OTS 208: Using the OT Lens to expand School-Wide Mental Health and Behavioral Supports
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Welcome to the show notes for Episode 208 of the OT Schoolhouse Podcast.
What if occupational therapy wasn't confined to pullout sessions and IEP goals? Nicole Pfirman, M.Ed., OTR/L, shares how she brought an OT lens to every role—designing multi sensory environments for behavioral regulation, creating prevention and wellness teams that operated outside of special education, and reframing the "mental health crisis" as an intensity crisis that demands systems-level change.
You'll learn why sensory regulation and mental health can't be separated, how to advocate for OT involvement at tier one and tier two, and what it takes to shift from waiting for an IEP to meeting student needs proactively.
This conversation will challenge you to reclaim participation as the core of your practice and see new pathways for OT leadership in schools.
Listen now to learn the following objectives:
— Learners will recognize the distinction between a "mental health crisis" and an "intensity crisis," and explain how this reframing reflects the current reality school-based OT practitioners are seeing in students' behavioral presentations.
— Learners will identify that sensory system regulation and mental health outcomes are directly connected, and that trauma responses impact the sensory system — meaning trauma-informed care cannot be effectively delivered without also addressing sensory dysregulation.
— Learners will identify how OTP's core focus on participation and meaningful occupation applies across all MTSS tiers — from tier one environmental and policy conversations to tier two consultation — not only at the point of IEP eligibility.
Guest(s) Bio
Nicole brings extensive experience as an educational leader in school-based mental health, with a unique occupation-based perspective that recognizes meaningful engagement in daily activities as foundational to identity, connection, and overall wellness. Throughout her career, she has focused on aligning educational and medical models through collaborative, multidisciplinary approaches that support the whole child.
Quotes
“We are more in an intensity crisis than we are a mental health crisis, meaning that the intensity of the anxiety, the intensity of the trauma, the intensity of the behaviors is showing up in a different way. And that's what our teachers are feeling.”
— Nicole Pfirman M.Ed., OTR/L
"Because you have tier three behavior doesn't mean you're a tier three student."
—Nicole Pfirman M.Ed., OTR/L
"We can't do trauma-informed care if we have a dysregulated sensory system."
—Nicole Pfirman M.Ed., OTR/L
"We don't often hear sensory integration and mental well being or mental health in the same sentence, but you just kind of align them together and and that's unique”
— Jayson Davies
Resources
Episode Transcript
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Jayson Davies
On this podcast, you have heard me time and time again advocate for OT practitioners getting into administrative and district level roles. Today, I'm excited to talk with an OT who has actually done just that and then some. Nicole Pfirman started her OT career in the same place we all did, on the floor with kids, maybe you know in that isolated OT room, sensory plans in hand, in fighting for meaningful participation one student at a time. But over the last two decades, Nicole has moved from school-based OT to behavior coach to special education supervisor to director of prevention and wellness, and now to the executive director of Mindpiece, a nonprofit supporting mental health systems across 250 schools in Southwest Ohio, and while none of these jobs had the familiar OT initials in their job title, Nicole never stopped thinking like an OT or using what she learned as an OT to best support the teams that she supported. In this episode, Nicole and I dig into what it actually looks like to bring an occupational therapy lens into an administrative leadership position. Why she believes we're not in a mental health crisis, but actually an intensity crisis, and how OT practitioners belong in tier one conversations about discipline just as much as they belong in an IEP. If you've ever felt like OT is being overlooked at the table, or wondered what's possible beyond a traditional caseload, this one's for you. I'm Jayson Davies, and this is the OT Schoolhouse Podcast. Let's dive into this episode with Nicole Pfirman.
Amazing Narrator
Hello, and welcome to the OT Schoolhouse Podcast, your source for school-based occupational therapy tips, interviews, and professional development. Now, to get the conversation started, here is your host, Jayson Davies. Class is officially in session.
Jayson Davies
Hey, Nicole, welcome to the OT Schoolhouse podcast. I am excited for today. We have been planning this for a while. I'm glad that we finally have a chance to sit down with you. It's summertime, so yeah. Thank you so much for being here. Really appreciate it.
Nicole Pfirman
Yeah, thank you. I am so excited to be here. Definitely love the opportunity to come on and talk about occupational therapy, which is not necessarily something I get to talk about as much as I would like these days.
Jayson Davies
Right, and it's you have had a lot of different roles in your OT career. We're going to get into some of those because I love how you have transitioned now from 13 years as a school-based OT to kind of in this more supervisory and now even administrative role. And we're going to dive into all that. But you sent over your bio to us, you know, just for the reason for the podcast. And there was one line that really stood out to me, and I wanted to get more of your take on that. You said that you have focused on aligning educational and medical models through collaborative, multidisciplinary approaches that support the whole child. Now, I just want to get your idea on that because a lot of times we don't see focusing on educational and medical models in the same sentence. A lot of times, people are trying to actually differentiate the two. So, I'd love to get your thoughts.
Nicole Pfirman
Yeah. So, I think one thing that I found out pretty quickly in my career, starting in the medical model setting and then switching over the educational model, was just the disconnect or the misunderstanding between how those two systems need to be integrated to really support students, youth, adults, but you know, in the medical model, everything was about treatment. It was about diagnosis. It was about specific goals. And yeah, those things were true in the schools as well. But the real truth around educational model is understanding how all of that then integrates into a classroom setting, or onto a playground, or into the cafeteria, and so I feel that throughout my career, a lot of the conversation that I've had with other colleagues is how do we bring what works in the medical space into the educational space, and vice versa, so that kids are getting consistency and continuity and care, and not something completely different in medical model than they are in educational model.
