This commentary is by Jeff Benay, a resident of Fairfax.
In the zeitgeist of contemporary Vermont thought, there appears no word more ubiquitous than “equity.” In most Vermont public K-12 and college school systems, we now have “diversity, equity and inclusion” specialists who work with all stakeholders to ensure sensitivity to these concerns.
These specialists at every level work with faculty, students, staff and community members to help realize equity of educational opportunity in our schools. Unfortunately, it appears that the field of mental health has not developed a comparable level of commitment and concern in regard to issues of equity.
If we are capable of making certain assumptions about how children learn in school, can we not seek a similar understanding about how youngsters internalize therapeutic approaches? To illustrate: We know that some students learn best through “hands-on,” project-based lesson plans that present them with “hands-on” opportunities to solve real-world problems.
Other learners need both visual and auditory presentation of new material, opportunities to hold discussions with peers, readings, and other cognitive approaches that differ from the needs of their peers who need the “hands-on” approach.
Several years ago, cognitive psychologist Howard Gardner described a framework of learning using “multiple intelligences.” His work led the field of education toward what researcher Carol Ann Tomlinson described as “differentiated instruction,” whereby educators designed lessons that allowed for adjustments in content, process, products, or the learning environment to respond to the unique needs of the individual.
Contemporary educational theorists are emphasizing “Universal Design for Learning,” based on research at Harvard by Dr. David Rose and Dr. Anne Meyer. In this approach, lessons are designed in a manner that allows maximum access by all learners, eliminating the need to push for specialized, individualized instruction.
If a teacher can craft lessons and learning environments using “universal design,” one might posit that a therapist could practice their craft in a similar vein. In other words, a therapist could use those methods or approaches that might best teach a child to think more clearly about any issues that are brought to the fore.
For a “hands-on” learner, the therapist might use a form of art or play therapy that allows the client the opportunity to work through issues in a modality most comfortable for that learner. A more cerebral client might benefit from reading articles or stories and discussing those with their therapist. Ideally, a therapist would design the therapeutic environment in such a way that the client could lead the approach by being offered several choices in a “universally designed” therapeutic environment.
Unfortunately, in Vermont, Medicaid administrators have recently informed art therapists and others that they will not be reimbursed if they choose these approaches. At a time when research is beginning to question the efficacy of cognitive-behavioral “talk therapy” (the most dominant modality used by therapists), Medicaid is closing the door on more innovative strategies that might have a more positive impact, especially for for youngsters from culturally and economically diverse backgrounds.
I am suggesting that it is possible to determine that some therapeutic approaches are a better match for some youngsters, just as some approaches to classroom instruction are a better match for students. In other words, if we ask, “Is it possible to determine which kinds of therapy work best for which clients?” the answer is a resounding “yes.”
Among Native American communities, for instance, there is a preference for art therapy. Through experience, we have learned that very bright Native students are better able to communicate through drawing and exploring art than they are with “talk therapy.”
In a local Vermont school system, Abenaki parents and students alike were thrilled to learn that a highly skilled art therapist had been hired to work with students. These are the very families that had been told in the past that their children were not well suited for therapy.
Many parents lamented that their child did not engage verbally with therapists. Of course, the locus of the problem was the approach. “Talk therapy” is not well suited to a culture where expression is not primarily verbal, but rather the people communicate through art, drumming and dancing. Art therapy showed promise in helping to bring out issues these children struggled with, allowing the therapist the opportunity to teach coping strategies and other means of overcoming mental health challenges.
In returning to the rejected art therapy invoices, Medicaid has often claimed that meta-analyses of extensive, concentrated research has been offered regarding “talk therapy,” whereas other modalities, including art and play therapy, are less well examined. If researchers feel more comfortable with their own verbal strengths, and they know government support will be afforded the more dominant “talk therapy” approach, it only makes sense that more research will be conducted about this dominant modality. Fewer researchers have shown interest in studying how innovative approaches such as talk and play therapy have impacted diverse populations.
If Vermonters are indeed concerned with equity issues, we must examine equitable practices not only in our schools and workplaces, but in therapeutic settings as well.
It appears that Vermont schools are taking concerns of equity, diversity and inclusion with serious conviction and a desire to effect change. Good for them. We hope to see a similar commitment in the field of mental health here in our state.
Without this level of commitment both in state mental health agencies and with private practitioners, genuine equity in mental health services will remain elusive, and everyday Vermonters will see “equity” as nothing more than “lip service.”
