Moving Beyond Pull-Out Therapy Through True Classroom Collaboration

We ask where school-based SLPs truly belong and why that answer reshapes goals, service delivery, and impact in the classroom. I trace how the medical model became the default, then map a practical route toward collaborative, curriculum-connected support that fits inclusive education. 

• a mailbox story that reveals role confusion and broken systems 
• how the medical model shaped pull-out therapy in schools 
• why legislation changed placement faster than practice 
• the “forest versus tree” lens for ecological validity 
• the three stages from pull-out to collaborative intervention 
• expert consultant versus collaborative consultant mindsets 
• structural, cultural, and psychological reasons change is slow 
• deploying SLP expertise differently without losing it 

If this episode resonated with you, I'd love to hear about it. Share your experiments, your questions, your aha moments, because your experience matters and maybe exactly what another SLP needs to hear. 

https://sarahdowlingschoolslpcoaching.com

Music: Daniel Chui

Transcript

Welcome And The Big Question

Sarah 0:02

Welcome back to the Aligned SLP. I'm Sarah Dowling. If you're new here, this is where school-based SLPs stop being clinical islands and start being collaborative partners. We're ditching the impossible caseload, embracing the workload approach, and reclaiming our joy as professionals aligned with the education world. Welcome back. Today I want to talk about something that I think sits at the heart of what we do as school-based SLPs. And honestly, something that has been sitting there quietly unresolved for a very long time. So, where and how do we actually belong in a school? Are we clinicians who happen to work in a building with children and teachers? Or are we educators with specialist skills who understand that language is the very foundation of learning? Because the answer to that question shapes everything. It shapes where we see our students, how we write our goals, how we talk to teachers, how we think about success, and ultimately how much good we actually do. And here's the thing that gets me every time I go back to the literature on this. We've known the answer for decades. The research, the frameworks, the calls for change. They go back to the 1970s, the 1980s, and the 1990s. We're not waiting for evidence. We have always had the evidence. What we've been slower to do is to change the culture. So let's get into it.

Clinician Or Educator In Schools

Sarah 1:45

One morning I passed my mailbox and saw a pile of about 35 blue pre-referral forms. They were all from two kindergarten classes. I was shocked. It seemed audacious and also reflected the unclear expectations of my role. I took the pile directly to the principal and said that if there were that many referrals from two kindergarten classes, then that is a school issue, not just an SLP issue. I told him that I was happy to help the school, but I wasn't accepting 35 pre-referral forms and all the work that entailed. I shared that I wanted to support the school staff to support the students. This was 2003, and I'd recently arrived in Canada. So I'm sure that story is familiar to you all. To understand where we are, we need to understand where we started, because the medical model didn't arrive from nowhere. I'm mainly drawing on four books: Merrit and Cullata from 1998, Wallach from 2008, Ukrainitz from 2015, and Schrader and Seidell from 2026. You will have heard of Alexander Graham Bell. He invented the telephone. His grandfather was fascinated by elocution and speech and was an early phonetician and speech therapist in Scotland and London in the 1800s. Alexander Graham Bell continued his grandfather's scientific work, eventually establishing an oralist school for the deaf in Boston in the 1870s. Around this time, most Western countries were establishing public schools. Now, for a few years of their life, most children were attending a local school, and speech difficulties were becoming more apparent. Speech correction services in the US first appeared in public schools in the early 1900s, with programs developing across Wisconsin,

The Day 35 Referrals Arrived

Sarah 3:45

New York, Illinois, Ohio, and Michigan from around 1910 onwards. The people who shaped the profession were primarily physicians. Doctors were the advocates who defined what communication disorders were, what they looked like, and how you should respond to them. But here's what that medical foundation meant in practice. The professional, the speech correctionist, as they were then known in the US, focused on the problem and on curing or diminishing its symptoms. The student was taken out of the class, seen individually or in small groups, in a separate room. The goals were written by the speech correctionist, the materials were chosen by them, the criteria for success were set by them, and none of it had any meaningful connection to what was happening back in the classroom. That pullout model, rooted in a medical orientation, became the default, and by the 1940s and 1950s, services were still almost entirely focused on speech, fluency, and voice, with sessions conducted in isolation. The speech room was, in every sense, a clinic that happened to be inside a school. This wasn't malicious, it made sense in context. The early pioneers genuinely wanted to help children, but the framing, the idea that you diagnose, you treat, and you cure was borrowed wholesale from medicine. And medicine, for all its strengths, was not designed around the idea that a child needs to go back and function in a noisy classroom, navigate a social studies textbook, and participate in a cooperative group discussion. Now I do recall learning about the history of pragmatics and how in the 1930s this was a focus of some work in schools and speech therapists. But other language aspects became prominent before the resurgence in the 1980s and the 1990s. I would need to check the histories in other countries for cultural and societal differences, but this story probably has some resonance across the planet. What changed? Slowly, and in the US largely thanks to the