Jayson Davies
I really appreciate that answer because I've long said like that you know a lot of times the difference between educational and medical model to a degree is like the goals, right? Like in in school based OT, our goals are more educational versus in clinic based. Typically, you know more ADL and and functional living skills, but the way that we go about developing our treatment plan and the modalities that we use aren't necessarily confined by the setting that we're in. I don't know if you want to follow that up or if you have different names. No,
Nicole Pfirman
I agree with you. I think I mean when we look at it from like the goal perspective, yeah, obviously we have educational goals, we have medical medical model goals, but I think the other piece too is that oftentimes I felt like in either setting there was a silo in working on and achieving those goals, and that in a school setting you really had the opportunity to bring what you know from a medical. The model lens into an environment in which kids naturally progress through a variety of different areas during the day, and the goals can't just be siloed to what are we doing to work on fine motor in the classroom setting? What about what are we doing to work on fine motor in the cafeteria and outside? And how is that generalizing to the community environment? And then how are those goals also helping to achieve maybe the private OTs goals that are being worked on in a medical model setting? So, really, just the integration of systems, I think, is so important.
Jayson Davies
Yeah, yeah, absolutely great. Well, thanks for for for answering that one. It was just something I was reading your bio, and I was like, this is a great place to start because I think a lot of OT practitioners struggle with that. Whether we, you know, it's one of those things where even when you believe something, you still question yourself all the time about that. I feel like, and so it's always a good discussion. Now we're going to talk about your, you know, supervisory and administrative roles first. But you were a school-based OT practitioner, you know, in the thick of it for 13 years, and I would love to hear a little bit about those days and how that shaped who you became as a leader.
Nicole Pfirman
All right, yeah. Well, that's something I love to talk about. So, actually, you know, I started my career. It definitely was not a linear path, starting in adult rehabilitation and psychiatry. In my short period of time of doing adult rehab and adult psych, I quickly realized that pediatrics was something that was a calling of mine. I wanted to do that type of work, focusing on mental health and behavioral concerns, but with younger children. And at the time in 2003, 2004, there really wasn't a space for being able to provide what I felt like was mental health or psych treatment or care to pediatric in pediatrics unless you were in a school setting. And so when I made my shift over to the school setting, I I was pretty particular that I did not want to be a traditional school-based therapist. I wanted to be a school-based therapist that was working towards changing systems, that was working on program development, that was really being able to improve youth and young children's mental health outcomes through participation in meaningful occupations. And how does that look different than how historically OT was provided in a school setting, so I spent about eight years in the space of specialized programming for kids who were in a classroom of about six kids to one adult, severe to profound autism and other neurodivergent disorders, working mostly on behavior modification and sensory integration, so that was the core of the work I was doing as a clinician before moving on in my career.
Jayson Davies
Gotcha. And now you did have that, you know, emphasis in mental health and behavioral support. And in 2003, like that was the big, you know, autism rates were just climbing, and so I heard you say you wanted to focus on mental health and behavioral support. But then on the flip side, kind of at the end there, you really talked about doing a lot more sensory and fine motor type of stuff. Was that a bridge that you kind of had to like gap from the from the sensory fine motor to mental health, or is that kind of something that you've managed to kind of just seamlessly do together?
Nicole Pfirman
Yeah, I mean, honestly, I would probably say that it was a seamless integration. I think working on fine motor and sensory skills and isolation really didn't mean much to kids who were struggling with intense behaviors, who had a loss of connection, who had difficulty participating in normal occupations or routines during the school day, and so I actually probably functioned more in the mental health and wellness space and integrated fine motor and sensory activities into those spaces. So, for example, I used a lot of multisensory environmental approaches, a lot of vibration, a lot of low lighting, a lot of vibroacoustics, and in doing that, also worked on fine motor skills, but in a very calm and and sensory based setting versus in a sterile classroom setting. And I think you know at the time, as you mentioned in 2003, autism rates were really starting to climb. Schools were struggling with kind of what what was the programming that would be successful for students. And I think in in designing a program that worked for some of our most severe to profound students with autism, we also found that so many of the things we were doing and specialized programming also would benefit kids who just were having behavior or mental health concerns in the general education environment. And so, then, how did we start to integrate those things in a way that you didn't have to be in specialized programming to benefit from these environments, the sensory activities, the other types of mental health supports, and that really was the catalyst to a lot. The work that I continued to do over the last 20 years.
Jayson Davies
Wow, I'm struggling right now because I want to continue on. But one of the things that I that I kind of gleaned from this last response here, sensory integration and mental health, like those are honestly, when you think about it, sensory integration, your your sensory processing absolutely impacts your mental well-being, but that said, we don't really see that. Like it's not; those aren't two terms that are often put together. Whether it's in the research, in the IEP room, you know, in professional development, we we don't often hear sensory integration of mental well-being or mental health in the same sentence. But you just kind of align them together, and and that's unique, I think.
Nicole Pfirman
Yeah, well, I think that is a huge miss in our profession in general. Honestly, to not be tying those two things together more closely. When you think about kids with significant mental health concerns, often trauma difficulties with resiliency, difficulties with regulation, low participation and engagement, and then you think about sensory integration, and you think about the heightened trauma response also impacting sensory integration, the intensity of behavior impacting the ability to regulate and or and vice versa, and so really, if we're talking about improving mental health, we also need to make sure that the sensory systems are working appropriately and in the same lane as we are when we're working on mental health outcomes. We can't do trauma-informed care if we have a dysregulated sensory system. We can't teach kids how to regulate if their sensory system is dysregulated, and so why are those two things not more commonly talked about? I'm not sure. I did often wonder when I worked with kids with severe behavior. One of the first things I did was implement a sensory diet, and these were not kids with sensory integration concerns. They were not kids on the autism spectrum, but I knew that if we found the right regulation activities, we could get generalization in the classroom just from traditional behavioral approaches. And it, I think, was one piece for me that anytime I'm looking at a student with mental health concerns or behavioral concerns, the first thing I'm thinking about is: Are their sensory systems regulated?
