Providing Mental Health Care in Schools with Dr William Dikel - Part One

Embark on an enlightening exploration of the complex world of children's mental health with us, as we sit down with child psychiatrist, Dr. William Dikel.  As a vanguard in child psychiatry, Dr. Dikel offers a wealth of knowledge on how our societal systems can better support youth facing mental health challenges. Our conversation delves into the heart of the matter, dissecting the successes and trials faced by school districts in their pioneering efforts to integrate mental health services into educational settings. This episode serves as a beacon of hope and guidance for mental health professionals and educators navigating the challenges of mental health advocacy in schools.

 Dr. Dikel's expertise shines as we examine the co-location of mental health services within schools, a model that has the potential to revolutionize early intervention for children in need. This episode peels back the layers of complexity in mental health care, revealing the intricate dance between legal concerns, financial implications, and the unwavering commitment to the well-being of students.

Dr. Dikel introduces the concept of the clinical behavioral spectrum as a vital tool in distinguishing between behavior that can be managed and conditions requiring medical intervention. We grapple with the stark realities faced by children within the juvenile justice system and underscore the pressing need for advocacy groups to merge special education with mental health services. Dr. Dikel's passion and insights resonate throughout our dialogue.  Join us for a powerful episode that promises to reshape the way we perceive and address mental health in our children's lives.

Transcript

Joe Boyle: 0:05

Welcome to Stories in Life. You're on the radio with Mark and Joe. We share stories that affirm your belief in the goodwill, courage, determination, commitment and vision of everyday people.

Mark Wolak: 0:20

Our goal is that through another person's story you may find connection. No matter your place in life. The stories we select will be inspiring and maybe help you laugh, cry, think or change your mind about something important in your life.

Dr. William Dikel: 1:01

When you look at the big picture, you say that about 18% of children and adolescents have some mental health disorder or evidence of that's a lot of kids, right. And when you look at the mental health issues, some of them are biological. They could be related to trauma. They could be related to genetic issues, medical problems. They're all over the map and they can look like one thing, but it would really be something else.

Mark Wolak: 1:48

Will Dikel and I met about 30 years ago, when we were working together to solve some dilemmas of children's mental health in the education circles. He brings some challenging viewpoints about how the systems that we have created are potentially not working to address the very needs that we are trying to address in juvenile justice, in children's mental health services and in education. I believe we all will be challenged by the information that he shares in this episode and in the following episode that we've created. To begin, everyone has mental health and occasional mental health challenges. Wellness matters. Social and emotional well-being is just like physical health, is just like physical health. Physical health helps us deal with stress. Physical health helps us deal with social and emotional well-being. We need to relieve stress by sleep, by exercise, by being with family and being with friends. Mental wellness means you can manage the challenges of life.

Mark Wolak: 3:11

Mental illness is a diagnosis conducted by a professional. Mental illness leads to high levels of distress In children. Most children are dealing with anxiety, depression and behavioral problems, typically in schools and in communities. We can live with mental illness if we reduce the stigma about it. We need to be open to accept mental illness as part of our families, our schools and our communities. On a personal note, I grew up with one of my parents struggling with mental illness for her entire life. We adjusted, we accommodated. We did carry some burdens from this, but the challenge for all of us is to educate each other and learn more about what we can do to address children's mental health needs. Accept mental health and mental illness as part of our culture, support children and support adults as they navigate these issues of mental health and mental illness. Dr Will Dikel is an author, a sculptor, an artist, a drummer a very talented resource for all of us. I think you're going to really enjoy this episode. Thanks for listening.

Joe Boyle: 4:37

How long have you been doing child forensic psychiatry?

Dr. William Dikel: 4:46

Well, forensic is one of the types of psychiatry, meaning that sometimes the case goes to the legal system, in which case I might be an expert witness either for the plaintiff or the dependent, either for the school district, for example, or the family, and I've been doing that for probably 25, 30 years. But most of what I do is consult at this time and helping systems work with kids with mental health problems. That's where my real uh love is, because people want to do stuff, but it's so overwhelming to even try to understand what needs to be done that I try to break it down in a simple manner. Maybe we could talk about the book that I wrote, because it's really written for people who are in the field of mental health, but also education.

