David Hager: Understanding Minds: From Vet Schools to Mental Health Advocate

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We're igniting a global movement to empower everyone to make a lasting difference by fostering deep awareness, unwavering acceptance and profound understanding of autism and mental health, to an end, be inspired and join us in transforming the world one story at a time. Hi, I'm Tony Meantor, welcome to Why Not Me, Embracing Autism and Mental Health worldwide. Joining us today is David Hager, who interestingly never planned on becoming a psychiatrist.

He started a college at Texas A&M, dreaming of a white coat for four legotations, set on veterinary medicine. But some way between anatomy labs and late-night soul searching, the human mind pulled harder than any animal heart ever could. He pivoted, earned his MD at UTMB Galveston, completed his psychiatry residency and move forward

from there. He then walked into state prisons in Florida and Illinois where the patients were human, but often treated it's less. His journey is outstanding and he has so much information to give us today. So before we dive into our episode, we'll be back with an uninterrupted show, right after

a word from our sponsors. Thanks for coming on.

Yeah, this is interesting, it's our first time experience for me.

Well, that's good. I do not think there'll be any problems.

“I think the most important thing is getting it started.”

So let's do that. If you would introduce yourself and tell us what you do. Oh, I'm David Hager and I am a psychiatrist. Okay. Now, the big question, what led you to go into psychiatry?

Well, I didn't plan on psychiatry. I went to Texas A&M to be a veterinarian. Okay, I safely can say I didn't expect that. Yeah, it's actually more difficult to get into vet school than medical school. That's interesting.

Yeah, it is. It's just a numbers thing. So I applied in my sophomore junior and senior years of college to vet school and then that last time I also applied to med school because I realized there was a couple of things. One is the veterinarians I was working with all of a sudden they had wished they had

got a medical school. And I realized the main reason that wasn't going to medical school or considering it is because my father wanted me to go to medical school. Anyway, when I got up at medical school, it was accepted to three med schools and I got

the third alternate spot at that time to the vet school.

Yeah, so when to UTM being Galveston, after going through the third year, which was the usual round of clinicals, I had boiled down to surgery or psychiatry. Okay. The psychiatry was unexpected. What I liked about psychiatry was listening to people's stories.

Yeah, I get that completely. And those stories can get pretty intense. They can. Yeah. One is, how do you deal with that?

From a standpoint of someone that wants to help someone, I've been told all my life that I'm a fixer because I like to help people. In your scope of work, fixing means helping people. And sometimes when you're trying to help these people, you can't fix them. Right.

That can be very frustrating. So how do you deal with that? Well, not always. It's gracefully. I'm a human.

Sometimes with stiff professional formality and sometimes, I think more so as my career is progressed and I become more human as a psychiatrist that I'm able to listen to people's stories without having to be necessarily strictly a psychiatrist while doing so. Okay. That makes sense.

Now, I'm guessing by doing it this way, you're able to hopefully break down some barriers, which will allow them to get into a comfort zone with you, which allows them

“to tell you more things that you need to hear in order to be able to help them.”

Yeah, a lot depends on the setting. How clinical interviews go in a correctional setting, for instance, is very different from how interviews go and let's say a substance abuse rehab. Now, I had worked for several years at a rehab and lots of stories there.

It worked better to be a little bit more myself in those settings.

“You don't really let people know much about yourself personally when you're working with”

folks in a prisoner jail. Yeah, that makes sense. Yeah. But one of the ways I tried to deal with that to reduce some of the morality of the interviews was I actually, I wrote a program to do a computer psychiatric interview before I saw

the patients. So I get through a lot of these structured stuff beforehand that I could follow up on during the actual face-to-face interview and then focus more on human elements instead of going through a whole bunch of rigid diagnostic stuff that can chew up a lot of time. That computer program is such a great idea.

It saves a lot of time, I'm sure I'm sure you're like everyone else that you have

a limited amount of time to give to these people.