Jayson Davies
Yeah, yeah. Wow. You know, we've been talking all of seven minutes, and I can already kind of feel an answer to this next question here. But you know, you were realizing all of these things pretty early on, and then you started to look toward program development and supervisory roles, and and now even administrative roles, so I'm curious how you feel that your background as an OT really prepared you and maybe even incentivized you or made you the best candidate for some of those supervisory roles. What are your thoughts on that?
Nicole Pfirman
Yeah, well, I think that's a question I get a lot. I think the through line of participation and engagement in meaningful activity or meaningful occupations really is what has led me in all of the positions that I've had. When when you're talking about working one on one in a clinical setting and you're talking about meaningful occupation and participation. What does that look like? But then, as I moved on in my career into more administrative roles, it really was about participation at a classroom level, or at a building level, or at a system level. And even now, in the work that I do, looking at it at a regional level, it's the idea of looking at participation, trying to determine what are the barriers to participation, and then how are we focusing on meaningful occupation to get the results that we want from kids, regardless of the concerns that maybe are arising?
Jayson Davies
Yeah, and you're in Southwest Ohio. You have your master's in education. Was that a requirement for you to get some of these positions, or what made you decide to to get your master's in education?
Nicole Pfirman
Yeah, that's a great question, and that was also by chance. So when I started my OT education, I was actually at Indiana University, and throughout my time there, I found that Xavier University offered a dual program, and I had enough transfer credits to get both my post baccalaureate and OT, and also my master's of education administration at the same time. And so I transferred during my educational career to Xavier so that I could end my four years with both a post bacc and masters in education administration. At the time, I actually thought that it was hysterical that I was going to have an education degree, and I think some of my college colleagues would say the same because I was like, I will never use this. But it was I wanted the master's degree, so I ended up getting it. And what was so. Interesting to me about that connection is that the second I stepped into the school setting and really got into the work, I thought, "Oh my gosh, it is so great that I got that education administration degree because it's going to help me in these leadership positions that I'm interested in. But I will tell you that even moving from clinician to behavior coach was not easy, regardless of having the education administration degree. It was a position that I had to advocate for. It's a position that I had been told no to multiple times. In fact, there were two people that were hired in that same position prior to me basically begging at the time, like please, I know I'm an OT, but let me try it. I'm telling you, I can do it in a different way than what you've seen before. And it was because they were coming at it from traditional, you know, ADA approaches to behavioral concerns in the school environment, which is great for some kids. But really, it wasn't a system. It wasn't a system move. And so, yes, I think having the educational administration degree helped. It was not a requirement in Ohio, but it was a requirement once I got to central office leadership, and so that was definitely a benefit there. But in the early days of moving through leadership, it really was about advocating for what OTs could bring to the table.
Jayson Davies
Yeah, yeah, so interesting. Did the original, you know, the first two times that they posted that job description, did it have something in there like must have teaching experience or anything like that? And did you have to eventually get that removed?
Nicole Pfirman
You know, it's funny. The original job descriptions were very ABA based in that you needed to have been a behavioral analyst, or you needed to have been a teacher, you needed to have direct classroom experience, and the pushback that I always had with that was a as an occupational therapist we do analyze behaviors. It's something we do for a living, regardless of the setting.
Jayson Davies
Absolutely,
Nicole Pfirman
and also I had spent eight years in and out of classrooms, I didn't need to be the teacher to be able to understand how the system worked, and so helping them to redefine the scope of occupational therapists in a school setting was really what had to be done in order to for them to see me in that role. Because I think you know, as you would probably agree, historically our role has been pretty siloed in a school setting. There are very few school administrators that I work with that, if I ask them what is the scope of an occupational therapist, that they can actually answer with the scope of work we do. And so it was it was definitely convincing the school that my OT lens would be beneficial in that space,
Jayson Davies
yeah. You were at the district for 13 years, I think, before before you moved into a supervisory role. How many of those, you know, how many years at the tail end was you trying to convince them this is a job that you could do?
Nicole Pfirman
Yeah. So I I was actually probably treating for 11 or 12 years, and then in the next two or so years, I was in what I would consider like a trial period of being a behavior. It wasn't a trial in their mind, but in my mind, it was like, no, I I need to take these couple of years and prove to them and prove to myself that really this is the role for an occupational therapist, and so it was during those two to three years that I think it was my proving the worth of an occupational therapist in that space that then really helped me get into the actual leadership positions that I was in the last eight years that I was at that district.
Jayson Davies
Well, two things come to mind. One, that's kind of you know a benefit to staying in one job for a while, right? People get to know you, they get to see you, they get to see the work that you're doing. And two, they often say like, dress for the job you want, not the job you have. It's like you were kind of doing that, right? You were you were doing the job you wanted, not necessarily the job that you were assigned to at the point, and and you had to prove to people right that that you wanted that, and I think that is something that that we have to do to advocate for occupational therapy sometimes, and we have to be willing sometimes to have that short term pain per se of you know trying to do something while also having a high caseload. And I know it's not easy. I've done that, you know, but it's amazing what can be on the other side of that when when we're you know put the effort energy time because it does take a lot of time to do that extra work and to show people hey we we can support behavior and we can support teachers and yeah
Nicole Pfirman
and that is something I would love to see OTs do more of right is that we advocate for why we have a desire to be in the room, or a desire to have a seat at the table, and I think so many times we limit ourselves by not bringing our skill set and occupation to every conversation. You can tie occupation into every single career, every conversation that happens. You can tie in occupation, and so why are we not doing?
Jayson Davies
Absolutely, absolutely, yeah. But let's just end the podcast here. No, all right. We're going to take a quick break, but when we come back with Nicole, we're going to start to talk about some of the programs and the systems that she's developed over time in her various different roles. Okay, we're going to start to get to this transition where you, you know, became that behavioral supervisor. But before we do, were you already starting to create programs in different you know formats while a quote unquote traditional school based OT?
