A heads up for listeners, this episode discusses topics including mental illness, sexual assault, and suicide.

I want you to remember the last time you were at the hospital.

Maybe you needed to admit yourself for a broken bone, or maybe you brought a family member or friend to get treated.

The last time I was at the hospital was for a UTI gone wrong.

Yeah, my kidney almost failed.

Now I want you to remember leaving the hospital.

You probably got discharged from the facility with some meds and or maybe a cast that fixed your bone.

And sometimes they tell you to follow up with your general practitioner to make sure you're healing well.

At most healthcare facilities, this is the norm.

You, the patient, are at the center of it all, and the main goal is to get you better.

But what if I told you that this isn't always the case?

What if I told you that there are healthcare facilities that can inadvertently worsen your condition?

I'm talking about the case of inpatient psychiatric care.

Today I'm featuring a special guest whose lived experiences might make you question the state of mental health care in the United States.

From witnessing it from the sidelines as her father experienced bipolar disorder to experiencing psychosis and manic episodes herself, she found herself asking time and time again for help, only to walk away feeling disappointed, hurt and abandoned by the system.

Her journey is one that you'll be thinking about weeks after hearing her story.

Foreign.

Welcome to another episode of the Global Health Pursuit Podcast, the podcast where we explore the world's most pressing health challenges through a beginner's lens.

My name is Hetal Daman.

I'm a biomedical engineer turned social impact podcaster and I'm your host.

Today we're talking about inpatient psychiatric settings in the United States.

Our guest today shares a story that exemplifies how research on the quality of inpatient psychiatric care is lacking, how ironically untherapeutic inpatient psych care can be, and actually how unsafe it can be for patients who experience this type of care.

We're talking about suicide rates exponentially increasing post care, and how all of these experiences have culminated into her research focusing on driving patient centered care and equity in these critical settings.

In order to do that, she tells me that she's working to understand these two questions now.

How might we best try to measure how loving care is?

And how might we think about implementing interventions to improve care quality in ways that are maybe more aligned with principles of love?

The voice you just heard is Dr.

Morgan Shields.

She's an assistant professor at Washington University in St.

Louis, and she leads a lab Dedicated to understanding how care quality varies in behavioral health settings beyond just clinical effectiveness.

She's one of the few researchers focused on the quality of inpatient psychiatric care, which makes her work and her personal experience so critical.

And speaking of experiences, what were the experiences that you've had, you know, growing up?

What were those life changing moments for you that catalyzed your way into this research?

Yes, everyone's always so curious.

Why would you be interested in, in, in particular, inpatient psychiatric care?

Because that is where I've.

I've focused most of my work.

And I think people are so curious as to what types of lived experience I must have.

Because why else would you be interested in a setting in a population that is so dehumanized.

Right.

It's so dehumanized to the point where it seems people can't fathom that anyone would actually be interested in understanding what's going on there and trying to improve care for the population.

So I can share two buckets of lived experience.

So the first is I.

I'm a family member to people who have significant mental health struggles.

My father in particular was diagnosed with bipolar disorder.

And, you know, I totally respect and appreciate that survivors of the mental healthcare system might not feel comfortable with diagnoses.

I just want to kind of put that out there that I respect that.

I think in the case of my father, bipolar disorder really does appropriately capture the condition that he really struggled with.

So he would be manic and enter psychosis, and that would last for about two years on average.

And he would enter depressive episodes that also would last for about two years on average.

These are very significant, prolonged episodes, very disruptive.

My father struggled with employment, so he was.

He experienced homelessness for most of my childhood.

He couch surfed, he slept in cars, and when he was depressed, it was terrible.

I mean, there was.

We couldn't leave, we couldn't do anything.

When I was spending time with him, it was really sad.

And when he was manic, it was frightening.

And quite honestly, he would do things that were abusive in his mania.

He would say really awful things, he would get angry, he would drink, et cetera, et cetera.

And so the reality of living with a parent who has pretty significant mental health struggles like my father had, it is tr.

It could be traumatizing for the child.

So I just, I want to validate that.

Right.

How old were you when your dad was diagnosed with this?

Oh, he was diagnosed before I was born.

And, and actually my parent.

When my parents met and they conceived me, my father did not have stable housing.

So actually, I was kind of born into a state of instability with my father.

I'll just say for context, my mom, kind of witnessing some of my dad's cyc, became quite afraid.

And I grew up.

I grew up in constant fear that my dad was going to kill himself and.

Or if he was in mania, other things.

Other things could happen.

So.

But please, if I can, I.

I love my father, like, deeply.

So multiple things can be true at once.