Joe Boyle: 5:37

So let's start at the beginning. How'd you get started in the first place? Where are you from? Where did you go to school? That sort of thing.

Dr. William Dikel: 5:47

I'm from Minnesota. Okay, lots of Minnesotans want to escape Minnesota, but then they come back later on when they appreciate how great it is. Yeah, that is the trend. I went to St Louis Park High School. I went to college in Berkeley, California. Okay, I actually made my way back to Minnesota again, went to the University of Minnesota Medical School and I really like psychiatry, partly because there's so much to learn about it and you don't ever get bored.

Mark Wolak: 6:16

One of the things that you mentioned earlier was our meeting point and you know I've had 20 years plus experience working in special education programs and one you know I've had 20 years plus experience working in special education programs and one of the and a long professional history of observing what's happening in special education with kids with these, you know, challenging mental health issues. So when we met, one of the big insights I got from you was how poorly we manage the treatment of a medical diagnosis in the education programming for kids. And I don't know if you remember this, but we studied the individual education plans of 65 students who were placed out of the school district and, through your help and diagnosis of and review of those plans, we realized that only one or two of those kids were really getting the treatment that was recommended, both from the medical professional, but also from the individual education plan team, which you know was a huge systems insight for us.

Mark Wolak: 7:24

We changed a lot of programming based on that, changed the way we referred students for assistance and so forth.

Joe Boyle: 7:33

And this was 30 years ago, 30 years ago.

Mark Wolak: 7:36

And what I think about you know. Since then, have you seen any trends, anything that gives you a sense that we're doing better than that in the work with children?

Dr. William Dikel: 7:50

I think there's been a paradigm shift because when we started out I couldn't use the words mental health and education in the same sentence. There were a lot of very hardened people to mental health. They say that's an education issue, for educators to do education only. They shouldn't be doing mental health and the mental health people should do mental health, et cetera. And we got a lot of that at the time. What was interesting is that the kids who were in special education in your district for the emotional and behavioral disorder EBD category had a very significant amount of mental health problems and by looking at that question we found that by bringing them back to the district schools out of these level five, setting four programs, we saved $800,000 a year in the Minnetonka School District and the kids' mental health problems got treatment. Finally, I'd like to say we've solved most of the problems, but we still have a lot of the problems. But at least people are aware that you can understand mental health from an educational point of view.

Dr. William Dikel: 9:16

I tell schools to stay out of the mental health business. What I mean by that is I don't think schools should be the place where you get diagnosed and treated by school professionals, where you get diagnosed and treated by school professionals. There are professionals who work in schools who could hang up a shingle and do treatment of mental health problems, such as a school social worker, but I strongly recommend against that being done. I think the school should stick to school business and medical and mental health stick to medical and mental health business. But what's different with mental health is to medical and mental health business. But what's different with mental health is if you have a health condition, say asthma or something like that, you will, or diabetes, say you'll have a health plan for a kid with that. But if you have a kid with depression, anxiety, there's no mental health plan in most school districts.

Dr. William Dikel: 10:05

So what I try to do is help school districts create a mental health plan that doesn't say they do mental health, but that they work with mental health people, just like they would work with a doctor if a kid had a problem with medical problems. So it's a collaboration, which is what I really strongly recommend is done, and that can be done in a lot of ways. I've done a lot of consultation around the country and I can tell you that people want to do it right, but they need to understand what needs to be done in order to do it right, because a lot of money goes into stuff called mental health, but it doesn't really do much except people make people feel good, without really showing any positive outcomes yeah, I, I completely see that and the need for that separateness of the medical care, the medical treatment plan and the educational plan, do you?

Mark Wolak: 11:05

you see, you know, one of the things that I think was emerging when I was working with you in the Minnetonka school system was this idea of co-location of services, where a local children's, a local mental health agency, could collaborate with a school district and bring services into the school and offer those professional services. Do you see that as a trend in the public school system in the United States today, or any inkling of what that looks like?