Nicole Pfirman
Yeah. So a lot of the programmatic work that I was doing as a school based OT was with a team. So it was with an incredibly talented special education teacher that I worked with. It was with a speech therapist. We also had PT and we had school counselors and school psychs. So of course, I was one of the individuals helping create programming. But I think what was my specialty really was multisensory environments and how we could use multisensory environments to change behavior, and that was something that really hadn't been done before. It was like, oh, this child is struggling. We're going to take them to the sensory room, or this child sensory diet, and we're going to maybe do this a few times a day, right? But the idea of creating programming in which preventatively we were using multisensory environments to stimulate the sensory system, so that when we sent kids back into the classroom, that their sensory systems were regulated in a way that they could stay there, participate meaningfully, and not have behavioral concerns that were getting them removed from the classroom. So my time as a clinician really was spent on developing multisensory environments more so than specific programming or treatment modalities.
Jayson Davies
Okay, but when you say creating multisensory environments, what what did that even look like, and how did it kind of get started?
Nicole Pfirman
Yeah, well, it was probably about 2006, I would say. Really, it was pretty early in my career, and I had read a research article on a snoozeling environment. And at the time, snoozeling environments were being used in adult psych or nursing home type settings to help to regulate adults who were in crisis. And the idea of a Susanne environment is to use vibration and vibroacoustic lighting to stimulate the nervous system in a way, in whichever way you want to stimulate it. So there are activities that you do to rev up the nervous system, and there are activities that you do to calm down the nervous system. A lot of proprioception, a lot of vestibular input, and I kept thinking, why is this not being used in a school setting? I mean, it was bright lights, it was colorful activities, it was you know equipment that looked fun, and I thought kids would love this. Like, how come we're not using this in a school setting? And so, at the time, Ohio had a grant at the Ohio Department of Education, that was for preschool, in particular, and so the special education supervisor and I at that time were struggling with a lot of kids who had just they were in general education, but they were being removed from general education consistently. You know, every day at 12 o'clock, this child's being removed from the class because they've escalated in their behavior, and so we wrote a proposal for this grant funding to bring a snoozlein environment to our school building, and we got the grant funding. We spent about 35 or $40,000 that first year creating a state-of-the-art snoozelin' environment. Everything was, you know, snoozling designed, and we used a company up in Canada actually that helped us to design this for a pediatric setting. And for that first year or two, we just took data on general education students' behaviors. So we identified students across grades preschool through second grade who were being removed from class, who were being disruptive, who had trouble with peer relationships or trouble regulating, and we started scheduling them in our snoozle environment in 10 minute increments once or twice a day, and then watching their behavioral change over time, and we saw incredible behavioral change. Things like 60% reduction in classroom disruptions, 40 or 50% of reduction of needing to be removed from the classroom, increased participation and engagement just after being in the environment. And what's so unique in that programming space is it really was about the environment, so that was a no-talking environment. We would take a child in one-on-one. They would move through a rotation of the activities in a very dark space with vibroacoustics that lit up in response to different types of stimulation. So we would use stimulating music, or we would use calming music. Based on which behavior we wanted to come out of that environment, but we as the therapist were really just supervising. We were making sure that the child kind of rotated through these activities, but but we were not actually working with them. You know, we weren't doing hands on. There was no hands on. It was just environment itself that was being used, and that to this day is still being used in that district for kids every single year with the same types of benefits and outcomes, and I think that that was really the the catalyst for me that we were waiting too long to give kids the supports they needed, whether it be for sensory or behavior. And what if we just started giving kids the supports they needed when they needed it, versus waiting until a diagnosis came, until an IEP came, until we had to sit down and write a goal, and that environment really allowed for that. And so that that then was kind of a throughput, and still is in the work I do in meeting kids' needs when they have the needs, and not waiting until there's such a significant impairment that we are working backwards,
Jayson Davies
and even after that, it took the district like another five years to figure out that they should make you a supervisor some kind. No, I'm kidding. You said it still exists there. Is it still the OT supervising, or have they transitioned to the OT training someone else to supervise? Do you know, or even so,
Nicole Pfirman
by the time our like pilot of the room was over, we had transitioned it to paraprofessionals, to teachers, intervention specialists, speech language pathologists, anybody who was working with a student that felt that the student would benefit from that environment. Now it is a scheduled environment, so if you go at 12 o'clock, you go at 12 o'clock every day. Okay, so it is like who's with you at 12 o'clock as a younger child. That's the person that's likely going to take you to the room. Um, it's not the type of room you would take someone to in a reactive state. Um, you get the benefit from that proactively.
Jayson Davies
Yeah, so interesting. Um, thanks for sharing that. That that's really cool. But it it's really awesome to to hear that you were already kind of doing this stuff before you had to take on an administrative position. Like this is something you took initiative on and got started with it. And it sounds like it was a tier one, maybe a tier two type of MTSS thing before MTSS was even a thing. So yeah, that's really cool. And then it sounds like eventually you kind of parlayed this a little bit, you know, this experiences and grant writing and all that fun stuff into the behavior support role. That was the next role, right?
Nicole Pfirman
Right. Yep. So after being a clinician, I moved into a behavior coaching and then a behavior supervisor role. And in that role, really, what I did was respond to kids in crisis, and create behavioral support plans. And if you would read a behavioral support plan of mine, you would say this is an OT plan. So much of it is proactive sensory supports. It's about the time out, time
Jayson Davies
out, time out. Are you are you free? Like august 12, we're gonna have to do a podcast just on behavioral support plans. Like we'll have to do that again sometime. But go ahead and continue. Yeah.