What happens when a patient starts opening up and digging into some of these things that you really need to know and then all of a sudden, the time's up. Yeah.

“So do you go into overtime, do you punch the clock?”

What do you do? Again, that depends on the setting. In that substance abuse rehab setting, I had a schedule and patients are kind of notorious for bringing up the most difficult thing right at the end of a session and there's a tab dancing that then occurs hopefully a compassionate tab dancing that says, "Our time is limited

and I hope continue to talk about this the next time we sit down." Yeah, that's a tough one. On the other hand, in institutional settings, there's not so much of a hard time limit

can be a lot more flexible and how long a particular session lasts.

That makes total sense. Are you working with people that are incarcerated or are you still working with people that need help with substance abuse or is it a little bit of everything? What's your schedule look like now? Well, I'm partially retired now.

Okay. But you know what I'm doing right now is contract work and I'm doing contract work doing correctional psychiatry because over the years I have found that to be the most interesting work. Okay.

And the contract work is there are other factors that play into why it works out well for us at this point so that I can work half the year and still get by. Tell you a little bit about how I got into correctional work and what that experience has been like. Yeah, that sounds great.

And did that start? It's 2001. I'll tell you that I'm not great at running a business and I had a practice in South West Florida, a private practice with a number of clinicians and that financially didn't go well.

I wound up in a lot of dead out of that. I learned some hard lessons and the job that was available in nearby was that a prison. And I had an interest in forensics already. I was doing court evaluations and such and so I figured it was a good way to round out or flesh out some of my forensic experience.

So I started working at this prison, Charlotte correctional in South West Florida, turns out that's a place that has a bit of a reputation. It's a tough place. It's a close management camp on site, which is a prison within a prison. And it also happens to have the crisis unit, one of the crisis units, and transitional

care unit for people with severe mental illness or people with mental health concerns. Because it kind of parses out into a few basic categories in a correctional setting. OK, can you expand on that some? You've got people who are real deals severely mentally ill. You've got people who are trying to make you believe that they're real deal mentally ill

because of various reasons either they want special considerations or they want the medications or either they want to take the medications or sell the medications. And then there's a population that's important to manage from a safety perspective that folks for risk per suicide. There are some people who are actually at true risk for suicide, but our experience is

that most of the people who say there are risk for suicide are using that particular process to try to make a change happen. So at Charlotte correctional, I begin to appreciate what happens to people who have severe mental illness, real deals of your mental illness.

“With that said, does anyone or any particular situation stand out to you?”

I remember this one guy in particular, I'd go look at the classification file for people where I wasn't really sure what was going on and this one guy wasn't quite sure and I looked through his classification file and I saw his history of arrests and it was a whole bunch. It was like 30 trespassing arrests.

Wow. Yeah, and then he became in the course of me trying to take care of him. He became forwardly psychotic, he became, you know, there was no ambiguity at all. There was the progression of people for this person anyway of all these misdemeanors, misdemeanor

for a longer period of time and why he didn't wind up in a forensic psychospital.

It's just, you know, it's luck that draw it seems probably depends on who's public defender was or how well put together he was at the time of the hearing, real deal people because of Anna's ignosia, they don't declare themselves. There's actually, there's a semi-apocryphal story out of one of the big urban jails in Houston.

“Remember a colleague telling me, it fits perfectly.”

A hairy, busy psychiatrist was showing up for what was essentially a mental health sick call and she saw that there was an impossible number of people to see. So she had to make a decision about who she was going to try to see and who she wasn't. She calls out to them, she says, okay, all of y'all here who have a mental illness raised your hand.

So a whole bunch of hands go up and she says, okay, y'all can go back to yourselves. I'll see the rest of you. Wow.

That's pretty unbelievable, actually.

That's kind of the world, that's the world of corrections. I worked at that facility for 15 months and I worked subsequently at the Palm Beach County Jail. Jail work is very different. It's a whole different vibe.

“Yeah, I can just imagine now what happened after that.”

