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

Embracing Autism and Mental Health: Psychiatrist David Hager's Journey
In this episode of 'Why Not Me, Embracing Autism and Mental Health Worldwide,' host Tony Mantor speaks with psychiatrist David Hager about his unplanned journey into psychiatry, his work in correctional facilities, and his unique perspectives on mental health and serious mental illnesses like schizophrenia.
Hager shares his experiences from various jobs, discusses the challenges and strategies of treating incarcerated populations, and underscores the importance of viewing severe mental illnesses as neurological disorders.
The conversation also touches on the issue of anosognosia and the need for better systemic support. Tune in for an insightful and heartfelt discussion aimed at fostering awareness and understanding of autism and mental health.

Meet David Hager: From Vet School to Psychiatry
David's Journey into Psychiatry
 Challenges and Rewards in Psychiatry
Correctional Psychiatry: A Unique Perspective
Forensic Psychiatry and Systemic Issues
Reframing Mental Illness: A Neurological Perspective
Personal Reflections and Closing Thoughts

INTRO/OUTRO Music: T. Wild
Mantor Music BMI

The content on Why Not Me: Embracing Autism amd Mental Health Worldwide, including discussions on mental health, autism, and related topics, is provided for informational and entertainment purposes only. 

The views and opinions expressed by guests are their own and do not reflect those of the podcast, its hosts, or affiliates.

Why Not Me is not a medical or mental health professional and does not endorse or verify the accuracy, efficacy, safety of any treatments, programs, or advice discussed.

Listeners should consult qualified healthcare professionals, such as licensed therapists, psychologists, or physicians, before making decisions about mental health or autism- related care.

Reliance on this podcast's contents is at the listener's own risk. 

Why Not Me is not liable for any outcomes, financial or otherwise, resulting from actions taken based on the information provided.

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intro/outro music bed written by T. Wild
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Transcript

SPEAKER_00 0:05

Welcome to Why Not Me, Embracing Autism and Mental Health Worldwide. Hosted by Tony Mirator. Broadcasting from the heart of Music City, USA, Nashville, Tennessee. Join us as our guests share their raw, powerful stories. Some will spark laughter, others will move you to tears. These real life journeys inspire, connect, and remind you that you're never alone. 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. Tune in, be inspired, and join us in transforming the world one story at a time. Hi, I'm Tony Mantor. 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 college at Texas AM, dreaming of a white coat for four-legged patients set on veterinary medicine. But somewhere 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 moved forward from there. He then walked into state prisons in Florida and Illinois where the patients were human but often treated as 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.

SPEAKER_01 1:59

Yeah, this is interesting. It's a first uh first-time experience for me.

SPEAKER_00 2:04

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.

SPEAKER_01 2:14

Oh, I'm David Hager and I am a psychiatrist.

SPEAKER_00 2:18

Okay. Now, the big question: what led you to go into psychiatry?

SPEAKER_01 2:24

Well, I didn't uh I didn't plan on psychiatry. I went to Texas AM to be a veterinarian.

SPEAKER_00 2:30

Okay, I safely can say I didn't expect that.

SPEAKER_01 2:34

Yeah, it's actually more difficult to get into vet school than medical school.

SPEAKER_00 2:39

That's interesting.

SPEAKER_01 2:40

Yeah, it is. It's just a it's a numbers thing. So I applied in my sophomore, junior, and senior years of college to vet school. And then that that last time I also applied to med school because I realized uh there's a couple of things. One is the veterinarians I was working with all of a sudden they wish they had gone to medical school. And then I realized the main reason I wasn't going to medical school or considering it is because my father wanted me to go to medical school. Anyway, wound up in medical school, was accepted to three med schools, and I got a third alternate spot that time to the vet school. Yeah, so uh went to UTMB and Galveston. After going through the third year, which is the usual round of clinicals, I had it boiled down to surgery or psychiatry.

SPEAKER_00 3:27

Okay.

SPEAKER_01 3:28

Psychiatry was unexpected. What I liked about psychiatry was listening to people's stories.