Nicole Pfirman
So, so much of my role there was just a continuation of the OT and sensory work that I was doing programmatically to say when we're responding to kids' behaviors, are we seeing the behavior as a behavior, or are we seeing the behavior as a symptom of something else? And if we're seeing it as a symptom of something else. Our role is to do a root cause analysis. Our role is to figure out what is causing the behavior, and then put in the supports proactively to prevent that behavior from happening. So, really, in my behavior coaching and supervisor role, it was just that. It was designing behavioral support plans that were heavily sensory based and proactive, and then also designing response plans for what it looked like to respond to a student in crisis, what it looked like to remove them from the classroom. How are we consistently following systems so that students have come to an expectation of what we need from them to to regulate and to calm down? And so that was then my work for the next two or three years, was really just putting systems in place to change behavior, but not change the behavior just based on what we were seeing in the classroom. Change the behavior based on the root cause.
Jayson Davies
Yeah, and last time I checked, you don't have a BCBA after the end of your name, right?
Nicole Pfirman
I don't.
Jayson Davies
Just the just the OT and the MED. Awesome. Okay, so a few episodes ago, we actually had a colleague of yours on the show, Brianna Lynch, and she shared that she was on one of your teams and and worked along with you. I believe it was on the prevention and wellness department team that you put together, and so I would love to hear a little bit about that. Was that around the same time during the behavioral time, or was that at a different point?
Nicole Pfirman
That was at that was actually when I was a special ed supervisor for the district. So once I once I moved on from behavior coaching, I moved into special education supervision and oversaw elementary special education for a group of our students. And it actually is kind of funny. So. Brianna Lynch was actually applying for a traditional school-based OT role.
Jayson Davies
Yeah,
Nicole Pfirman
and she was new grad, had only worked a couple of years, I think, and we're sitting in the interview. And I already had this idea of creating this prevention and wellness team, but I wasn't sure that people were going to buy in that, and by people I mean administrators. That they were going to buy in that OTs should be on this team. I think they were thinking it'll be school counselors and it'll be school psychologists and it'll be other support professionals, which of course even
Jayson Davies
after
Nicole Pfirman
even after even after
Jayson Davies
all the work you had done,
Nicole Pfirman
yeah, this is this has continued for the last 20 years, really. But um, she sat at that table for the interview, and she walked out of the interview, and I was like, "Okay, yeah, we are going to hire her as an OT. And then I turned to the other supervisor in the room, and I said, "What if we actually offer her the job of prevention and wellness coordinator? And she looked at me, and we said, "Let's go find her. We like ran out into the parking lot. We were like, "Hey, we know you just interviewed for this OT job, but what would you think about interviewing for the prevention and wellness work, but bringing your OT lens as the core to the position? And Brianna was super excited. So she was the first OT that I hired in prevention and wellness work, and lucky for me, she's also going to be joining me in my new organization as well next year on a on a part time basis to help me bring OT back to the space in other places.
Jayson Davies
Awesome, congratulations! That man loves. It's a small world. It's always fun when you get to work with good people and find good people and and keep them around. That's awesome. I love it. Awesome. All right. So we talked a little bit about your original the the original room that you developed, very much behavior centered. You did become the behavioral behavioral coach, writing support plans, coaching teachers, and then you became an administrator, and you were still focusing on mental well-being, mental health, all that. Were there other programs that we haven't discussed yet that you know, or things that you're just really proud of, and things that you were able to kind of do during that time with the school district?
Nicole Pfirman
Yeah, I think I mean honestly, my biggest passion area or success that I had in school-based practice really was the development of the prevention and wellness team. The idea that when I was a special education supervisor, I was always questioning why we wait until kids are on an IEP to receive services. But at the same time, I was struggling with the fact that mental health really was becoming a concern in schools across the country, and mental health and wellness and behavior were often tied to the special education systems, and to me, that was the completely wrong way to view mental health, wellness, and behavior. Every human has mental health. Every human has behaviors. Every human has a need for wellness. And so, to keep that siloed in special education really meant that our systems were going to be reactive or responsive in nature, versus looking at prevention and wellness in a proactive, foundational way, in which that is what drives outcomes, and so we can't say that we actually care foundationally about student mental health and wellness if we're waiting to address it until there's a problem, and so that's something for me that I am very proud of in the work we did. I worked for an incredible school district with incredible leaders who believed in the work that I was doing, and also had an innovative mindset to say how can we do something different. And I think that that team in in itself was just a continuation of great work that was already being done. All these folks that were in this school district were already doing the work, but how do we systemize it? How do we systematize it? How do we take something that works for one kid and take it to scale so that it works for all kids? And that really was my goal with prevention and wellness work. And I think what I'm grateful for is to see that so many other schools across the region, across the country, have moved in that direction over the last eight years as well, to really say that mental health and wellness should be foundational to what we do in schools every day.
Jayson Davies
Yeah, and let's talk a little bit about that that team a bit more. You had Brianna, an occupational therapist, acting as a coordinator. What other professionals were you, you know, looking to bring on and be part of the team,
Nicole Pfirman
yeah. So the prevent the idea behind the prevention and wellness team really was to make it a multidisciplinary team approach. I feel that kids get the best care when there are multiple disciplines sitting around the table, all with the same common goal and theme to improve outcomes for kids, and so on. That team. My initial team was a school social worker. Brianna was an occupational therapist. A one of the other prevention and wellness coordinators was a intervention specialist who had worked specifically with kids with severe behavioral disorders. We also had a school counselor on the team, and then let me think the last oh and then we had a resource coordinator so somebody that could work with families to just provide the connection to the community which is something that I felt like schools really had a gap in we put a lot of things in place for kids at school or we put a lot of place things in place for kids in the community but who's connecting that to the life outside of school so we used this team to kind of make a three-pronged approach of the student, the environment, and the community.
Jayson Davies
Sounds a little bit like the PEO model, a little bit, right? Okay, so so you had this team. Was this also grant funded?
Nicole Pfirman
No, actually, we when we started this team, it was through reallocation of supports. At that time, our district was willing to invest in the work of student mental health and wellness, which was a huge help. But really, what we did was we reallocated some roles. So we didn't do excessive hiring. I think we only actually hired Brianna. The other roles, we just took roles that were already in place, and then kind of redesigned what they were going to be doing during the day, and and what that looked like from a support model instead of a direct service model. And that is a unique difference too. Is that the prevention and wellness team really was support model versus direct service model. So we were supporting also staff who were directly servicing kids. So how are we working with the school counselors who are seeing the kids? How are we working with the therapists who are doing direct service? Really, from a consultative and collaborative standpoint.
