Latest / Brain Stories / Episode 21 - Brain Stories Connections: The Astonishing Truth About Psych Wards with Morgan Shields

Transcript

Episode 21 - Brain Stories Connections: The Astonishing Truth About Psych Wards with Morgan Shields · Brain Stories

• 0:00
  SPEAKER_00: Most every time after we go to a hotel or short term rental, we get the question, how many stars would you give us?
• 0:05
  SPEAKER_00: It's so automatic we often find it annoying.
• 0:09
  SPEAKER_00: Now imagine this.
• 0:11
  SPEAKER_00: You go to a place for a week.
• 0:13
  SPEAKER_00: Maybe not by choice.
• 0:15
  SPEAKER_00: You're not allowed to leave when you want.
• 0:17
  SPEAKER_00: You might be given ejections, again, not necessarily by choice, and when you do leave, no one asks you how your stay was, because your opinion is considered unreliable and not trustworthy.
• 0:31
  SPEAKER_00: In fact, you find out that instead of you rating the place the whole time, the employees have been rating you.
• 0:38
  SPEAKER_00: That is a typical experience at a psychiatric hospital.
• 0:42
  SPEAKER_00: Today on Brainstories Connections, we're talking to a professor of public health who launched her career asking the questions: who's rating psychiatric hospitals?
• 0:51
  SPEAKER_00: How are they accountable?
• 0:53
  SPEAKER_00: And is patient health their actual top goal?
• 0:57
  SPEAKER_00: Her name is Morgan Shields.
• 0:59
  SPEAKER_00: She teaches at Washington University.
• 1:02
  SPEAKER_00: As the expression goes, she's come by her career honestly, because as a teenager and young adult, she spent significant time in psychiatric hospitals and programs, accruing a gold mine of personal data that today goes by the term lived experience.
• 1:18
  SPEAKER_00: By now, she's done a lot of research getting system-wide data.
• 1:22
  SPEAKER_00: And what she's found is astonishing.
• 1:25
  SPEAKER_00: Here's Morgan.
• 1:27
  SPEAKER_00: Oh, by the way, let us know how many stars you give this conversation.
• 1:31
  SPEAKER_00: Hi, Morgan, and welcome to Brainstories Connections.
• 1:35
  SPEAKER_01: Thank you, Frank.
• 1:36
  SPEAKER_01: Thanks for having me.
• 1:37
  SPEAKER_00: I want to dive right in today and talk about your personal story because it seems to inform so much of what you do.
• 1:45
  SPEAKER_00: And your personal story starts with your dad.
• 1:48
  SPEAKER_00: He had some serious mental health issues.
• 1:49
  SPEAKER_00: What were they?
• 1:51
  SPEAKER_01: He uh really struggled with what we might call, you know, bipolar disorder.
• 1:56
  SPEAKER_01: So he had really intense manic episodes where he was really up and then up to the point where he would experience um psychosis and wouldn't sleep.
• 2:06
  SPEAKER_01: And, you know, believing certain things like his dad was still alive, that the government was keeping him alive on an island in the Bahamas and and whatnot.
• 2:15
  SPEAKER_01: His episodes lasted about two years at a time.
• 2:18
  SPEAKER_01: So they were very prolonged.
• 2:20
  SPEAKER_01: They were very enduring.
• 2:22
  SPEAKER_01: Um, and from my memory, his he only came down from mania if he was arrested.
• 2:30
  SPEAKER_01: Now I'd hear my mom say, Oh, if only we can get him into the hospital.
• 2:34
  SPEAKER_01: And and certainly like, because when he was manic, there was there's so many emergencies happening constantly.
• 2:40
  SPEAKER_01: And my mom was always having to respond to these emergencies.
• 2:44
  SPEAKER_01: Um, and it was really stressful for me as a kid.
• 2:46
  SPEAKER_01: And so I used to just pray, like, please, like, if we could just get into the hospital.
• 2:51
  SPEAKER_00: Which is a great segue to the next question I have for you, which is that you began experiencing your own mental health issues.
• 2:57
  SPEAKER_00: Tell me about that.
• 2:58
  SPEAKER_01: So when I was uh uh 16, I was struggling in various ways.
• 3:03
  SPEAKER_01: My mom was dating a man, she had been dating him actually for quite a while, um, who um saw this as an opportunity to take advantage of me.
• 3:12
  SPEAKER_01: And so he started grooming me.
• 3:14
  SPEAKER_01: I remember telling my mom, we were watching Oprah actually, and I said, Mom, um, I have to tell you what G has been doing.
• 3:22
  SPEAKER_01: This guy, his name was G, or that's what we called him.
• 3:25
  SPEAKER_01: He asked if he could touch my breasts.
• 3:27
  SPEAKER_01: He, you know, all this.
• 3:28
  SPEAKER_01: Anyways, and um my mom was concerned.
• 3:32
  SPEAKER_01: Um, you know, she said she would keep him from me, but for whatever reason, he ended up coming back to our house about three weeks after this.