How The Medical Model Took Hold

Sarah 6:05

civil rights legislation, was the broader understanding of where children with disabilities belong. The US landmark court cases of the early 1970s established that exclusion from education on the basis of disability was not legal. Similar movements occurred in the UK, with children previously housed in hospitals gaining access to the public education system. I personally recall students with disabilities in my infant and junior schools in the 1960s. In fact, I also recall myself and my peers supporting those students. In 1975, a US law mandated a free and appropriate public education in the least restrictive environment for all students with disabilities. So the idea that you could pull a child into a separate room, run isolated sessions that had nothing to do with their curriculum, and call that an adequate educational service was legally and philosophically challenged. But here's the irony: the setting changed faster than the mindset. We were still working in schools, but we didn't move into the school system. We often remained a pullout service. So to put it plainly, working with a school building is not the same as becoming an educational professional. Wallach has some really useful ways of thinking about this. One is the idea of looking at intervention through the lens of a forest versus a tree. When we work in the traditional medical model, we zoom in, we find a problem, a student can't sequence narrative events, or their syntax is below age level, or they're struggling with cause and effect reasoning, and we get to work on that specific thing in a specific room with specific clinical materials. We're focused on the tree. She says that while it may be appropriate to focus on one component or one aspect of language at certain points in time, it helps to keep our eyes focused on the forest, stepping back to assess the way our day-to-day clinical and educational choices relate to where we really want to go with the child and the adolescent in our care. We need to keep our eyes focused on the big picture, to think about language intervention as being authentic and real world relevant for our students. She uses this and other metaphors to point out that traditional interpretations of speech, language and communication disorders fail to capture the dynamic and complex nature of language. But what is the forest? The forest is the curriculum, the classroom language environment, and the communicative demands of school. And if our intervention is entirely disconnected from that forest, we might be making small measurable gains on a clinical measure while the student is still getting lost every single day. And if we treat only the tree, if we design our intervention around the symptom rather than the system, we miss the deeper need. We might even be working on things that have very little ecological validity. Tasks that look like language, but are actually exercises that exist nowhere in the student's real school experience. Wallach wanted clinicians to question not just the theoretical principles they operate from, but whether those principles actually connect to the real world their students must navigate. So back to the historical perspective. In the US, through the 1980s and into the 1990s, research and legislation were pushing in a clear direction. The medical model, the idea of curing students of their disability, was being replaced by more complex models. The new model said educators must work as a team to build on the strengths of the individual student, to modify the teaching and the environment, not just the child. I personally used the term social educational model for a while to make the point of why I wasn't using the medical model. The focus moved, in theory, from fixing the student to supporting the student within the educational environment. We have moved even further now in 2026, taking into consideration the student's perspective and possible life goals through advocacy from the disability and other communities. They don't want to be fixed but supported, want to be included in the planning that is happening to support them. This has led to the neurodiversity movement using a social justice lens and a fuller view of inclusion in our schools. We now have universal design for learning. How does a fix-it model work within a social justice and universal design for learning approach? It doesn't, or if it does, its use occurs following a team decision about the many strategies and supports for that student with that student. But I am confident that you will lose the desire for a fix-it model once you truly understand how to work as a true educational professional. So let's talk about what a genuinely educational, genuinely collaborative model actually looks like in practice. Because I think it's easy to say the word collaboration and picture something much less transformative than what the research describes. Merritt and Cullata in 1998 laid out a really clear framework for this in their work on collaborative partnerships. They described three stages that teacher SLP teams need to move through, and I think it's worth sharing them because they're honest about where most of us still are. These ideas had a huge impact on me. I bought the book at a conference in 1998 and I can honestly say it changed my work life. There were two books available: a thin book and a fat book. The bookstore person was trying to sell me the thin book, but I chose the fat book and it became my go-to resource for my school-based SLP journey. It basically blew my mind. The first stage in Meritt and Cullata is the traditional intervention stage. This is your classic pull-out model. The assessment uses normative clinical tools focused on identifying deficits. Goals are about building developmentally appropriate skills that are specific to the disorder. The materials are clinical, different from anything the classroom uses. The location is a separate setting. And the contact between the SLP and the teacher is limited. This can be where many school-based SLPs