SPEAKER_00 3:34

Yeah, I get that completely. And those stories can get pretty intense. They can, yeah. I guess my question 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?

SPEAKER_01 4:02

Well, not always gracefully. I'm a human. You know, sometimes with uh stiff professional formality, and sometimes I think more so as the as my career has progressed and I've become more human as a psychiatrist, that um I'm able to listen to people's stories without having to be necessarily strictly a psychiatrist while doing so.

SPEAKER_00 4:26

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.

SPEAKER_01 4:45

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

SPEAKER_00 5:16

Yeah, that makes sense.

SPEAKER_01 5:18

Yeah, but one of the ways I I tried to deal with that to um reduce some of the formality of the interviews was I actually I wrote a program to do a computer psychiatric interview before I saw the patients. So get through a lot of the structured stuff beforehand that I could follow up on during the actual face-to-face interview and then focus more on the human elements instead of going through a whole bunch of rigid diagnostic stuff that can chew up a lot of time.

SPEAKER_00 5:50

That computer program is such a great idea, 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.

SPEAKER_01 6:00

Right.

SPEAKER_00 6:01

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?

SPEAKER_01 6:17

Again, that depends on the setting. You know, in that substance abuse rehab setting, I had a schedule. And you know, 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. Um, yeah, hopefully a compassionate tab dancing that says our time is limited, and and I hope we'll continue to talk about this the next time we sit down. Yeah, it's uh that's a tough one. On the other hand, in institutional settings, there's not so much of a hard time limit. It can be a lot more flexible in how long a particular session lasts.

SPEAKER_00 6:54

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?

SPEAKER_01 7:08

Well, I'm partially retired now.

SPEAKER_00 7:10

Okay.

SPEAKER_01 7:11

Yeah. 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.

SPEAKER_00 7:23

Okay.

SPEAKER_01 7:24

And the contract work is uh there's 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.

SPEAKER_00 7:40

Yeah, that sounds great. When did that start?

SPEAKER_01 7:42

It's 2001. I'll tell you that I'm I'm not great at running a business, and I had a practice in Southwest Florida, a private practice with a number of clinicians, and that financially didn't go well. Yeah, I wound up in a lot of debt out of that. I learned some hard lessons, and the uh the job that was available nearby was at 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 Southwest Florida. Turns out that's a place that has a bit of a reputation. It's 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 a transitional care unit for people with severe mental illness or well, people with mental health concerns. Because it kind of parses out into a few basic categories in a correctional setting.

SPEAKER_00 8:38

Okay. Can you expand on that some?

SPEAKER_01 8:41

You've got people who are real deal 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 uh population that it's important to manage uh from a safety perspective, the folks who are at risk for suicide. There are some people who are actually at true risk for suicide, but you know, our experience is that most of the people who say they're at 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 deal severe mental illness.

SPEAKER_00 9:28

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

SPEAKER_01 9:33

I remember this one guy in particular. You know, I'd go look at the classification file for people where I wasn't really sure what was going on. And this one guy I 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, you know, in the course of me trying to take care of him, he became floridly psychotic. He became, you know, it was there was no ambiguity at all. You know, there was the progression of people uh for this person anyway, of um all these misdemeanors, misdemeanor arrests, and eventually he finally got popped with a felony and he wound up off the streets for a longer period of time. And why he didn't wind up in a forensic psych hospital, it's just, you know, it's luck of the draw, it seems. Probably depends on who his public defender was or how well put together he was at the time of the hearing. Real deal people, because of anasygnosia, they uh they don't declare themselves. There was actually there's a semi-appocryphal story out of one of the big urban jails in Houston. Remember a colleague telling me, and I'm it fits perfectly. A Harried, busy psychiatrist was showing up for what was essentially a mental health sick call, and she saw that there were 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. So she calls out to them. She says, Okay, all of y'all here who have a mental illness, raise your hand. So a whole bunch of hands go up. And she says, Okay, y'all can go back to your cells. I'll see the rest of you.