• 3:41
  SPEAKER_01: Um, and I was sort of pressured to go to the grocery store with him.
• 3:47
  SPEAKER_01: And um, long story short, uh, you know, apparently my mom had confronted him.
• 3:52
  SPEAKER_01: And um, and now I was in the car with him, and he was very angry with me.
• 3:58
  SPEAKER_01: And um, and so long story short, he ended up raping me a couple of times and then had me promise that I wouldn't tell anyone.
• 4:07
  SPEAKER_01: My mom sort of pried the information out of me the next morning.
• 4:11
  SPEAKER_01: She said, Worgen, what happened?
• 4:14
  SPEAKER_01: And then the police got involved and there was a formal investigation.
• 4:18
  SPEAKER_01: So, from my uh my perspective, I was I promised this guy I wouldn't say anything, and now the police are involved.
• 4:26
  SPEAKER_01: And so I was petrified that he was going to kill me.
• 4:30
  SPEAKER_01: So I um barricaded myself in our bathroom with um couch cushions and um couldn't sleep.
• 4:39
  SPEAKER_01: And so I was just going a day a few days, not being able to sleep, really scared that I was going to be killed.
• 4:48
  SPEAKER_01: The reality of what was happening was almost too much.
• 4:51
  SPEAKER_01: And it was a lot easier to go manic and um to sort of channel Jesus Christ than it was to process in that moment what had happened.
• 5:01
  SPEAKER_00: Were you hospitalized at that point?
• 5:03
  SPEAKER_01: Yes.
• 5:03
  SPEAKER_01: So I I ended up being going to a few different institutions.
• 5:08
  SPEAKER_01: And I actually entered an intensive outpatient treatment program for about six months, which is actually a long time for for that type of program when I was a teenager.
• 5:17
  SPEAKER_01: Um and you know, so then I have my own journey after that.
• 5:21
  SPEAKER_01: I ended up back in Florida when I'm 20.
• 5:25
  SPEAKER_01: Um, and I then have another episode of mania.
• 5:28
  SPEAKER_01: And at this time, my dad is also in a manic episode.
• 5:32
  SPEAKER_01: So he's manic, I'm I'm manic.
• 5:35
  SPEAKER_01: You remember meeting him in a bar and um saying, Dad, I think I figured it out, you know, because it's like figured out this game, right?
• 5:43
  SPEAKER_01: And he's and and I explained it to him and he goes, Morgan, yes, you have cracked the code.
• 5:50
  SPEAKER_01: Now keep it hush.
• 5:52
  SPEAKER_01: And he's like, You're exactly right.
• 5:54
  SPEAKER_01: You are the product of a government experiment.
• 5:59
  SPEAKER_01: You are part alien.
• 6:01
  SPEAKER_01: We are aliens.
• 6:02
  SPEAKER_01: And you know, the truth is, is like I actually do feel part alien.
• 6:06
  SPEAKER_01: You know, I do I do think my dad and I are a little alien in some ways, you know.
• 6:10
  SPEAKER_01: And um, and I said, Do you think that that camera is watching us?
• 6:13
  SPEAKER_01: So at the time I was like, there's cameras everywhere.
• 6:15
  SPEAKER_01: And he goes, Yes, but don't even worry about it.
• 6:19
  SPEAKER_01: You are winning.
• 6:20
  SPEAKER_01: And I remember we we danced in this bar to a song.
• 6:24
  SPEAKER_01: It was like a celebratory dance.
• 6:26
  SPEAKER_01: And honestly, it's like one of the most beautiful memories I have with my dad.
• 6:29
  SPEAKER_01: Um, and it's the only time I ever danced with him.
• 6:32
  SPEAKER_01: Um, and you know, and we were in our own reality, but like it was almost a shared reality in a way.
• 6:39
  SPEAKER_01: And it was it was a little beautiful.
• 6:41
  SPEAKER_00: And how did that lead to the your actual hospitalization then?
• 6:44
  SPEAKER_01: I was hospitalized a couple of times.
• 6:46
  SPEAKER_01: And in this first time, um, this was a um an uh psychiatric emergency department, and my mom actually was standing next to me uh while I was talking to the psychiatrist.
• 6:59
  SPEAKER_01: And I said, at the so Michael Jackson had died a year prior.
• 7:04
  SPEAKER_01: I was scared that they were going to kill me.
• 7:06
  SPEAKER_01: So I asked the psychiatrist, are you going to kill me the same way you killed Michael Jackson?
• 7:12
  SPEAKER_01: And his response was to laugh at me.
• 7:16
  SPEAKER_01: And then um he called in this big group of men and they they grabbed my body and they um they pinned me down and um they gave me a chemical restraint and I chemical restraint, meaning they injected you with something?
• 7:32
  SPEAKER_01: Yes.
• 7:32
  SPEAKER_01: They gave me something in my butt, um, a shot, and they didn't tell me what it was.
• 7:37
  SPEAKER_01: And I asked, there was the woman there, and I said, What did you just give me?
