report to (Leads at the district level), and we report to people who haven't hired us (principals and admins at the school level). This ensures that no one feels quite responsible for us, and we have no representation in the system. One consequence our participants mentioned: the constant pressure to make up missed minutes. Special ed teachers don't have to do that (let alone general education teachers) but we do - and no one at the higher levels understands the problems with that. (And if you don’t understand, it’s difficult to care…) As a result, especially those of us who are on a small campus or serve multiple schools are lone wolves, out on their own.


And this plays into some dark corners in our profession, as per the SLP culture bubble. As the elementary group taught us, we are perfectionists who tend to try and handle things on our own. Which all but ensures burnout when you're faced with all the issues mentioned above. So, our elementary SLPs had to learn to set boundaries the hard way, by getting overwhelmed and needing to do something about it (that's the lack of boundaries and martyrdom codes). Of note, it was our sole male participant who most clearly articulated how he went from "grinning and bearing it" to speaking up. It may well be that males are more encouraged than females, in our culture at large, to do exactly that.


And as mentioned, it was only the elementary SLPs who made any meaningful strides in that regard. The secondary clinicians were too alone, and too overwhelmed by the issues they were facing.


 

The way forward - some thoughts


So what can we do? We have some thoughts on that, which come both from the collective wisdom our participants shared with us, and our own reflection(especially Phương's, with her years of experience inside the school systems.). Based on that, we suggest three ways forward: setting boundaries, advocating collectively, and leadership responsibility.


Setting boundaries: Clearly, this is a winning strategy. SLPs need to delineate their workload, schedule, and responsibilities. Which our elementary SLPs did, more or less successfully, after a painful amount of burning out and learning. And it helped.


But there's problems with that. The most glaring one is that it adds to SLPs' invisible workload. For in most work environments, you can't just change your approach to work entirely from one day to the next. You have to do even more communicating and advocating: with colleagues, administrators, and other stakeholders. If you're overwhelmed and burned out from doing that already, and to no effect, piling more of the same on top sounds more like an invitation to martyrdom than a viable way forward.


This is where the second strategy could come in. Advocating collectively has made a difference in the lives of our elementary clinicians. Even if they didn't get all their demands met, it helped just to band together and support each other.  


But, as we also saw, even collective advocacy has its limitations. Sometimes it "only" provided a sense of comradery (not to dismiss the importance of that) but no actual solutions. Plus, our secondary SLPs didn't even bring it up as an option. We don't quite know why, but we do know that there are way fewer of them, limiting their opportunities for banding together. (Or they may have simply been too overwhelmed to try.)


And that brings us to our third way forward. Setting boundaries and banding together are great and all, but when clinicians run into systemic issues too grinding to overcome, both of those bump into their limits. That's where leadership responsibility comes in. At some point, the onus of making change needs to be put on those in positions of power, not deflected back, over and over again, to those at the lower end of the pecking order who are already struggling.


What could that look like? We have some ideas. For example, school and district leadership could rise to the challenge. Administrators and supervisors could provide adequate resources for clinicians, education for their community (so SLPs don't have to explain themselves all the time), and a clear system of supervision (so SLPs know whom to turn to when problems arise). This would also include admins, district Leads/Coordinators and principals advocating for manageable caseloads and workloads, streamlining clinicians' administrative tasks, and promoting a culture of collaboration and teamwork.


Most importantly, perhaps, this would require leaders to value their SLPs as people first, and put productivity second. Based on Phương’s observations over the years, this is what truly makes a difference. The work is vast everywhere; however, where districts understand that SLPs are people - with families and feelings and health needs - clinicians thrive, and so do their students.


"Yeah, right, I hear you say. "How are we going to get them to do all that?" Well, one way could be by putting more SLPs in leadership roles. As we learned from our participants, when the Lead is an SLP themselves, they know what's going on with their clinicians, and they are willing to help. Another route to getting there could be to start everyone early. Why not teach about roles and responsibilities of SLPs in teachers' pre-professional educational programs (and in ours)?


Still not sure how to make this happen? Well, neither are we. Changes at any of those levels are way above our paygrade. We know only one institution big and powerful enough to get all the relevant players to listen. That would be our professional organization, dispenser of credentials and continuing education units: ASHA, the one and only American Speech-Language-Hearing Association.


We're emphasizing "one and only", since SLPs have literally no one else to turn to. And frankly, it doesn't seem like they feel well-represented currently. We're referring to the recent (and ongoing) outburst of anger aimed at ASHA on social media, of course. The trigger, remember, was a rather modest increase in dues. The resulting upheaval may seem out of proportion to that - until you listen to SLPs on the ground, like the folks in our study. There is an amount of hurt and burnout in our clinicians that those of us in more privileged positions can hardly fathom.


And ASHA doesn't engage with that. In fact, they keep insisting that clinicians can do more advocacy (using workload calculators and sending advocacy letters have been among recent suggestions). But as our study demonstrates, they are already doing that, and no one acknowledges them.  No wonder SLPs lashed out when that same organization announced they were going to take even more money from them. We suspect, rather strongly, that clinicians' anger arises directly from the invisible workload they are bearing, and which grinds them down.


In fact, reading through the comments during the dues backlash, we found many of our findings reiterated. (And it did seem it was mainly school-based SLPs voicing their anger, although we couldn't verify that.) Perhaps, then, with the information added by our study, ASHA could support overwhelmed clinicians by:


  • helping leadership in school settings get a better understanding of SLP roles and responsibilities

  • advocating for manageable workloads and equitable treatment (e.g. for SLPs to be treated like SpEd teachers, who do not need to make up missed minutes)

  • finding ways to get SLPs into district leadership positions

  • providing resources and opportunities for SLPs to team up

  • encouraging academic programs to become more knowledgeable and responsive with regard to school-based SLPs’ needs


We’re not saying SLPs are helpless, mind you. There is room for agency at all levels. SLPs can and should make changes to support their day-to-day mental health, for example by setting boundaries or teaming up with each other. Campus and district leaders need to engage with their SLPs in thoughtful and intentional ways. And so forth. But our research also shows, quite starkly, that these efforts have found their limits. Rather than making a difference, SLPs are burning themselves out trying to improve the situation for themselves and their students.


Let’s be honest. If change from below isn’t possible, then it must be initiated from above. Dear ASHA, you are the one player who can make the most public difference in the issues we found. SLPs on the ground need your help and understanding. Let's do this together.


 

Tell us what you think in the comments! About our study, our findings, our conclusions - and about our formatting experiment. We bolded key points throughout to make for more efficient reading. Did it work? Let us know!

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