Where did you go? I went up to Indiana. I was the director of the mental health services for the Indiana Department of Correction for a while and we lost that at ReadBid, working for one of the for-profit companies contracts coming.

Go.

And I subsequently worked at the Marion County Jail and Velucia County Corrections

and Central Florida. After that, I went on in 2008 to shift from corrections, which especially in jail work, it can be difficult. There's stories around that, but there are difficult political stories around that. And I came back to Texas and worked at a curvil state hospital, which is a primarily

forensic hospital. It's a hundred percent forensic at this point. It's got a crisis here, but that went away while I was there. And it has specialized even more in people who are not guilty by reasoning in sanity. So that's pretty much the entire population at curvil state hospital.

So I worked there for four years at one point and then two years again during the pandemic. That's quite a path of different scenarios that you've worked with in. Working with the forensic population in that setting, different experience, different system, feel to how that system works, but there's the length of stay. If you look at prisons and you look at forensic psych hospitals, there's one common theme

and that is, the length of stay is much, much longer. You can debate whether that's a good thing or a bad thing. For some of the people as debilitated as they were, especially at the forensic psych hospital, at curvil state hospital, oh my god, some of these people are so low functioning. There is no other option for them, really.

Another thing while working at curvil state hospital is a sad comment that families would make. A repeated question from families was, "Why did my loved one have to kill somebody to get services like this?" Yeah, that's a tough question and unfortunately, I've heard that so many times with people

that have been on my podcast. This podcast has been really good to get a lot of information out there. Unfortunately, a lot of this information is things that people just don't want to hear and shouldn't have to hear. A lot of people will see something that's on TV.

They don't understand it, they don't know what it is because of the sensationalism of the TV, they will get their perception of what it is, usually it's the wrong perception. Unfortunately, it's a situation of where the system failed the person that had the problem. Yeah. Before I started addressing serious mental illness and anti-signosure on this podcast,

I hate to say it, but I had a lot of the same thoughts. It truly is sad that you had to comment on how many people will say, "Why did my loved one have to do something so bad to get the help that they need?" What's even sadder is it doesn't seem to matter which state I'm talking with. They all have the same issues.

So I'm interested because you worked in so many different facilities. You've seen the issues that they face firsthand. So everyone has a different approach. I'm interested in what your approach would be. What are your thoughts?

“How do you think we can make things better to help people that really need the help?”

It's a sad irony that at this point the criminal justice system does a better job with accountability. I hate to use work containment, but the containment within a process, whether it's outpatient or whether it's somebody who's incarcerated actually or in a forensic system because

of the criminal justice system in some way or another.

So the civil sector way it works.

“If somebody with a severe mental illness doesn't show up for an appointment, well, that person”

will be replaced by somebody who does show up for appointments. And that tends to be a less sick population. So what do we do to change that outcome? My personal take on this is when that person but the truth of your mental illness doesn't show up for an appointment, you go get 'em.

You go track 'em down. And AOT is supposed to be a way to do that and certainly programs like sort of community treatment. Those are good programs.

They're not used enough and then AOT, I don't think it's used enough and when I've seen

it used, because I did some outpatient forensic work as well. It's not necessarily backed up with as much emphasis should be like if the person doesn't show up for the psychiatrist appointment and then doesn't show up for the psychiatrist appointment and then doesn't show up for the psychiatrist appointment. There's inconsistency about whether anybody actually goes to say, "Hey, how can we not

showing up for the appointment?" So there's some inconsistency and implementation of that. What's the next step then?

“So I think beefing up AOT assisted outpatient treatment.”

The original idea was outpatient commitment but the phrase "yology" was changed to AOT. Making a sort of community treatment more available for the real deal people so that people

aren't lost to follow up and then I have something that's a little off-script.

Okay. There are other psychiatrists who think all of these lines and neurologists. Historically, schizophrenia spectrum illnesses have been a fallen under psychiatry. It just has. You know what the original term or name for schizophrenia was?