• 7:41
  SPEAKER_01: And she said, You know exactly what you got.
• 7:45
  SPEAKER_01: I thought, oh my gosh, this is confirmation that they've given me um lethal injection.
• 7:51
  SPEAKER_01: And so then they they put me in um a uh a room, like a cell.
• 7:57
  SPEAKER_01: I started pleading with God.
• 7:59
  SPEAKER_01: I said, if you let me live, I promise I'll do a lot of good with my life.
• 8:03
  SPEAKER_01: You know, um, I was I was terrified.
• 8:06
  SPEAKER_01: I mean, this is I thought I was dying.
• 8:08
  SPEAKER_01: Um, and then, you know, eventually I couldn't stand any longer.
• 8:12
  SPEAKER_01: So I laid down and I just said a bunch of prayers.
• 8:16
  SPEAKER_01: And I I told myself, you know, you you just have to be brave and die and let your spirit go.
• 8:24
  SPEAKER_01: Just let it go.
• 8:25
  SPEAKER_01: And of course I woke up and I didn't die.
• 8:28
  SPEAKER_01: But the but the reality is is that my my body and my my psyche lived through the terror of thinking that I was dying.
• 8:38
  SPEAKER_01: It's actually caused, you know, a lot of pain for me in my life for a very long time.
• 8:43
  SPEAKER_01: I was hospitalized um and then I was discharged.
• 8:46
  SPEAKER_01: I had no follow-up care.
• 8:47
  SPEAKER_01: I told my dad I'm really struggling to sleep, and he said, You need some, you need some pot.
• 8:53
  SPEAKER_01: Why don't why don't you meet me in front of Target?
• 8:55
  SPEAKER_01: I've I found this guy.
• 8:57
  SPEAKER_01: And then it gives me this joint.
• 8:59
  SPEAKER_01: And I took a couple of hits from it.
• 9:01
  SPEAKER_01: And now, you know, I haven't slept.
• 9:04
  SPEAKER_01: I I'm in psychosis still, and I was just sort of catapulted into the most extreme state of uh paranoia, and I had to leave everything behind, including my clothes.
• 9:17
  SPEAKER_01: So I took all my clothes off and I'm completely naked.
• 9:21
  SPEAKER_01: And I go up to a couple of cars and I said, Can you give me a ride to Miami?
• 9:25
  SPEAKER_01: And uh finally the cops show up and um they put me in the back and they drove me pretty far away to a place that was extremely scary.
• 9:36
  SPEAKER_01: Um, I I I would describe it as a place where they send the undesirables.
• 9:40
  SPEAKER_01: They had me on uh many different drugs.
• 9:43
  SPEAKER_01: I wasn't really drinking or eating because I thought everything was poisoned.
• 9:47
  SPEAKER_01: Um, and uh I could barely speak, I could barely walk.
• 9:51
  SPEAKER_01: And then I was I was sent home uh again, no follow-up care.
• 9:56
  SPEAKER_01: And um, and that was that.
• 9:58
  SPEAKER_01: I I was I had a prescription for several antipsychotics.
• 10:03
  SPEAKER_01: I remember looking at my mom and saying, I'm nothing now.
• 10:07
  SPEAKER_00: Yeah.
• 10:07
  SPEAKER_00: I mean, so first of all, so many truly awful experiences, one after the other after the other.
• 10:13
  SPEAKER_00: Then there's all sorts of medications, and you can barely function at the end of this.
• 10:18
  SPEAKER_00: And yet you got yourself on the path to a PhD just really briefly.
• 10:23
  SPEAKER_01: I'll try to be brief.
• 10:24
  SPEAKER_00: How did you how did you get to getting a PhD?
• 10:28
  SPEAKER_01: You know, I had a bit of a rough journey there for a bit, but I took a statistics class and my instructor invited me to work in her lab.
• 10:37
  SPEAKER_01: For me at that time, being invited to work in a lab felt like such an honor and such a sign that someone saw something in me.
• 10:45
  SPEAKER_01: Um, and so I took it really seriously.
• 10:48
  SPEAKER_01: I loved the work of research so much.
• 10:51
  SPEAKER_01: It was so good for my brain.
• 10:54
  SPEAKER_01: It gave me something to focus on.
• 10:55
  SPEAKER_01: It was very grounding.
• 10:57
  SPEAKER_01: I loved thinking about problems and I loved coming up with research questions.
• 11:02
  SPEAKER_01: And so I then asked them, okay, how can I keep doing research?
• 11:06
  SPEAKER_01: I love this.
• 11:07
  SPEAKER_01: And they said, Well, you have to go to graduate school.
• 11:10
  SPEAKER_01: And I said, What is graduate school?
• 11:13
  SPEAKER_01: So I researched it and then I figured out what you had to do to go to graduate school.
• 11:18
  SPEAKER_01: One of my mentors said to me, Well, Morgan, if you're really interested in this topic of inpatient psychiatry, you could just study that.