Dr. William Dikel: 11:36

The spectrum of services and the spectrum of different ways of looking at who should do what is really all over the map. But I can tell you that if you are a school district and let's say you're the superintendent and you decide you want to do mental health and people convince you to just hire mental health people and supervise therapists and have them do mental health treatment in the schools, you're going to have a rude awakening when you find out number one, that you really can't get malpractice insurance for the district if something terrible happened. Number two, you don't really have privacy. So in the US law, when you look at who's responsible for what US law, when you look at who's responsible for what, privacy is not really something that is maintained in educational records. So, in other words, if a school social worker is doing treatment of a kid and then they have an issue related to, they tell the parents, for example, if the kid says something that's very confidential, well, in fact, educational records would have all of that. You want to have a wall built.

Dr. William Dikel: 12:55

But the number one problem that I've seen is that schools are the payer of last resort for mental health treatment in some cases. What that means is in 1975, there was a 94142 was the number assigned to special education. And when mental health came into the picture, people said well, if they need to go down the hall and talk to some counselor, let's do that. And so suddenly you had the school paying for mental health treatment for a kid going to residential treatment at the cost of $500,000. And school districts got very nervous so they said we really shouldn't identify mental health problems.

Dr. William Dikel: 13:44

The payer of last resort issue, in my opinion, is one of the most problematic issues which people don't understand that if you have payer of last resort issues in a situation where somebody needs treatment, the schools are the only place that you can.

Dr. William Dikel: 14:03

You don't have an opportunity or ability to get the kid out of your system because everybody needs an educational system. It's an underfunded system and, as a result, mental health services often go to the most severe individuals. Problem with that being that, what about early intervention and prevention? So, long story short, there are many ways to do it, but because of malpractice issues, data privacy issues, payer last resort issues, in my opinion it's much better to hire someone who comes in, because if you have a clinic, come in co-located in the school. What you is a situation where the school is leasing a room, for example, for a dollar a year or some small amount from the school, but the clinic that is in the school are responsible for malpractice, responsible for billing, responsible for data privacy, and that creates a situation where it's just like the clinic was right next door to the school. Now you can do other things as well, but that's the main concept and I still strongly recommend that concept.

Joe Boyle: 15:19

Yeah, Is that playing out in school districts as we speak?

Dr. William Dikel: 15:26

All around the country. Yes, and how they do it is a challenge, because there are people you really have to define where the line in the sand is as to who's doing what, because you bring in a social worker to do therapy, you contract with the clinic and then suddenly your school social worker says what's going on? Am I going to lose my job now that we have other social workers here? And so they can get very upset and nervous for good reason, and I think those things have not been worked out most of the time.

Dr. William Dikel: 16:05

I've written numerous articles around school mental health issues, including legal issues related to school mental health, and I think it would be useful to your listeners to be aware that there is a lot out there in terms of school mental health. I also wrote a book called the Teacher's Guide to School Mental Health, and the negative feedback that I got was one piece of feedback, which was why did you call it the teacher's guide? You should call it the guide for teachers, educators, social workers, administrators, parents, you name it, and I came out with another edition of the book just like that, but more broadly expanded, so that anybody working with kids with mental health could learn about how to work with the kids and be successful.

Mark Wolak: 16:52

Thank you Will, and we do. We will reference your book a couple times in our podcast. So the name of the book, though, is Student Mental Health, and then it's a guide for all those people that you just mentioned, and it makes a lot of sense to me because, having been an educator, so many people are involved when a child has issues of mental health and they're presented in the school setting. So I like that you did that, and I also think that what you're talking about is the complex delivery of services from different systems, and you know it isn't just the school's responsibility, but how does the school work with other agencies, other community providers, in order to do the right thing?

Dr. William Dikel: 17:42

So let me give you an example. If you go to a school district in a place that has collaboratives, where supposedly the social service agency, the education agency, the corrections agency, the different people who work with kids with mental health problems, all get together and they collaborate. And what do they do? If they do it right, they'll look at their data and what the data is. If I turn to the um, if I'm at a meeting with all these different systems and I say to the um special ed director for the district that is there, I say what percentage of kids in your district are ebd emotional behavioral disorder and it's about two percent as a typical. But if I turn to the head of juvenile probation and I asked that person what percentage of kids in juvenile probation have mental health problems, they say it's very high and I said, well, what percentage of them are in EBD? They'll say, oh, 50, 60, 70%. Well, if you know, it's 2% of the general population and over 50% in the juvenile corrections.