Who my dad was, at his core was an incredibly loving human being.

I mean, and brilliant.

He was brilliant.

He was funny, loving.

He could get along with anybody.

And so learned a lot from my father.

I.

I felt that he loved me deeply.

And I'm so glad that I had him in my life.

So a part of me is really glad that my mom sort of kept him around me.

So.

Okay.

I know it's a deep breath.

Yeah.

So that's some context.

What I can say is, from my perspective as a child, my father had these episodes, and they were really frustrating, right?

All I wanted, and I would pray for it at night, all I wanted was for my dad to get help.

And from my perspective, there was help out there, right?

There is health care, and someone could help him.

But the issue was, was that he was totally unwilling to engage in care.

And when he would get very acute, especially when he was experiencing psychosis, I remember my mom sort of trying to think of different ways to get him hospitalized.

And it was challenging because patients do have rights.

You can't just take your family member and, say, hospitalize them.

But that was frustrating to me as a child because then my father knew how to perform.

If he ended up at a hospital in a way that, you know, oftentimes they would say, we can't do anything, and he would leave.

And then the only way that we could intervene is if he did something so awful that then he was arrested.

And then.

So he would.

He would get arrested, he'd go to jail.

Sometimes my mom would leave him there for several months.

And so he totally came down from his manic episode, had no access to alcohol or, like, stimulating environments, and he would come down.

So I viewed the hospital as almost like a savior.

Like, if only.

If only we can get him hospitalized, this hospital can save the day because they know what they're doing, they are skilled and competent.

If only my dad would engage in the healthcare system, everything would be okay, because the care is there, the expertise is there, and the issue is my dad not wanting to engage.

So that's so so that's part one.

My first category and then my second category of lived experience, where things sort of shifted for me is I had my own lived experience of inpatient psychiatric care.

And through those experiences, I then gained some insight into how non therapeutic inpatient psychiatric facilities can be and why it was that my dad was not trusting of healthcare providers and not willing to engage in care.

Research shows that people discharged after inpatient psychiatric care experience a suicide rate within 7:30 days post discharge, estimated to be approximately 300 and 200 times the general suicide rate, respectively.

These high suicide rates following discharge from inpatient psychiatry have led some researchers to hypothesize that psychiatric hospitalization might have an iatrogenic effect among some patients.

Iatrogenic meaning it's something related to an illness.

In this case, suicide rates caused by the medical examination or treatment inpatient psychiatry.

Dr.

Shields writes more about this in her 2023 paper, Patient Centered Inpatient Psychiatry is Associated with Outcomes, Ownership and National Quality Measures.

And I'll also link the paper in the show notes.

The first experience I had was when I was 16.

And I'll just give a.

A warning to your listeners.

Although I.

I sort of did just jump into some very light trauma.

So just a little warning that there's going to be brief mention of sexual assault, but I'm not going to go into too many details, but I'm just gonna.

For context.

So when I was 16, my mom's boyfriend actually raped me.

And it was in a pretty horrific way and very scary.

After that happened, I became very scared that he was going to kill me.

And things kind of spiraled and police and detectives became involved and my life felt like it was totally out of my control.

Something very scary and life threatening had happened.

I'm having to do all of these interviews with investigators.

Everything is very stressful.

And I stopped sleeping.

I barricaded myself in our bathroom to try and hide essentially every night.

And I wasn't sleeping.

And this whole series of events then triggered a manic episode.

And so then I entered mania at age 16, which for me did include psychosis.

Can you explain what that means?

Like psychosis?

So there's usually a trajectory where you start with a little hypomania and it feels great.

You don't need as much sleep.

You're able to focus, you want to stay busy, you're cleaning a lot, maybe you're very happy and you're just a ray of sunshine.

And you, you may actually be a very fun, good time for people.

Right.

You may get annoying if you're like talking a lot.

And, and so there, there are like social consequences to this.

But generally like hypomania, that beginning stage feels good.

If it then continues to escalate and you enter full blown mania and you have psychosis that occurs, which tends to happen especially if you stop sleeping.

Right.

If you stop sleeping in general, that's, that's a risk, then it can become quite darker.

You might experience more agitation or anger.

And yes, if you have psychosis, then of course there's paranoia, there could be delusions.

So something, for example, that my dad experienced was feeling that we were part of a holy family or that we were aliens, we had alien DNA, or that his dad was still alive on an island and that the government kept him alive.

And these were very real to him.

And I would say for me, when I experienced my episode, I also had very creative ideas of, of my reality that started to emerge which, yeah, again it, it was a coping mechanism I think for me when I was 16, because instead of being really devastated by what had happened to me when I entered hypomania, it was, it's okay, I forgive my rapist.