• 11:27
  SPEAKER_01: Then I just applied to public health graduate schools.
• 11:29
  SPEAKER_01: Um, and I did a master's at Harvard, the Harvard T.H.
• 11:32
  SPEAKER_01: Chan School of Public Health, um, and then a PhD at Brandeis and Social Policy.
• 11:38
  SPEAKER_01: And I had sort of a research proposal in mind when I applied to grad school.
• 11:42
  SPEAKER_01: So when I arrived in my master's program at Harvard, I immediately started knocking on a bunch of doors and said, I want to do this project.
• 11:51
  SPEAKER_01: I want to interview service users and staff of psych facilities.
• 11:55
  SPEAKER_01: Will you support me?
• 11:56
  SPEAKER_01: And then I met this woman, her name is uh Meredith Rosenthal, and she's a she's um a health economist.
• 12:03
  SPEAKER_01: And she really is the one who helped me think about, okay, you know, documenting experiences is one thing, but why don't you start thinking about how these facilities are actually held accountable?
• 12:15
  SPEAKER_01: Um, because that's how you that's how you make systemic change.
• 12:19
  SPEAKER_01: Why don't you first try to understand the mechanisms that oversee these facilities and where there might be gaps?
• 12:27
  SPEAKER_00: What did you find when you began looking into those?
• 12:29
  SPEAKER_01: Our standards are pretty weak when it comes to inpatient psychiatric care in particular.
• 12:35
  SPEAKER_01: Um, that there's maybe an over-emphasis on risk mitigation and not a lot of emphasis on any sort of therapeutic benefit.
• 12:44
  SPEAKER_00: So is that where you we get strategies like for someone who's in serious crisis?
• 12:50
  SPEAKER_00: The best way to make sure nothing happens is to medicate them so they sedate them so they can barely move.
• 12:55
  SPEAKER_00: Is that basically Yes?
• 12:57
  SPEAKER_01: And that's actually an evidence-based way to prevent the use of physical restraints.
• 13:03
  SPEAKER_01: It's an evidence-based way to, in some ways, some would argue, to reduce violence.
• 13:07
  SPEAKER_01: Because yes, of course, if you medicate someone to a certain degree, then you are going to probably decrease agitation um and movement in general, um, and and the need for any sort of physical restraints.
• 13:20
  SPEAKER_01: Um, and so, and this is this sort of touches on some of my concerns with the overuse of the language of evidence-based, because it sort of masks values.
• 13:29
  SPEAKER_01: Um, and so, well, to your point about what I've discovered about accountability, I mean, at a very high level, I would say that our north star for accountability is there's risk mitigation, which, as I mentioned, includes liability management, but then also like safety management.
• 13:47
  SPEAKER_01: And then there's profit, making money or saving money.
• 13:50
  SPEAKER_01: So, and some might call that efficiency, right?
• 13:53
  SPEAKER_01: So we use the language that sort of masks other values.
• 13:57
  SPEAKER_01: And then sometimes there's clinical effectiveness, but nowhere up there is there human rights or recovery.
• 14:07
  SPEAKER_01: And I would argue that our current North stars for our system actually undermine uh recovery and also conflict a great deal with human rights.
• 14:19
  SPEAKER_01: Those are the values that are guiding it.
• 14:21
  SPEAKER_01: And so then it makes sense that when you're looking at the regulatory language and you're looking at our quality measures and how we're paying for care, that it's it is aligned with those values and it's not aligned with what I would argue actually is of therapeutic benefit to people.
• 14:42
  SPEAKER_01: And the one other thing I'll add is this is a population that is um, well, especially folks who experience crises or, you know, hospitalization, they can't easily speak up about what's happening.
• 14:53
  SPEAKER_01: If they did speak up, um uh they may not be believed.
• 14:58
  SPEAKER_01: Um and uh there is just sort of this underlying dehumanization, this view of dehumanization.
• 15:05
  SPEAKER_01: Um, and so as a result, I would argue that we allow for a much lower standard of care for this population than we would for other areas of healthcare.
• 15:19
  SPEAKER_01: Um uh and it is in part because it's a population that lacks power to push back against that and to push for accountability.
• 15:28
  SPEAKER_01: Inpatient psychiatric care historically has been the only hospital setting uh systematically excluded from patient experience measurement.
• 15:37
  SPEAKER_00: Oh, wow, that's interesting.
• 15:38
  SPEAKER_00: I didn't know that.
• 15:39
  SPEAKER_01: Yeah, the federal government for many years has sampled uh patients discharged from the hospital about their experience.
• 15:46
  SPEAKER_01: And then they publicly report it.
• 15:48
  SPEAKER_01: But psych patients are excluded.
• 15:51
  SPEAKER_01: And and and categorically, if you if if you have a principal diagnosis that is psych, that means you're hospitalizing a psych facility, you are not eligible to be sampled.
• 16:00
  SPEAKER_00: So if you go in a hospital for anything except a psychiatric treatment, your opinion matters.