That's something that I do not know. Yeah, the original name for schizophrenia in the early 1900s was dementia precox. A premature dementia. No, that's very interesting on how that's changed over the years as well. Yeah, and that way of looking at the illness holds the more we learn about it, the more

we realize or I mean, it's accepted, it's a brain level disorder, it's a neuropsychiatric disorder, it's neurological disorder. In fact, what I tell families and patients, I don't say that they have a mental illness. You know, people who's schizophrenia, I don't say they have a mental illness anymore. Because that gets conflated with a lot of other stuff that, you know, panic disorders

of mental illness, drinking too much coffee is a mental illness, apparently, because it's in DSM, right? Look at the list of things that's in DSM, you know, it's a book of psychiatric disorders, schizophrenia is kind of in there as well, but schizophrenia is pretty serious. Yeah, it is.

“And I think that you have a great way of looking at it and which other people would look”

at it the same way as well. So I tell families, and I talk with patients about schizophrenia being a neurological disorder with neurological symptoms, helps families to accept it better and understand it better, especially when I point out that there is neuropsychological decline, a cognitive decline, that hallucinations and delusions are neurological symptoms, they're not unique to schizophrenia.

There's an enormous multitude of pathways, anybody can become psychotic. Actually, I do a teaching thing with patients, I used to do with my forensic patients. My guys, they're at Kerville State Hospital, I would teach them about psychosis. I would start with what is psychosis and the ones who already knew the answer would say the right answer, the sort of a trick question, I'd say, what is psychosis and the answer

is psychosis is a symptom. Wow, that makes sense. It's a symptom of something, whether it's because I have a brain tumor or because I'm doing too many drugs or because I have schizophrenia, it's a symptom of something. Psychosis is a symptom and hallucinations and delusions are the common forms of manifestations

of psychosis. So schizophrenia is a neurological disorder with neurological symptoms, including neuropsychological decline, delusions, hallucinations, can include disorder thinking, disorder behavior, and also anesthetic nausea, and I talk some about anesthetic nausea. So when I talk generally about what agnosias are in neurology because there's a variety of agnosias,

and then when I talk about what anesthetic nausea is, because anesthetic nausea is not unique to schizophrenia, present in other disorders as well, and one of the common ones that people can relate to is Alzheimer's disease. So I'll ask people, do you know anybody with Alzheimer's, did they know they had Alzheimer's, and they usually say no, and they'll say, well, they're saying there's agnosia.

And the same thing applies to people as schizophrenia, and then they get it. Well, that's impressive. The people as schizophrenia don't necessarily get it, but depends on how they're doing. Because fortunately, some people as schizophrenia with treatment, with effective medication,

You know, as much advantage of that as possible, and kind of cram as much education

“and rapport building into that time of lucidity as possible, if that's how the course of the”

illness proceeds in response to the medication. But yes, schizophrenia and neurological illness with neurological symptoms. So here's a little bit of a question for you. Okay. How many homeless people have you run into that have Alzheimer's disease?

To my knowledge, that would be none. How many homeless people have you run into who have multiple sclerosis? Again, that would probably be none. Which can also be accompanied by anesthesia. If you look at neurological disorders, you don't see a lot of those sleeping under the bushes

because the law says they can choose to be there. Going back away is a long thought to be unfair that a person who is psychotic and doesn't know she's afflicted because of dementia is handled differently from somebody who is psychotic and has anestecnesians unable to function normally but they're in their thirties. So it's okay for that person who is a similar level of neuropsychiatric debility to

consign themselves to sleeping under the bushes because they quote unquote choose to be there. I don't know, there's the recent executive order encouraging reinstitutionalization and I've got mixed feelings about that. But on the other hand, there are some people who don't need to be sleeping under bushes anymore. Yes, I agree.

And hopefully something like that would be enough ammunition to get our legislators involved, make some new laws and help these people out that need that help. I remember a conversation I had with a legislator. I actually was involved for a while trying to keep a state hospital open in southwest Florida and it was slated for closure.