SPEAKER_00 11:07

Wow, that's um pretty unbelievable, actually.

SPEAKER_01 11:13

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

SPEAKER_00 11:25

Yeah, I can just imagine. Now, what happened after that? Where did you go?

SPEAKER_01 11:30

I went up to Indiana. I was the uh director of the mental health services for the Indiana Department of Correction for a while. We lost that at Rebid. Working for one of the for-profit companies, contracts come and go. And I subsequently worked at the Marion County Jail and Valuesia County Corrections in 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 Kerrville State Hospital, which is a primarily forensic hospital. It's it's 100% forensic at this point. I used to have a crisis unit, but uh that went away while I was there. And it has specialized even more in uh people who are not guilty by reason of insanity. So that's pretty much the entire population at Kerrville State Hospital. So I worked there for four years at one point and then two years again during the pandemic.

SPEAKER_00 12:29

That's quite a path of different scenarios that you've worked with in.

SPEAKER_01 12:32

Working with the forensic population in that setting, different experience, a 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 Kerrville State Hospital. Oh my God, some of these people were so low functioning. There was no other option for them, really. Another thing while working at Kerrville State Hospital, it was 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?

SPEAKER_00 13:20

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.

unknown 13:40

Yeah.

SPEAKER_00 13:40

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. Before I started addressing serious mental illness and anesthynosia 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?

SPEAKER_01 14:53

Yeah, it's a sad irony that at this point the criminal justice system does a better job with accountability. I hate to use the word containment, but a containment within a process, whether it's outpatient or whether it's uh somebody who's in incarcerated actually, or in a forensic system, because if they're in a forensic system, forensic psychiatry hospital, they're still under the umbrella of the criminal justice system in some way or another. So um the civil sector, the 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.

SPEAKER_00 15:32

So what do we do to change that outcome?

SPEAKER_01 15:36

My personal take on this is when that person with a true severe mental illness doesn't show up for an appointment, you go get them. You go track them down. And AOT is supposed to be a way to do that. And certainly uh programs like uh 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 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 oomph as it 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 come we're not showing up for the appointment? So there's some inconsistency in implementation of that. What's the next step then? So I think beefing up AOT, assisted outpatient treatment. Um, you know, the original idea was outpatient commitment, but the the phraseology was changed to AOT, making assertive 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 along these lines and neurologists. You know, historically, schizophrenia spectrum illnesses have been, they've fallen under psychiatry. They just have. You know what the original term or name for schizophrenia was?

SPEAKER_00 17:02

That's something that I do not know.

SPEAKER_01 17:04

Yeah, the original name for schizophrenia in the early 1900s was dementia precocks, a premature dementia.

SPEAKER_00 17:12

Now that's very interesting on how that's changed over the years as well.

SPEAKER_01 17:17

Yeah, and and that 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 a neurological disorder. In fact, what I tell families and patients, I don't say that they have a mental illness. You know, people with 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 disorder is a mental illness. Um, 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, and schizophrenia is kind of in there as well, but schizophrenia is pretty serious.

SPEAKER_00 18:00

Yeah, it is. And I think that you have a great way of looking at it and wish other people would look at it the same way as well.

SPEAKER_01 18:07

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, you know, cognitive decline, that hallucinations and delusions are neurological symptoms. They're not unique to schizophrenia. There's an enormous, a multitude of pathways. Anybody can become psychotic. Actually, I do a teaching thing with patients. I used to do it with my forensic patients, my guys there at Kerrville 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. But it was sort of a trick question. I'd say, what is psychosis? And the answer is psychosis is a symptom.

SPEAKER_00 18:56

Wow, that makes sense.

SPEAKER_01 18:58

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 or manifestations of psychosis. So schizophrenia is a neurological disorder with neurological symptoms, including neuropsychological decline, delusions, hallucinations, uh, can include disordered thinking, disordered behavior, and also anasygnosia. And then I talk some about anzygnosia.

SPEAKER_00 19:31

How do you define that to people that don't understand it?