Jayson Davies
Yeah. So I imagine there might have been like a few stages or like a an action plan, right? I'm assuming that some of these team members needed to get some education. I'm assuming they brought some of that education back and shared it. Was there kind of a plan laid out, and is that something that that you can share a little bit, or the ultimate goal?
Nicole Pfirman
No, I don't. You know, I'll be really transparent in that initially the plan was to create a team that could support mental health and wellness outcomes for all students, all students, all staff, all families, and it was a build the plane as you fly it type. That's
Jayson Davies
what happens sometimes because
Nicole Pfirman
all of us were skilled in our individual professions, and all of us, I would consider experts in the work that we were doing. But then to come and sit around the same table and say, okay, but how are we going to change the environment? How are we going to change these huge systems like discipline, attendance, homelessness that have historically really negatively impacted kids for the most part, and how are we going to take our collective expertise and try to change these systems? So when I think about our initial plan, it really centered around behavior and mental health, and and what I mean by that is aligning partnerships, bringing outside partners into the school, providing education, providing training to staff, providing training to parents, connecting families to resources-that really was the initial plan. And then COVID hit, and when COVID hit, the multidisciplinary team went into overdrive, and we really became the connection for a lot of families who were struggling with kids having behavioral crises at home? Kids who were struggling with the routine change, the inability to participate in meaningful activities, and so then we became kind of an extension of a social service model during that period of time during COVID, in which we really were helping families to navigate something that none of us had walked through. Yeah, and everybody
Jayson Davies
was struggling with.
Nicole Pfirman
Yeah, and and I mean, and I think that then became a lot of the goal of the team moving forward was that we wanted a multidisciplinary team that supported the whole child, and it needed to be both in the school environment and in the community as well.
Jayson Davies
Wow, just happened to have this team available when. Yeah,
Nicole Pfirman
honestly, honestly, I think back, and I'm like, it was by fate that we had this team in place before COVID hit. Now, of course, all of our other professionals took a huge lift during that time too. Right, teachers were incredible, counselors were incredible. Psychologists were incredible. We just had this bonus in our district to have an additional team to support families during that time.
Jayson Davies
Yeah, yeah, awesome, love it. All right, well, we're going to take our final break, and when we come back, I want to talk more about your current work with Mindpiece and how you're kind of using that to expand a lot of the work. You've done at the school district to other districts. All right. During the break, I had one more thought that I wanted to ask you. Now, you did have Brianna come on, and she was kind of your pseudo OT, not working as an OT, but as an OT. Were you going to use one of the district OTs before you found Brianna?
Nicole Pfirman
No, honestly, I wasn't. Initially, I thought, well, I'll be the OT representative.
Jayson Davies
Ah, okay.
Nicole Pfirman
So because I wanted a multidisciplinary team, I thought, well, I have the OT lens. But what became clear in choosing Brianna was that as the leader of the team, I was able to remain neutral, and she was able to have the OT voice in most of the conversations, which I think was a healthy balance in leading a brand new team. That that I myself was not the only OT voice.
Jayson Davies
Gotcha. Yeah, I wanted to ask that because I have often, you know, and I have no research behind this or anything, but I often have this feeling like the last people that a special education director is going to reach out to for a team is the OT, because typically the OT is also and the speech therapist are also the people that are screaming from the rooftops. My caseload is too high. I need more support. Like, and it's fair, right? All of our caseloads are high, but that's also going to prevent people from asking us for help when it comes to like programs like this, and so that's why I wanted to ask you. And I don't know if you have any thoughts on that idea. Well, that
Nicole Pfirman
that really does go back to what I always say, which is OT deserves to have a seat at the table or should be advocating for a seat at the table. And when we talk about OT caseloads, yes, they are high. So are a lot of support professionals in a variety of fields. But in some way, I would push that thought to say, are our caseloads so high because we wait too long to get the OT involved? And when we actually think about occupation, and we think about participation, and we think about the real skill set of an OT. I think we could mitigate a lot of high caseloads by accessing, allowing students, families, staff to access the knowledge base of an OT at a much earlier time. And when we do that, I think truthfully, a lot of the skills could be generalized in a way that other professionals could be working on them, and we're not waiting till the moment of crisis where we have to go through an ETR or an IEP and diagnostic criteria, and that that's the piece that I think to me is where having the OT having a seat at the table in early planning conversations is vitally important, but doesn't have a lot.
Jayson Davies
Yeah, yeah, absolutely. And you have a unfair advantage that 95% of OT practitioners don't have that you have sat in a lot of district level meetings, you know, upper management meetings, and I mean, obviously, you're an OT. People, I would assume that you work with know your background is an OT. Some may not understand what the OT behind your name means. But when you sit in these meetings, a is OT even a conversation ever? And B, what are those conversations about?
Nicole Pfirman
Yeah. Well, to me, occupation is always part of the conversation, right? So when I sat in leadership conversations, I wouldn't necessarily always be calling out my lens of an occupational therapist, right? But I would be talking about things like if we're going to talk about attendance, why are kids not coming to school? Where is there a gap in participation? If we're going to talk about discipline, where is the root cause of the discipline concern itself? If we're going to talk about why kids are not achieving the way they should be, is there a lack of relational connection? Is there a loss of meaningful participation? And so, those are the words I would use in leadership conversations that brought the conversation back to OT. Yes, there are lots of conversations I sat in where it might have been unclear that I was an occupational therapist, but if they listened to me long enough, they would hear the common thread of participation, engagement, relational connection, sense of belonging, and when we had those things, outcomes improve. So honestly, I feel like having an OT lens really allows you to move system change at a faster pace than just having had an educational lens, where all I knew was the classroom environment.