Dr. William Dikel: 18:57

You can connect the dots. What you find is that you need to understand how to really collaborate because they're the highest priority kids If you want to prevent crime. Look at the kids who are committing crime and what are their issues, and their issues are often tension, problems, impulsivity, poor judgment, etc. And these kids are in all these different systems but the systems don't always collaborate. There's a saying that collaboration is an unnatural act committed by non-consenting adults. Collaboration is an unnatural act committed by non-consenting adults, and I think if you've ever tried to collaborate with a different system, you know what I mean.

Mark Wolak: 19:35

Yeah, Well, that's the kind of wisdom that we're hoping to capture with you today because of your long history of experience in this whole arena. So when people use your book as a guide or a resource, will they find some things that in that reading that would help them navigate some of these pathways that you're talking about?

Dr. William Dikel: 20:11

That's why I wrote the book, because I thought I can do one case at a time. But if I can reach more people and they can understand that a behavioral model is useful for behavioral issues. What I mean by that is, most interventions in school, especially for kids with serious mental health issues, are behavioral. There's this behavior, we have to deal with this way, etc. And so you get a functional behavioral assessment. And the thing that drives me nuts about that is that the concept is what is the function of this person's behavior? Right, very behavioral concept is that if you have diabetes and your blood sugar is low, you might be very irritable and you might do something bad. But what is the function of your behavior? There is no function of your behavior. You have a medical problem that makes you anxious and agitated and acting out. Your problem is that your blood sugar is off. But try to find a factual behavioral assessment that comes to that conclusion in the education setting. In education, the behavioral model does work for individuals whose problems are due to behavioral influences and it doesn't work for individuals who, for example, are hallucinating or manic or agitated because of medical issues, and because of that I came up with the concept with Jan Ostrom, who's a behavioral analyst.

Dr. William Dikel: 21:44

It's the clinical spectrum, clinical behavioral spectrum, where on one end you have an image of an individual who cannot help. What they're doing, they're hearing voices, they're acting out of control, they need medication, they need treatment. All the behavioral issues in the world are not going to be improved because there is no function to the behavior. On the other end of the spectrum is someone who's very behaviorally oriented in terms of their problems. They people who do things that they know are wrong. They do it on purpose. There's no medication for it. They don't need therapy, they need a narrow path with high walls on either side. And you find that for this behavioral end of the spectrum it's not really a therapy issue, it's. It's the people need their behavior treated accordingly to the issues involved with the behavioral behaviorism.

Dr. William Dikel: 22:46

So what I mean by that is, if you have a kid who is a delinquent and they're out of control, with physical violence, and they're doing it on purpose and there's no mental health issue, you need to be able to address it that way. Well, what you find in the real world is that you hardly ever see a kid who is purely behavioral or purely clinical. When people say at team meetings in schools. Well, I don't understand. Uh, is he doing this on purpose or you can't help it? Right where people will say um, you know, those mental hospitals are filled with delinquent kids and the juvenile corrections are filled with mentally ill kids. And if we could only figure out whether the kid was in the mental health or the corrections, then we'd know where to send them and everything would be fine.

Dr. William Dikel: 23:41

Well, the truth is, if you look at the concept, what you'll find is that spectrum on one end is, let's say, behavioral and the other end is clinical. But in between those two are little gradations. What that means is, if I have one notch in from the purely behavioral, we'll see a kid who does have a mental health problem, but they are mostly behavioral. Now what does that mean? Well, if you have a kid like that, I would call it predominantly behavioral and the concept to think about is if you give him Ritalin for his ADHD, he'll be able to plan his crimes better. In other words, he's leaning towards the antisocial, but he does have a mental health problem. But that's not the real issue. I think we all know people like that. On the other end of the spectrum, if you go one notch in from the clinical, where the person does have some behavioral component, but they're not purely clinical. That would be somebody like an oppositional kid who, when they get to be a teenager, get bipolar disorder.

Dr. William Dikel: 24:56

Okay, so now the predominant issue is mental health. It's not behavioral, and you need to treat it accordingly. And finally you have the real challenging ones, who are both mental health and behavioral. And what's interesting about that is you can diagnose this educational system at a team meeting by just saying let me present this concept. It's the clinical behavioral spectrum. You go through it like I just did in five minutes and then you say to the team where do we think Johnny fits on this spectrum? And if the school social worker says, well, I think he comes from a troubled family, I think he's very clinical, we need to do therapy with him, and the teacher says I think he's doing it on purpose and I don't think that there's any reason to do any kind of mental health stuff.