It was back in the '90s. When up to tell I asked a couple of times, one of the times I went up, I spoke with a guy who used to be my boss. He was a physician who became a floor to legislator. And I asked him that question about why is it that grandma with dementia, we take

better care of her than the 30-year-old who's hiding from the lasers under the bushes in the park. And he was kind of a blunt guy. I want to use all of the words that he used. He said, because we care about grandma, but we don't give a blank about the lady under the bushes. So working in jails, working in prisons, I see from that perspective how broken things are

on the civil side because they come to me. Yeah, I cannot disagree with you at all. What do you think is important that people here, they may be well-versed on schizophrenia and execnosure, or they may not.

“They may not have encountered anyone, but yet they're hearing what you have to say.”

What is important for them to know and understand about this subject? Personally, based on my experience with families and to some extent with the patients, reframing the illness to be a neurological illness. It's a neurological illness. It's the old dementia precox, it still is.

The illness has always been with us.

And think in terms of how would you manage a person with a dementia, and would you just let them sleep under the bushes? Yeah, I agree. That is a great point to make. I think one of the biggest issues that I've seen since I've been doing this

is that everyone has their thoughts on what they think it is. Because of that, I try and use the word perception because everyone can have their perception on what they think it is, but usually the reality is something completely different.

“So I don't like to use that word stigma anymore because I think people have to”

learn and understand or at least try to understand so that way they might have a little empathy for what others are actually going through. This way, when they hear something about serious mental illness or an ex-signosure, at least they'll have a comprehension of what people are talking about. I really think the way that you put it across is really good.

Yeah, and as a nauseous neurological symptom, you can see a dementia, you can see with certain strokes, you can see it multiple sclerosis. Any number of other neurological afflictions can have that anosignosure, which is the inability to know that one is afflicted. I'd a friend of mine who, this is a common one, I'd a friend of mine who had a dense stroke

affected half of his body. And as can happen with that kind of a stroke, he no longer knew that part of his body existed anymore. And so he had what's called heming neglect. And he functioned as if that part of his body didn't exist anymore and it caused problems for him. That's a form of anosignosure.

I think that's a great analogy.

You are one of the first people I've spoken with that has brought out anosignosure in this kind of context.

And I think it's used a great way of putting it across with this kind of thought process.

Yeah, it's not a willful denial of the illness.

It is thought out and inability to see. It's like a person who's colorblind. They're just certain colors that can't be seen. Yeah, that is so true. I think you've got a great look at things and I think all the stories that you've heard across

your career has helped you bring this to the light for everyone.

“That's what attracted me originally to psychiatry was the ability to hear people's stories.”

Yeah, both good and unfortunately some that weren't so good. It's not a lot of change in the profession. It's a whole another conversation. Yeah, I'm sure.

Now, that brings up another interesting point.

You've moved around and done so many different things along the way. You've also seen so many different things from your different jobs that you've done. Now, instead of talking about the people you've helped, how has this helped you?

“How have you seen yourself evolve from the early days to today?”

Well, you know, I thought I knew something when I finished my psychiatry residency in 1992. I was a smart fellow and then life happened. And I've had a few decades of life since then including substantial hardships, personal hardships on my own end that I've had to recover through. And that and having to learn that having to learn from other people who have had hardship,

who don't necessarily have college education but learn by their example.

“You know, I'm an alcoholic, I'm in recovery and I've had to learn from other people how to live life.”

And that actually works out as worked out much better than I could do on my own. Yeah, lots of times life gives us more knowledge than college ever would. Well, this has been a great episode. Lots of good conversation, lots of good information. I really appreciate you taking the time to join us today.

Yeah, I appreciate you interviewing me. Oh, it's been my pleasure. Thanks again. Thanks for taking time out of your busy schedule to listen to our show today. We hope you enjoyed it as much as we enjoyed bringing it to you. If you know someone who has a story to share, tell them to contact us at whynotme.world.

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