• 16:06
  SPEAKER_00: But if you go in for psychiatric treatment, your opinion doesn't count at all.
• 16:10
  SPEAKER_01: Exactly.
• 16:11
  SPEAKER_01: But I do want to say the federal government very recently has now mandated that CMS start collecting patient experience for inpatient psych.
• 16:21
  SPEAKER_01: January of 2026.
• 16:22
  SPEAKER_01: So this year, so this year they are now yes, they are now collecting patient experience measurement.
• 16:29
  SPEAKER_01: Now, they have started doing this.
• 16:31
  SPEAKER_01: And so I think that that would you call that a step in the right direction?
• 16:35
  SPEAKER_01: Yes, I I would.
• 16:36
  SPEAKER_01: I would I would say it's it's actually a massive step and and totally insufficient.
• 16:42
  SPEAKER_01: So it's a massive step, but boy, we have a long way to go.
• 16:46
  SPEAKER_01: Um but that that's an example, like that's an example of um structural discrimination.
• 16:53
  SPEAKER_01: You know, it's a systematic exclusion through measurement.
• 16:56
  SPEAKER_01: And another example is for nursing homes, for example, we publicly report inspection reports.
• 17:03
  SPEAKER_01: So you can know if you have a loved one at a nursing home, you know, how they performed in terms of abuse and neglect.
• 17:10
  SPEAKER_01: We don't do that for inpatient psych.
• 17:12
  SPEAKER_00: Not just hospitals, but nursing homes as well.
• 17:14
  SPEAKER_01: I like comparing to nursing homes because they have similar arguments.
• 17:18
  SPEAKER_01: There's cognitive impairment, or there's also the use of restraint and and antipsychotics.
• 17:24
  SPEAKER_01: So pretty much any argument you have for inpatient psych is kind of reflected in nursing homes.
• 17:29
  SPEAKER_01: And so if we're able to do it for nursing homes, um, then then why can't we do it for for psych?
• 17:35
  SPEAKER_01: And also if we think nursing home residents are very vulnerable, why don't we think psych patients are vulnerable?
• 17:41
  SPEAKER_01: So I there's like a the logic isn't translating, um, which is quite frustrating.
• 17:48
  SPEAKER_00: Aaron Powell Yeah.
• 17:49
  SPEAKER_00: I I would don't want to be judgmental, but it sounds incredibly negligent.
• 17:54
  SPEAKER_01: Aaron Powell Negligent.
• 17:55
  SPEAKER_01: Yep.
• 17:56
  SPEAKER_01: I would say I I would argue betrayal and inpatient psychiatric care is an example of um profound betrayal by our healthcare system.
• 18:05
  SPEAKER_00: It's a powerful statement.
• 18:07
  SPEAKER_00: I want to jump to uh a trip that you made to Trieste, Italy.
• 18:12
  SPEAKER_00: What was going on in Trieste that made you want to go there?
• 18:14
  SPEAKER_00: And what did you see when you got there?
• 18:16
  SPEAKER_01: So I was part of a group that was on an eclectic group of people, clinicians, um, people, uh grantmakers, uh, a couple of people who work in policy, and a few of us were academics, and uh uh about three of us had lived experience ourselves who are part of this group.
• 18:32
  SPEAKER_01: Trieste is is a is considered to be a model of mental health care by the World Health Organization.
• 18:38
  SPEAKER_01: The foundation is based in respecting a person's autonomy, their right to shared decision making, um, their right to full participation in the community to be, to be meaningfully included in the community, and respect and dignity.
• 18:55
  SPEAKER_01: And these are these are sort of their core values.
• 18:57
  SPEAKER_01: And they're not, it's not just lip service.
• 18:59
  SPEAKER_01: And so they really invest in trying to operationalize this.
• 19:04
  SPEAKER_01: And um, so they have fully deinstitutionalized, that's sort of part of their claim to fame.
• 19:09
  SPEAKER_00: De-institutionalized, meaning like they don't have uh inpatient psychiatric hospitals?
• 19:13
  SPEAKER_01: Is that well, with a small caveat, they have a a small psych unit that's part of a general hospital that they do use quite minimally.
• 19:22
  SPEAKER_01: So rarely are the beds filled.
• 19:25
  SPEAKER_01: Um, it's really in the most extreme circumstances, um, truly when they're not able to support a person in the community, but they have such robust supports for people in the community where going to the hospital is actually a rare occurrence.
• 19:41
  SPEAKER_01: But then if a person does end up in this psych unit, they're they're kept there minimally.
• 19:47
  SPEAKER_01: It is open door.
• 19:48
  SPEAKER_01: So a person in theory could leave if they wanted to.
• 19:51
  SPEAKER_01: Um, and it is zero restraint.
• 19:54
  SPEAKER_01: And I remember uh visiting the psych unit and speaking with the director, and she's telling us a story about um going to someone's home and how, you know, they they determine, you know what, this actually is one of those cases where they could benefit from a few days in the in the psych unit.