Dr. William Dikel: 25:50

You're diagnosing your system because your system if you have a kid in various systems and each one sees the kid differently, it's going to give a message that's not helpful. It's going to lead to lots of problems. So if you use the clinical behavioral spectrum, which is chapter two in the book. If you use the clinical behavioral spectrum, which is Chapter 2 in the book, you find that people will say, well, I guess he's counting both. Actually, the parent will be in an IEP meeting, for example, and someone will say, well, what do you think? And the parent says, well, he's got ADHD and so we can't hold him accountable for anything. And you say, really, that's something that we need to look at, because most people are responsible and it's very rare to be completely in charge of your feelings and thoughts and behaviors if there are other issues involved. So it's a way to expand the way the concept works and I think that people find that it's very helpful when you're not rigid with the concept of either or.

Mark Wolak: 26:57

It really is both and yeah, that makes a lot of sense. It requires the capacity for some complex thinking and some complex dialogue. Contradiction between the behavioral model and the clinical model. That that contradiction, therein lies the innovation. You know from our earlier work with Daryl Mann and he's included in our podcast series. You know, rather than making trade-offs and saying we're not capable as a school to be learning from a clinical methodology or a clinical school of thought, the innovation is to do more of that, not less of it. So I'm intrigued with that and you know, I do think it's great to have people seek your knowledge through the book that you've written, because this is not something you're going to pick up in a teacher workshop, for example, in a school district. This is information that is really. It's more complex and it's more complicated than people maybe want to see or or believe.

Joe Boyle: 28:24

Yeah, what it made me think about was how often do you hear someone say something like oh, back when we went to school, we didn't have all this stuff going on. Everybody, just you know, fell in line. Yeah, we had our bad apples, but all the problems were still there.

Mark Wolak: 28:41

Right.

Joe Boyle: 28:42

They just weren't identified back then exactly is that accurate?

Dr. William Dikel: 28:47

well, when you look at the big picture, you say that about 18 percent of children and adolescents have some mental health disorder or evidence of that's a lot of kids, right. And when you look at the mental health issues, some of them are biological. They could be related to trauma. They could be related to genetic issues, medical problems. They're all over the map and they can look like one thing, but it would really be something else. So the question is where do you even start? And do you want to make it simpler? How are you going to do that? And I think, first of all, you have to take away some of the fear that if you identify a problem, you'll have to pay for it. And Minnetonka was very successful in turning that around and saying if you don't identify a problem, that's going to cost you $800,000 more a year than if you do. So what we found is you can be paranoid about having to pay, and I've written strong opinions about getting rid of payer last resort. If you look at special education rules, they haven't really changed in what 30 years in terms of children's mental health. They're not keeping up at all in the education field with what's going on in the mental health field. Now, on the other hand, mental health people often don't understand the education system either, and so they will be pushing for something that's not likely to happen. They'll go to a team meeting, and if they don't know what the law is, they don't know how they can be successful in addressing mental health issues. Minnesota we're very lucky to have PACER P-A-C-E-R, which is an advocacy group for children with mental health educational issues, and I think more and more people are recognizing that the special education and mental health systems are very parallel to each other, and I think there are ways to solve these problems. I consulted in the state of Hawaii around their mental health plan, because they were trying to provide actual clinical services in the school, and I learned an awful lot about the system, and I also learned that if I'm going to be a consultant, how do I get back to Hawaii every January? That one I didn't figure out, but I really loved it over there, and I can tell you that each system is different and you can't just take a boilerplate plan and take it off the shelf. If you go to my website, williambeichelcom, you can find, for example, probably 200 pages of my consultation to Minnetonka regarding the issues that I would recommend for that specific school district? That would make them more successful when dealing with mental health.

Dr. William Dikel: 31:56

A lot of it has to do with roles and responsibilities and you know I'm speaking. I'm very opinionated, but I'm speaking frankly. There are districts where I'll meet with the special ed director who will call me in to consult and I'll say, okay, you have social workers, you have counselors, you have nurses, you have psychologists. What is everybody's job actually? What do they do? And sometimes I get a look that says I don't know what they do. The special ed director will say I'm supposed to be supervising the social workers, but they say to me that I don't really have any mental health background. I'm a special ed person, so I can't really supervise them.