Jayson Davies
That is a powerful statement, and yeah, with that, I'm going to leave it. I'm going to let that one sit. But I do want to talk about your newest work. You have now been at Mindpiece for a few years. You are the, I guess. The The executive director to be very very soon. Congratulations on that! And it sounds like you're really this is an you know you're bringing all your past work together now to not just support one district but to support all of Ohio or at least the southwest part of Ohio. Please let share a little bit about how Mindpiece operates and what you know what they're doing and what your goals are.
Nicole Pfirman
Yeah, so MindPiece is a nonprofit in Cincinnati, Ohio. We support about 250 unique schools, 36 school districts, and really the way that I explain at a 30,000 foot level is that we stand as a neutral partner between the educational and medical model, and our role at Mindpiece is to facilitate partnerships, expertise, collaboration to change systems that improve mental health outcomes for kids. That might look like treatment. That might look like bringing treatment providers into a school setting, into the natural environment to allow for more engagement and participation in the treatment plan. When they are in their natural environment, we know they're going to attend more frequently. We know that they are going to participate more willingly. And so, bringing the connection of mental health providers into the school setting in a consistent way is a core foundation of the work we do, but changing mental health outcomes for kids does not stop with just putting a treatment provider in place. It starts the second the child walks into school. It starts on the school at the school bus stop. It starts on the school bus in the cafeteria in the hallways. And so, really, our role at Mindpiece is to see system change. I often say when I it was a hard it was a hard pull to get me to leave the incredible district I was at I often still sometimes think like oh if I could just go back for a day how would I do things a little bit differently but really what MindPiece gave me the opportunity for was to just increase the size of my caseload and the reason I say that is my caseload was initially starting as a clinician. My caseload were individual students. When I was a behavior coach or a supervisor, my caseload was an entire building. When I was the prevention and wellness leader, my caseload was the entire district system. And now, what I've been able to do is have a caseload of the entire region to look at how systems are improving or inhibiting outcomes for kids at a regional level, and if we start to actually do things that are focused on system change versus trying to change the kids or trying to change their diagnosis, I really think we can change outcomes in a much broader way for kids, and I would say that my biggest question I still ask at Mindpiece is, what's preventing participation in school,
Jayson Davies
yeah,
Nicole Pfirman
or in the treatment setting, and oftentimes meaningful occupation.
Jayson Davies
Yeah,
Nicole Pfirman
that is what's preventing participation.
Jayson Davies
That's awesome. So, so have you have you kind of been taking the programs that you had done before you got to MindPiece and trying to implement some of those? Are you creating new programs? I know that you were the director of school-based mental health systems before you, you know, eventually are now the executive director. But in that, you know, the first role that you had with MindPie's was that helping districts implement programs to a degree?
Nicole Pfirman
Yeah. So MindPiece is not a direct service provider, so we are a consultant really in the work. So what my role was is to press on school leadership teams to create systems that were responsive to the needs of their students, and so it looked a lot like talking to school leaders about their current district policies and procedures around discipline, attendance, homelessness, chronic absenteeism, achievement levels, and then connecting that back to the mental health outcomes they were hoping to achieve. And so, looking at do you have programming to address these needs? Do you have partners that can come in and help? Do you have mentoring programs? Are is the community coming in and work helping you work towards these same goals? So it was it was more consultative, and it still is in helping schools to see how all of their systems that are working in silos will actually improve outcomes if you start to integrate them. I think schools, to me, have always figured out a way to integrate the child, but none of the systems are integrated. And so, what if we start looking at actually integrating systems, and then we integrate the child into that? Won't our outcomes be improved? So we we definitely are not a program provider, but I believe that wellness in a school setting is more than the wellness program you have or the wellness curriculum you have. Right? It really is about how all your systems work together to. Towards the same goal for kids, which is that we want healthy contributing adults when they leave the K 12 environment for whatever path they may choose. They need to have an understanding that there's meaning in life, that they have a choice in participation, that there are occupations that bring them joy. One of the biggest things I talk to districts about is what brings your kids to school every day?
Jayson Davies
Yeah,
Nicole Pfirman
you know what? Why are they coming? What's their spark? What's their joy? And if you don't know it, you really need to find it because that's what's going to keep kids engaged.
Jayson Davies
Absolutely. Again, you you have this unfair advantage. You talk to a lot of people in leadership here, and so I'm going to ask you this one: What trends are you seeing right now when it comes to districts and wanting to, not wanting to, not being able to afford whatever mental health services and being able to provide the best mental health services for their students.
Nicole Pfirman
Yeah. So, well, at MindPiece, one of our goals is to have financially sustainable models, independently financially sustainable models, to bring mental health treatment to kids in their school environment, but I would say that some of the biggest barriers continue to be funding insurance, private or public funding. Obviously, we've done a great job. I feel like in this country on decreasing stigma around mental health concerns, but we're not there yet. We still have a lot of stigma in in certain communities. I also still believe that there's a bit of a lack of understanding of how how to change the academic pressure that kids are under and change systems to be more proactive and upstream versus looking at academic outcomes as the goal. So I think those are some of the barriers. I think the other patterns that we are seeing in schools is what I would call an intensity crisis. And I I could have brought this up earlier, but I think that you know if you're talking to school leaders over the last 10 years, you hear constantly, "We're in a mental health crisis. We're in a mental health crisis. That kind of becomes a crutch in a lot of ways. If if everything is because of the mental health crisis, it's really easy to not change systems. I believe we are more in an intensity crisis than we are a mental health crisis, meaning that the intensity of the anxiety, the intensity of the trauma, the intensity of the behaviors is showing up in a different way, and that's what our teachers are feeling. That's what our educators are feeling. That's what we need to be responsive to. We've always had anxiety. We've always had depression. We've always had trauma showing up in our schools. We haven't always had every one of those with high intensity, and so what are we doing differently? What we were doing for anxiety seven years ago when we had mild and moderate anxiety doesn't work anymore. We now have severe to profound anxiety showing up in the classroom, and that includes escalating behaviors, more need for crisis prevention and crisis intervention. And so, how can we not change our systems to be responsive to that, and I think that's that's one of the biggest conversations that I'm having with school leaders, but also that I think about all of the time is that we are in an intensity crisis, and we are not going to move the ball forward if we don't change our systems first, and then look at like programs and partnerships and expectations.