• 20:10
  SPEAKER_01: They um collaborated with them, they negotiated, they did radical negotiation for about four hours.
• 20:17
  SPEAKER_01: And I said, why would you spend four hours if in your mind you think they need to go to the hospital and you have the authority, they actually do have the authority there, you could just do it.
• 20:29
  SPEAKER_01: Why would you spend four hours?
• 20:31
  SPEAKER_01: Um, and I was asking this because I really wanted to hear how she would respond.
• 20:35
  SPEAKER_01: Because these are the types of questions we get in the US.
• 20:37
  SPEAKER_01: Um, it's like it's not efficient.
• 20:39
  SPEAKER_01: And and she just smiled and was like, what kind of question is that?
• 20:44
  SPEAKER_01: Why would we rush anything?
• 20:47
  SPEAKER_01: We are building a relationship, a long-term relationship.
• 20:51
  SPEAKER_01: The most important thing here is building trust.
• 20:54
  SPEAKER_01: If we just rush in there and we force them and we traumatize them, they're, yeah, we could maybe help them in the moment, maybe, but they're never going to want to engage with us again.
• 21:04
  SPEAKER_01: And so what benefit have we actually given them?
• 21:06
  SPEAKER_01: And so it sounds so simple.
• 21:09
  SPEAKER_01: And yet our system really struggles, I would say, with internalizing that.
• 21:15
  SPEAKER_00: This idea of long-term relationships is I think it goes back to what you were saying about uh North Star or lack thereof.
• 21:22
  SPEAKER_00: Um, it seems so important to me, also kind of common sense to me.
• 21:26
  SPEAKER_00: Like, why would you think that's not important?
• 21:28
  SPEAKER_00: And yet it doesn't seem to be in our in our system.
• 21:32
  SPEAKER_00: Why is it that we put so little value on long-term relationships in our system?
• 21:38
  SPEAKER_00: And how much is the evidence really there that long term relationships really matter?
• 21:43
  SPEAKER_01: Well, I would say that there's plenty of evidence that long term relationships matter and that trust is super important when it comes to mental health care.
• 21:50
  SPEAKER_01: Um, we know even in the therapy space that the therapeutic alliance is one of the most important predictors of outcomes, sort of beyond the actual modality that a therapist.
• 22:00
  SPEAKER_01: Using it's really that relationship, the alliance that it that is most important there.
• 22:05
  SPEAKER_01: I would say also that we are really obsessed with medicalizing mental distress here.
• 22:11
  SPEAKER_01: Um, and and that that if you think about it, you know, a med a medical approach is really oriented around looking at symptoms instead of orienting around a person's actual goals for their life, which would be more of a recovery approach.
• 22:25
  SPEAKER_01: So in Trieste, they are responsible for people.
• 22:28
  SPEAKER_01: So if someone, you know, has a really bad experience and then they go on to have another crisis and then they don't want to engage in care, that creates a challenge for the same exact entity, right?
• 22:41
  SPEAKER_01: Like it's the same people, the same entity, the same provider organization that is responsible uh for a population.
• 22:49
  SPEAKER_01: Versus in the US, you know, you go to you see your psychiatrist, which is might be in private practice and your therapist here, and then you may not see them in six months, you know, and it it's really hard to locate who is responsible.
• 23:04
  SPEAKER_01: So I would say that fundamentally in Trieste, they have a sense of responsibility, which is part of their culture, but is supported by their structure and how they pay for care.
• 23:12
  SPEAKER_01: And in the US, there is no sense of responsibility.
• 23:16
  SPEAKER_01: And I actually call it hot potato, especially when people are in crisis.
• 23:19
  SPEAKER_01: When you don't feel responsible for the long term and you really only care about your liability, then you, yeah, you may engage in behaviors that benefit you as an organization, but not the person.
• 23:30
  SPEAKER_01: There's a misalignment in our system with the person.
• 23:33
  SPEAKER_00: And that leads to the really big question that I think you're spending a lot of time trying to answer, which is how do we change our system so that we get actually good results?
• 23:44
  SPEAKER_01: There's so much to say.
• 23:44
  SPEAKER_01: I mean, I could say, oh, well, well, we should consider a single payer healthcare system as though that's easy.
• 23:49
  SPEAKER_01: You know, but I I think beyond something like that transformative that requires a great deal of political will.
• 23:55
  SPEAKER_01: I think that at a very basic level, really just trying to address um like a a culture of domination in in our country that I mean, I actually think that that is part of um our struggle here.
• 24:11
  SPEAKER_01: But really, really trying to bring people along with with um with this idea that the vulnerability of um people experiencing mental health crises or with mental health conditions um actually impacts us all, right?
• 24:25
  SPEAKER_01: If it's so easy to infringe on a person's uh human rights and to treat them without dignity and respect, that means actually all of us are vulnerable to potentially experiencing such indignity or people we love.
• 24:37
  SPEAKER_00: Um and so so give me, give me can you spell that out for me?