Seeing The Forest Not Just Trees

Sarah 13:20

still spend a significant amount of their time. The second stage is a transition stage. Here things start to shift. The SLP begins to move into the classroom, sometimes still pulling out, but also pulling in. Intervention becomes task-oriented, relevant to the specific classroom context. The goals start to reflect curriculum demands. The materials start to reflect classroom adaptations. Importantly, the relationship between the SLP and the teacher starts to develop. There's increasing communication, growing cooperation, a beginning of shared purpose. The SLP is getting to know the classroom, the teacher's style, the daily routines, the language demands. The third stage, the one we're actually aiming for, is the collaborative intervention stage. Here, the SLP and the teacher function as a genuine team. Assessment is curriculum-based. Goals are authentic, functional, and connected to classroom expectations. Intervention is delivered primarily in the general education classroom, using shared instruction and curriculum materials. The SLP is working with the full range of students, not just the identified caseload. They're proactively supporting at-risk students, establishing peer models, and contributing to the classroom language environment for everyone. This is what the least restrictive environment was always meant to look like in practice. Not just a location, but a philosophy. Anyone who has attended one of my workshops will recognise the ghost of this progression in my rubrics. And critically, this is something that cannot be overstated. The success of this model depends entirely on collaborative problem solving. Not the SLP arriving with a plan and presenting it to the teacher. Not consultation as expert advice delivery, but a genuine structured process of mutual problem identification, joint brainstorming, shared implementation and collaborative evaluation. Ukrainetz from her chapter on SLPs in schools describes the distinction between an expert consultant and a collaborative consultant. An expert consultant arrives, presents their findings, hands over recommendations, and leaves. A collaborative consultant arrives in the spirit of being there first to listen. The teacher is the client who knows the student, knows the classroom, knows what is and isn't workable. The SLP has specialist knowledge about language, but the teacher has ecological knowledge that no standardized assessment can capture, and neither set of knowledge is sufficient on its own. When this model works, it activates what Merritt and Cullata call the collective expertise of teachers and SLPs. The teacher starts to incorporate language facilitation strategies naturally throughout the day. The SLP starts to design goals that genuinely shift academic performance, and the student, crucially, begins to experience support that is woven into their actual learning environment, not something they have to commute to

Three Stages Of Real Collaboration

Sarah 16:55

and then leave behind. All of this is so well established, and it really is. This literature goes back decades. So why are so many school-based SLPs still spending the majority of their time in a pull-out model? Or if they aren't, why are they feeling that they have to justify this more embedded approach to others? That they feel like they are not a proper SLP? Why is it that we haven't fully accepted that the gold standard for speech language pathology services in schools is a truly collaborative approach with our teacher colleagues? Why do we have to defend being an educational professional? There is a real thirst out there for change. SLPs know that the old ways are not working in our modern world. So why has change been so slow? It seems that some of the reasons are structural, cultural, and psychological, and we should make them explicit rather than pretend they don't exist, so that we can check our own thinking and practices against these historical ways of being. So structurally, caseloads can be enormous. ASHA data has consistently shown median US caseloads hovering around 50 students, with many SLPs serving multiple schools. We have a similar situation in Canada, complicated by our large geography and fly-in communities. When you're juggling that many students across multiple buildings, finding planning time with individual classroom teachers for every student on your caseload feels impossible. The pull-out model feels more logistically manageable in the short term. Its familiarity is what maintains its use. So culturally, the pull-out model is what most SLPs were trained in and what most teachers have come to expect. SLPs have their rooms if they're lucky. Teachers have theirs. The lines feel clean and comfortable. Collaboration, as Merritt and Cullata note, is genuinely challenging. It requires people to relinquish control, accept ambiguity, share decision making, and face the discomfort of changing how they've always done things. Some teachers will push back, some SLPs aren't even sure that they want to give up the autonomy of the therapy room. And psychologically, the traditional model gives the SLP a clear professional identity. I am the expert, I diagnose, I treat, I measure change. Moving into a collaborative role, one where you're supporting the teacher to deliver the intervention within the curriculum, one where your contribution is harder to isolate and measure, can feel like losing ground professionally. In Canada, we are experiencing truth and reconciliation with our First Nation

Why Change Feels So Hard

Sarah 19:50

Metis and Inuit peoples. The traditional model needs to be challenged as we move forward in this journey. In conclusion, the school team needs the SLP for what the SLP uniquely brings. Specialist knowledge of language, literacy, and communication that no other team member has. Collaborative service delivery doesn't mean abandoning that expertise. It means deploying it differently. I'm going to say that again. It means deploying your expertise differently. I described my initial learning about how to do this in my first episode when I told you about my experience in a specialist school. I want you to learn how to do this too. I want you to not have to justify being a true educationally embedded SLP, that you are confident that what you are doing is a journey worth spending your career on. We didn't arrive at the medical model by accident. It was the only model available when our profession was being built, and the clinicians who built it were doing their best with what they had. We owe them a great deal. But we've had decades of research, legislation, advocacy, social justice, and honest clinical reflection pointing us in a different direction. We know that language is embedded in context. We know that what happens in the therapy room doesn't automatically transfer to the classroom. We know that teachers are not barriers to good SLP practice, they are our most essential partners. We know that children with speech, language and communication needs require support that is woven into the fabric of their school day, not tucked away in a separate room with a different set of materials and a different set of expectations. If we are not working collaboratively with teachers, then we have missed the whole point of the education system. We know all of this. We've known it for a very long time. That's it for today. Thanks for listening. Thank you for spending time with me today. Here's what I want you to take

Takeaways And An Invitation

Sarah 22:05

away. You're not failing. The system is asking you to do the impossible, and you're doing the best with what you have. But there is a different way. And remember, you're not alone in this. We're building something new together. One conversation, one collaboration, and one small change at a time. If this episode resonated with you, I'd love to hear about it. Share your experiments, your questions, your ha ha moments, because your experience matters and maybe exactly what another SLP needs to hear. Until next time, stay curious and be kind to yourself. I'm Sarah Dowling, and this has been the Aligned SLP.