Dr. William Dikel: 32:33

And so one district we went to I had all these people fill out anonymous forms what do you do all day? And you'd be shocked and surprised when you find out. People pretty much define what they think they should be doing and they do it for a long time without actually knowing whether they're addressing the kids who need the help the most. And it's very frustrating for people to listen to me give talks like this, because I'm very blunt, I haven't had a job in a long time, because I'm an independent consultant and nobody really tells me what I can say or can't say. But a lot of people are thinking this stuff. They're just not saying it. And the mental health field is frustrating enough as it is, without pulling in all kinds of other things which are very difficult to deal with. But unless you do that, you're not going to get very far.

Joe Boyle: 33:31

And now it's time for Stories in Life. Art from the heart, deep thoughts from the shallow end.

Speaker 3: 34:24

Each episode, we bring you a poem, a song or a reading just for you, guitar solo In the afternoon, in the afternoon, in the end of my road ¶¶ in my room, when I'm really down, get me off the ground. When I call ya, when I call ya, when I call ya in the morning time, when I go outside in the morning time, when I go outside In the morning time, it's like that all the while In the afternoon, when I'm in my room, every single day, it won't go away away when I call ya, when I call ya, when I call ya, and it's in my heart when we're apart, it'll stop since the day and it's in my heart every single day. Yeah, it's always in my way when I'm making and I ran my heart Every single day it's always in my way when I'm making hay. All I got to say Melancholia, melancholia, melancholia. Well, it's in my blood and it's in my blood and it's in my veins. Here it comes again when I'm in the rain, in the wind and rain. Well, the sun will shine. Well, it's always mine All of the time.

Speaker 3: 36:25

Well, I'm calling you. Well, I'm calling you. Well, I'm calling you and I'll send my life and I'll show the town. It doesn't go away On the church bell chime In the evening time, and it's all the time it doesn't go away On the church bell chime In the evening time, while I drink my wine In the evening time, when it's on my mind Melancholia, melancholia, melancholia, melancholia, it's only melancholia. Oh melancholia, oh melancholia, oh melancholia, oh melancholia, melancholia, melancholia, melancholia. They call it Melancholia, call it Melancholia, call it Melancholia, call it Melancholia, call it Melancholia.

Joe Boyle: 37:43

The lead-in song was Don Quanea by Lamin Sisko. That's off the 2011 album Pacquiao West African Chora Music. The next song was by Van Morrison, called Melancholia off the Days, like this album from 1995. William Deichel MD has a wonderful book out. It's called Student Mental Health a guide for teachers, school and district leaders, school psychologists and nurses, social workers, counselors and parents. It's the updated and expanded version. You can also find all this information on williamdeichelcom. Again, his website is williamdeichelcom.

Mark Wolak: 38:37

Well, that was interesting. A lot of information.

Joe Boyle: 38:41

Good stuff, really good stuff Interesting.

Mark Wolak: 38:43

Really challenges those of us, especially those people working with kids in schools and in the community on are we asking the right questions and getting the right information about what's affecting that child?

Joe Boyle: 38:56

Right. What Deichel is trying to do here is break things down to form guidelines to follow. You know, because you know this is new ground for a lot of school districts.

Mark Wolak: 39:14

you know it is and it's also being willing to say the system may not be meeting the needs and it's okay to challenge the system.

Joe Boyle: 39:21

Well, in most cases they're not meeting the needs yet.

Mark Wolak: 39:25

Yeah, we've really created some challenges for our children in this culture with the Internet, online, school, social media, yep A lot of really big challenges to try to have kids just be happy. So I hope, listeners, that you'll listen to our next episode with Will Dykle.

Joe Boyle: 39:45

Yep, it's going to be a continuation. We're just getting started here.

Mark Wolak: 39:49

Thanks for listening.

Joe Boyle: 39:53

We hope you enjoyed this episode. Please join us again next time on stories in life on the radio with Mark and Joe, and visit our website at storiesinlifebuzzsproutcom or email us at storiesinlifepodcast at gmailcom. Thank you, thank you.