• 24:41
  SPEAKER_00: Because I think you know, we tend to we tend to create this dichotomy in this world where those who have serious mental illness and the rest of us.
• 24:48
  SPEAKER_01: Right.
• 24:48
  SPEAKER_00: And so what happens to them doesn't actually matter to us, but that's not you're saying just the opposite.
• 24:53
  SPEAKER_00: Can you say why that's true?
• 24:54
  SPEAKER_01: Well, there's there's there's a couple of points to be made about that.
• 24:56
  SPEAKER_01: We all should be concerned, we all should be thinking, wow, so you know, for for the most marginalized people, what's happening to them, let's bring that up to a certain standard of care for selfish reasons.
• 25:08
  SPEAKER_01: Like there's a selfish motivation there.
• 25:10
  SPEAKER_01: There's also the reality that anyone could experience a mental health crisis.
• 25:14
  SPEAKER_01: Actually, we're not immune.
• 25:16
  SPEAKER_01: Um, and uh and you and you don't you don't know what might trigger it.
• 25:21
  SPEAKER_01: It brings me a great deal of pain to imagine anyone um being treated the way that I've I experienced or that I witness others being experienced.
• 25:30
  SPEAKER_01: Um it's terrible.
• 25:31
  SPEAKER_01: I I don't want to live in a world like that.
• 25:33
  SPEAKER_01: So I I would I say that that is foundational in our country because that's where we would actually get the political will.
• 25:40
  SPEAKER_01: There needs to be some some pressure on our system to change.
• 25:43
  SPEAKER_01: And that starts with people's consciousness.
• 25:47
  SPEAKER_00: This is all related to there was a study that came out in October of 2026 in uh JAMA, the uh Journal of the American Medical Association, a very prestigious publication.
• 26:00
  SPEAKER_00: It tells us a lot about how exactly what you're talking about, how we as a culture view those with mental health issues and substance use issues by comparing them to a community of people who have physical disabilities.
• 26:12
  SPEAKER_00: Yes.
• 26:12
  SPEAKER_00: Can you just really briefly tell me um what the study is and and what it was trying to find out?
• 26:19
  SPEAKER_01: What we found was that um the public is much more supportive of human and civil rights for people with physical disabilities, people who use wheelchairs, for example, um who have limited mobility, um, maybe some vision loss or deaf or hard of hearing.
• 26:35
  SPEAKER_01: Those would be like physical disabilities, and then severe mental illness, um, and then severe substance use conditions.
• 26:44
  SPEAKER_00: Those are the three groups.
• 26:46
  SPEAKER_01: Those are the three groups.
• 26:48
  SPEAKER_01: And just for an example, you know, uh one of the human rights was um freedom from torture and abuse.
• 26:54
  SPEAKER_01: Another was the right to be to live in the community.
• 26:57
  SPEAKER_01: And for civil rights, those included the right to be a parent, to run for political office, to um and to own a gun.
• 27:05
  SPEAKER_01: Um and and so the the public is much more supportive of all of those rights for people with physical disabilities than for the behavior for severe behavioral health conditions, broadly speaking.
• 27:16
  SPEAKER_01: And then actually, when it comes to those civil rights that we that we looked at, most respondents were not supportive of people's rights to be a parent or to run for political office, for example.
• 27:28
  SPEAKER_01: And so it suggests that there's a lot of room for improvement in terms of uh public support with regard to human rights and trying to imagine a rights-based approach to mental health care in the US, which is what they have in Trieste.
• 27:41
  SPEAKER_00: What's your personal opinion on what this indicates?
• 27:44
  SPEAKER_01: A culture in the US that is um not compassionate and does not appreciate the importance of uh human rights, which are not supposed to be conditional.
• 27:56
  SPEAKER_01: The whole point of human rights is that they're not supposed to vary across demographic groups.
• 28:02
  SPEAKER_01: Um and and so I I I do think that there's a lack of appreciation for why this is so beneficial to everyone.
• 28:10
  SPEAKER_01: And then there's also just a lack of compassion.
• 28:12
  SPEAKER_00: So in other episodes in the show, we were talking about uh alternatives to inpatient psychiatric hospitalization in general.
• 28:20
  SPEAKER_00: But really the purpose of the show is to talk about how do we do mental health care better.
• 28:24
  SPEAKER_00: If you were woke up tomorrow morning and and you were granted magically one wish to change the mental health system in this country, what would you wish for?
• 28:33
  SPEAKER_01: A single payer health care system.
• 28:35
  SPEAKER_01: Because single payer health care system basically is means essentially that the federal government is paying for health care and you know we pay into taxes essentially, and as opposed to uh everyone having a different health care plan and as opposed to provider organizations having to negotiate different payment expectations or contracts with various different payers, um, which can be quite burdensome.
• 29:01
  SPEAKER_01: Um, and also in mental health care, we have a number of organizations that um have been making a lot of money off of the vulnerability of patients.
• 29:09
  SPEAKER_01: And so it's not just like, oh, the providers aren't you know not incentivized to have long-term relationships, but that there are there's actual profiteering and people making money off of um the way that our healthcare system is structured.