Jayson Davies
So, if we if we kind of put this into an MTSS tier one, tier two, tier three, it sounds like we're saying we're seeing more tier three kind of in a way when it comes to anxiety and other mental health conditions. Well, I'll
Nicole Pfirman
interrupt there and say I I agree, but we're seeing tier three symptoms often in a tier one student, and that's something that we are not quite willing to look into. I think as an educational system, in that because you have tier three behavior doesn't mean you're a tier three student.
Jayson Davies
Yes,
Nicole Pfirman
because you have high anxiety doesn't mean that you're not also overachieving and a tier one student in all other aspects of your life, and so again, when we set these systems, sometimes it's like, well, if you're tier three, you get this support. Well, if you're tier two, you get this support. Well, what if you're a tier one student and you're just in crisis?
Jayson Davies
Yep.
Nicole Pfirman
Where's the support for that student? And so I think that you know it. It is a little bit of a upside down model in which tier three support should be also available for all students.
Jayson Davies
Oh yeah, I completely agree with that, and that's kind of where I was going with the question to to go a little bit further. Was like, do you feel like we have to do more tier one, more tier three, somewhere in the middle, and I would imagine. Obviously, the answer is all of the above, but it sounds like we need better tier one to start with to a degree, and then work maybe up from there. But yeah, wow, wow, that's yeah. I mean,
Nicole Pfirman
I believe, and and I know. Brianna may have alluded to some of this, or I have a lot of conversation around where we belong, right? As an OT, I think we belong in all tiers, right? At the tier one level, we we belong at environmental conversations, policy and procedure type conversations, activities or conversations around engagement and participation; those are all tier one activities, and we should be in the conversation at tier one, not necessarily providing the service. And then, really, when I look at tier two, we also aren't in the space of providing small group intervention in a lot of ways. That is just short term. That's addressing a short-term need. So I would love to see OTs at least be part of the conversation for all tiers of intervention for students. That would be my dream down the road.
Jayson Davies
Yeah, yeah, absolutely. We'll start to wrap up here. For anyone who is located in your general area, Southwest Ohio, and they're an OT, and they're like, "Man, we should really get in contact with you and with Mindpiece, and and make something work potentially, or at least you know connect with one another. Where's the best place for them to potentially start that process or reach out to Mindpiece?
Nicole Pfirman
Yeah, I love to collaborate with anyone from anywhere. I think being a thought partner in this work is so important. The best way to get in touch with us is honestly on our website, which is mindpeacincincinnati. com. You can find my information. You can find other team members' information. You can also find a lot of the resources that we use to consult with schools, but that would be the best way to get in touch with us. And please reach out whether you're an OT, a school leader. We would love to collaborate.
Jayson Davies
Fantastic! I just bookmarked mindpeacincincinnati.com on my browser because you said resources, and that is a that's an easy way to get bookmarked on my computer. So, all right. Well, Nicole, thank you so much. We really appreciate having you here. It's just, I mean, there's so many different things. We will have to have you back on to talk about behavioral support plans eventually. But I just love everything that you've done from from you know on the ground boots, school based OT, developing programs supporting students and kind of moving your way up is just so many things. It's so much good that that I see in the future for occupational therapy, and and you've done it, and you're helping others to do it as well. And so I just love it. Thank you so much for being here. Really appreciate it, and best of luck in your new role as as executive director. Congratulations.
Nicole Pfirman
Thank you so much. I appreciate your enthusiasm and time in this topic because it is definitely something that I am super passionate about. So, hope to connect again soon.
Jayson Davies
Absolutely, take care.
Nicole Pfirman
Thanks. Bye.
Jayson Davies
And that is a wrap on episode 208 of the OT Schoolhouse podcast. A huge thank you to Nicole Pfirman for joining us today and sharing so openly about her journey from school-based clinician to behavior coach to special education supervisor, and now as the executive director at MindPiece. I had never heard about MindPiece until I actually sat down with Nicole and learned about it, and it's just amazing what they are doing there. If you are in Southwest Ohio, please do look them up, find everything you can about them, and see if it's possible to somehow get your district in connection with them. If it will better support your students, your teams, and everyone involved, I've been really, really excited for you to hear about this episode. Not because you're in Southwest Ohio and can get in touch with Nicole, but I knew that this episode could be an inspiration to the many of you who love working one-on-one with kids, but also know the impact that you could have if you could just get into the educational system at an administrative level or at a district level, and even beyond just the students that you serve, but all the teams that you could support, and maybe even make an impact on the OT profession, and just so much more. So I really hope that this episode helped to kind of help you see that path or what it could look like if you decided to go down that path. And if today's conversation really did light up something for you, I want to make sure you know about the OT Schoolhouse Collaborative. The OT Schoolhouse Collaborative is our online community built specifically for school-based OT practitioners, where you'll find professional development, monthly mentorship calls with myself, a whole library of resources to support your practice, and so much more. To learn more about the collaborative, head on over to otschoolhouse.com/collab, and I hope to see you there. As Nicole reminded us today, OTs belong at every single table, especially in the educational world. Let's make sure that we're showing up. Let's make sure that we're advocating to be a part of those tables, to be a part of those tough conversations. I'll catch you next time on the OT School OTs podcast.
Amazing Narrator
Thank you for listening. To the OT Schoolhouse podcast. For more ways to help you and your students succeed right now, head on over to otschoolhouse.com. Until next time, class is dismissed.
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