SPEAKER_01 19:35

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 anasygnosia is, because anasygnosia 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 then they usually say no and they'll say, Well, that's anasygnosia. And the same thing applies to people with schizophrenia, and then they get it.

SPEAKER_00 20:04

Wow, that's impressive.

SPEAKER_01 20:05

The people with schizophrenia don't necessarily get it, but it depends on how they're doing. Because there are fortunately some people with schizophrenia, with treatment, with effective medication, some insight returns, and that's a blessing. You know, take 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 yeah, schizophrenia, neurological illness with neurological symptoms. So here's a little bit of a question for you.

SPEAKER_00 20:37

Okay.

SPEAKER_01 20:38

How many homeless people have you run into that have Alzheimer's disease?

SPEAKER_00 20:42

To my knowledge, that would be none.

SPEAKER_01 20:44

How many homeless people have you run into who have multiple sclerosis?

SPEAKER_00 20:48

Again, that would probably be none.

SPEAKER_01 20:50

Which can also be accompanied by anasygnosia. Yeah, if you look at neurological disorders, you don't see a lot of those, you know, sleeping under the bushes because the law says they can choose to be there. Going back a ways, I've long thought it 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 anasgnosia and is unable to function normally, but they're in their 30s. So it's okay for that person who has 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. It's you 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.

SPEAKER_00 21:45

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.

SPEAKER_01 21:56

I remember a conversation I had with a uh legislator. I Actually, I 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. Went up to Tallahassee a couple of times. One of the times I went up, I I spoke with a guy who used to be my boss. He was a physician who became a Florida legislator. And I asked him that question about, you know, 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 and uh in the park. And he was kind of a blunt guy. I won't use all of the words that he used. Okay. But he said, it's 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.

SPEAKER_00 22:46

Yeah, I cannot disagree with you at all. What do you think is important that people hear? They may be well versed on schizophrenia and exagnosia, 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?

SPEAKER_01 23:10

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 precocks. 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?

SPEAKER_00 23:33

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 anxygnosia, 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.

SPEAKER_01 24:23

Yeah, anzygnosia is a neurological symptom. You know, you can see it with dementia, you can see it with certain strokes, you can see it multiple sclerosis. Any number of other neurological afflictions can have that anzygnosia, which is the inability to know that one is afflicted. I had a friend of mine who, this is a common one, I had a friend of mine who had a uh 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 hemi neglect. He functioned as if that part of his body didn't exist anymore, and it caused problems for him. That's a form of anasygnosia.

SPEAKER_00 25:04

I think that's a great analogy. You are one of the first people I've spoken with that has brought out anasygnosia in this kind of context, and I think it's just a great way of putting it across. With this kind of thought process, it might just change the way people think about things and perceive them.

SPEAKER_01 25:24

Yeah, it's it's not a willful denial of the illness. It is flat out an inability to see. It's like a person who's colorblind. They're just certain colors that can't be seen.

SPEAKER_00 25:36

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.

SPEAKER_01 25:47

That's uh and that's what attracted me originally to psychiatry was the ability to hear people's stories.

SPEAKER_00 25:53

Yeah, both good and unfortunately some that weren't so good.

SPEAKER_01 25:57

It's been a lot of change in the profession. Uh a whole another conversation.

SPEAKER_00 26:02

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?

SPEAKER_01 26:23

Well, you know, I thought I knew something when I finished my psychiatry residency in 1992. I was a smart feller, and uh and then life happened. And I've had a few decades of life since then, including uh substantial hardships, personal hardships on my own end that I've had to recover through. And uh that and having to learn that, having to learn from other people who have had hardship who don't necessarily have college educations, 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 has worked out much better than I could do on my own.

SPEAKER_00 27:06

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.

SPEAKER_01 27:24

Yeah, I appreciate you interviewing me.

SPEAKER_00 27:26

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 why notme.world. One last thing spread the word about why not me. Our conversations, our inspiring guest, the Joe. You are not alone in this world.