• 29:21
  SPEAKER_01: A single-payer healthcare system would both would help with a lot better adjusting incentives and it would help with accountability and would create the conditions necessary for long-term relationships, I would argue.
• 29:35
  SPEAKER_00: I want to go to a very different place to something you did with that you included in your dissertation for your PhD.
• 29:41
  SPEAKER_00: And that's a poem that you wrote about your own experience when you were in mental health crisis.
• 29:45
  SPEAKER_00: It was that moment when you were being forcibly held down by a lot of people and forcibly injected with something that you thought was going to kill you, that you thought was a lethal injection.
• 29:57
  SPEAKER_00: Would you read us the last four lines of that poem?
• 30:00
  SPEAKER_01: The memory of being killed lives in the soil of my ground, binding to the motion of my feet.
• 30:07
  SPEAKER_01: Yes, I know what I got, and it continues to hurt.
• 30:12
  SPEAKER_00: I found that very moving, and your entire poem, I think, is moving.
• 30:17
  SPEAKER_00: Uh and for people who want to read the entire poem, we will post it on our website.
• 30:22
  SPEAKER_00: That's uh Brainstories Productions.com.
• 30:25
  SPEAKER_00: One thing you was really interesting was that you didn't, when you in your dissertation you didn't say who the author was.
• 30:31
  SPEAKER_00: Later on, when you revealed who the author was, what response did you get to that when you said when you said, actually, it was written by me?
• 30:39
  SPEAKER_01: People struggle to imagine that someone with the types of experiences I've had can also be a professor.
• 30:47
  SPEAKER_01: I have found such profound bias and discrimination in the academy towards people with diagnoses that might be considered serious mental illness, and and that there are a lot of barriers to succeeding in the academy for sure.
• 31:00
  SPEAKER_01: I think that that there's a character of people with serious mental illness that folks are really invested in.
• 31:07
  SPEAKER_01: There's this character that someone who is in crisis, it's almost as though they're constantly in crisis.
• 31:12
  SPEAKER_01: And there's a failure to appreciate what recovery might look like and the diversity of trajectories for people who've had these experiences.
• 31:20
  SPEAKER_01: And most importantly, I just want to say I have heard from other people with lived experience.
• 31:27
  SPEAKER_01: And they have, you know, you know, they have shared their stories with me, or they have said, you know, hearing someone, you know, uh, who's a professor or who has a PhD, um, validate the experiences I've had means a lot.
• 31:42
  SPEAKER_01: And it's quite powerful.
• 31:44
  SPEAKER_01: And so that that for me is very motivating.
• 31:46
  SPEAKER_01: And I I view that group as the group I'm I'm trying to work with and for, um, more so than some of the some of my other colleagues, even though, of course, I need them to approve of me so that I could keep living my life, you know, as a as a professor, but I'm not not really trying to perform for them in the same way.
• 32:07
  SPEAKER_00: Do you find a different response from students?
• 32:09
  SPEAKER_01: Well, I have found students to be much more open about their own lived experience in a way that I never can would have imagined myself being able to be open.
• 32:17
  SPEAKER_01: I do think that younger generations are just in general much more open about their their mental health struggles and their experiences.
• 32:25
  SPEAKER_01: And they sort of expect or even demand that the world be okay with them talking about it.
• 32:31
  SPEAKER_01: The students I work with uh don't seem phased, and if anything, they really value it.
• 32:36
  SPEAKER_00: Yeah, interesting.
• 32:38
  SPEAKER_00: I I think we could all learn from your students.
• 32:40
  SPEAKER_00: Last question how much, or maybe how little hope do you have for this country for delivering good quality mental health services?
• 32:48
  SPEAKER_01: Aaron Powell I oscillate on this.
• 32:50
  SPEAKER_01: I I would say that today, or this period of my life, um, surprisingly, I actually do have a lot of hope.
• 32:59
  SPEAKER_01: I think that um we're in a really dark period in our country, frankly.
• 33:05
  SPEAKER_01: And I think typically when we go through periods like this, there's a swing of some sort.
• 33:11
  SPEAKER_01: And I'm very hopeful that at a certain point we will experience a swing and that there will be policy opportunities and that there will be a cultural shift.
• 33:21
  SPEAKER_01: And to your point about my students and the younger generation, I do see in them um uh an expectation for compassion and inclusion that does give me hope with regard to our future leadership of our country.
• 33:38
  SPEAKER_01: There's a lot of really um caring people in this country, you know, and uh it's just yeah.
• 33:46
  SPEAKER_00: Yeah, I think that's the key is if we can help get the caring people to be in decision in in places where they're making decisions.
• 33:54
  SPEAKER_01: Yes, I agree with you.
• 33:56
  SPEAKER_00: Morgan, thank you so much for coming on Brainstorm.
• 33:59
  SPEAKER_01: Thank you for having me.
• 33:59
  SPEAKER_01: This was so fun.