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

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world one story at a time. Hi, I'm Tony Mantur.
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 A
and M 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
us 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 as the first 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 and 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 it's a numbers things. 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's a
couple of things. One is the veterinarians I was working
with al said they wish they had gone to medical school,
and 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. I was accepted to three med schools and
I got a third alternate spot, that time to the
BET School.
Yeah.
So went to utmbing Galveston. After going through the third year,
which is the usual round of clinicals, I had it
boiled down to surgery or psychiatry. Okay, Pschiatry 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. 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 us
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 gracefully. I'm a human, you know, sometimes
with a stiff professional formality, and sometimes I think more
so as my career has progressed and I've 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.
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 folks in a prisoner
a jail.
Yeah, that makes sense.
Yeah, But one of the ways I tried to deal
with that to 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 these 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.
That computer program is such a great idea. Saves a
lot of time. I'm sure. I'm sure you'll like everyone else,
that you have a limited amount of time to give
to these people.
Right.
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 over time, do you punch
the clock? What do you do?
Again? That depends on the setting. You know, in that
substance abuse rehab setting ahead of 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 in 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 was 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. When did that start?
It's two thousand and one. I'll tell you that 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. I wound
up in a lot of debt. Out of that, I
learned some hard lessons. And the job that was available
in nearby I 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. It 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 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.
Okay, can you expand on that sum.
You've got people who are real deal, severely mentally ill,
You've got people who are trying to make you believe
that the 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 it's important
to manage from a safety perspective of 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 Correction,
I begin to appreciate what happens to people who have
severe mental illness, real deal severe mental illness.
With that said, does anyone or any particular situation stand
out to you.
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 thirty 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, there was no ambiguity
at all, you know, there was the progression of people
for this person anyway of 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 whose 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 was actually there's a semi
apocryphal story out of one of the big urban jails
in Houston. I remember a colleague telling me, and it
fits perfectly. A haired, 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's
going to try to see and who she wasn't So
she calls out to them. She says, okay, ill 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.
Wow, that's pretty unbelievable.
Actually, that's kind of the that's the world. That's the
world of corrections. I worked at that facility for fifteen months.
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 rebid, working
for one of the for profit companies contracts come and go.
And I subsequently worked at the Marion County Jail and
Vaalujah County Corrections in central Florida. After that, I went
on in two thousand and eight to shift from corrections, which,
especially in jail work, it can be difficult there's stories
around them. There are difficult political stories that and I
came back to Texas and worked at Curville State Hospital,
which is a primarily forensic hospital. It's one hundred percent forensic.
At this point. You have a crisis unit, but that
went away while I was there, and it has specialized
even more in people who are not guilty by reason
of insanity. So that's pretty much the entire population at
Kerville 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 a 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 Curve
State Hospital. Oh my god, some of these people are
so low functioning there was no other option for them. Really.
Another thing while working at Kerville 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. Now, 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 fail the person that had the problem
before I started addressing serious mental illness and and itsignosia
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've 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 the word containment, but a containment within a process,
whether it's outpatient or whether it's somebody who's incarcerated actually
or in a forensic system. Because if they're in a
forensic system, forensic psychiatry hospital are still under the umbrella
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 truce se your 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 programs like a 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, I did some outpatient forensic work as well.
It's not necessarily backed up with as much omph as
it should be. Like if the person doesn't show up
for the psychiatrists appointment, and then doesn't show up for
the
psychiatrists 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. You know,
the original idea was outpatient commitment, but the phraseology 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 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.
That's something that I do not know.
Yeah, the original name for schizophrenia in the early nineteen
hundreds was dementia precox a premature dementia.
Now 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 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 disorders a 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 and schizophrenia is kind
of in there as well. But schizophrenia is pretty.
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 it 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, but 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 disordered thinking, disordered behavior, and also anazygnosia. And
I talk some about anazagnosia.
How do you define that to people that don't understand it?
So when I talk generally about what agnosias are in neurology,
because there's a variety of agnosias, and then whant to
talk about what anazygnosia is because anazygnosia 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? Then you
should say no, and I'll say, well that's antas a
And the same thing applies to people with schizophrenia and
then they get it.
Well, that's impressive.
The people with schizophrenia don't necessarily get it, but depends
on how they're doing because they're Fortunately some people with schizophrenia,
with treatment, with effective medication, some insight returns and that's
a blessing. 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 yeah, schizophrenia 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
multi sclerosis.
Again, that would probably be none.
Which can also be accompanied by anazygnosia. 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 aways, 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
anasagnosias unable to function normally. But they're in their thirties,
so it's okay for that person who has a similar
level of neuropsychiatrict ability 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.
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 actually
was I was involved for a while trying to keep
a state hospital open in southwest Florida, and it was
slated foreclosure. Who was back in the nineties. Went up
to Tallahassee 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 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 thirty year old
who's hiding from the lasers under the bushes 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.
Yeah, I cannot disagree with you at all. What do
you think is important that people here? They may be
well versed on schizophrenia annex ignosia, or they may 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 anexignosia,
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.
Anazagnosia is a neurological symptom. You can see with dementia,
you can see it with certain strokes, you can see
it multiple sclerosis. Any number of other neurological afflictions can
have that anazagnosia, which is the inability to know that
one is afflicted. At a friend of mine who this
is a common one. At 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 himI neglect. He functioned
as if that part of his body didn't don't exist anymore,
and it caused problems for them. That's a form of
and as ignosia.
I think that's a great analogy. You are one of
the first people I've spoken with that has brought out
anisignosia 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.
Yeah, it's it's not a willful denial of the illness.
It is flied out and inability to see. It's like
a person who's color blind. 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's And 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.
Got a lot of change in the profession. A whole
other 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 evolved from the early days
to today.
Well, you know, I thought I knew something when I
finished my psychiatry residency in nineteen ninety two. I was
a smart fella. 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've had hardship, who don't
necessarily have college educations, but learned by their example. You know,
I'm an alcoholic, I'm in recovery, and I've had to
learn from to people how to live life, and that
actually works out. It's 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
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