I love everyone.

I never, I didn't like go through a, like, oh my God.

I just went straight to, it's, it's okay everyone, let's just love each other.

Life is beautiful.

Let's just be family.

It's almost like that toxic positivity, like.

Yeah, yeah.

I was institutionalized at two different places.

One place ended up shipping me to another place because I was so manic.

And I'll share one story from this episode.

How long was this episode?

Oh, I don't know, maybe a couple months, which is interesting.

So it's very different than my dad who kept sort of experiencing these cycles his entire life.

They're very long.

I'll share a story that sort of captures how the healthcare system tried to support a 16 year old girl who had just been raped.

Right.

So for, for, just for some imagery, I, I want people to know that I still had my rapist's hands as bruises on my thighs and I was strip searched.

And I remember the woman saying, where are those bruises from?

And I said, well, I had, I was raped a couple weeks ago and standing there naked.

So you, you enter this is.

Not everyone is strip searched, but I was.

Then she allowed me to put on a hospital gown, which was very nice of her.

Now I'm a little manic, right.

And I'm like all about loving people, right?

So there was a nine year old boy who was crying.

He was crying.

He.

He missed his mom.

He just kept saying, I really want to see my mom.

There was a frontline staff person, a nurse or a tech, who, by the way, had, when I first got there, made fun of how small my breasts were.

Okay.

Which is like, yeah, strike one.

Strike one.

Yeah.

Whoa.

Then he starts yelling at this little boy and says, you need to stop crying.

You should have thought about missing your mom before you hit your sister.

And then he told this little boy, you need to man up.

So I come in because, you know, I'm feeling all like the hero.

And I said, you need to stop yelling at him right now.

And this staff member said, you need to shut up.

I used a curse word.

I used the F word in response.

He then said, if you.

If you curse at me one more time, I'm going to call him back up.

So I did.

I said, f you.

I.

Just to be clear, I was not violent.

It did not deserve this.

He called in a big group of really strong men who came down and they grabbed my body.

I was pretty thin at the time.

And they brought me into a padded room, and they pinned me up against a wall, and they took my journal away from me, and I never saw that journal again.

I was pretty upset about that.

And then they brought me into another room where they strap you down.

And they threatened to strap me down if I didn't stop asking questions.

Because I was asking some questions like, what's happening?

They injected me with a chemical restraint.

I then obviously took a nap.

When I woke up, I was.

As part of my punishment, I was not allowed to wear my clothes.

I.

Not even my underwear.

I had to wear a gown, and I had to sit in the hallway, and this is for humiliation purposes, and write an apology letter for my attitude.

Now, I just want to be very clear, as someone who actually has expertise on the regulations for inpatient psychiatric care, that that was a totally inappropriate use of chemical restraint.

You are not allowed to do that.

If you have a child or an adult who is cursing, who's giving you attitude, you cannot restrain them for punishment purposes.

Restraint should be used in only, like, the most extreme circumstances, to be clear, because it can be traumatizing in extreme circumstances.

Like, examples of that would be, well.

You have a patient that's so agitated, they pick up a chair and they throw it.

I mean, there's, like, clear evidence that they're about to cause harm to people or to themselves.

Oh, and then I lost access to visitation, so I wasn't allowed to see My parents, they were.

The entire time I was hospitalized, my mom could not access anyone at the hospital, so my mom didn't know what was happening.

I actually.

Because I had been transferred from another facility to this place, and she was unable to speak with anyone about what was happening to me when I was going to be discharged.

And so that was really upsetting.

From a family member perspective, you can imagine being the mother in that situation and feeling, like, pretty out of control and no way to get your kid out.

You're.

You're sort of trapped there until they decide that you're ready to be released.

Needless to say, I did not find that experience to be therapeutic.

I had just been raped, and that was a precipitating factor, trauma.

And I was restrained by really strong men.

A big group of them pinned me against the wall.

My clothing was removed, and I was humiliated and blamed.

So really upsetting.

And so that's.

I was 16.

There you go.

I got my first dose of lived experience in my skin.

Now I have lived experience as a family member.

And now I totally get why my dad did not want to go to the hospital.

Right.

And so I'm.

I'm.

Now I'm, like, feeling less resentful.

I'm feeling like a little bit more of a kinship, sort of with my father.

Now flash forward to age 20.

And this was 2010, so not that long ago.

You know, at this point in time, I was living at my mom's house in Florida, in South Florida.

And my father was in a manic episode at this time, for context.

And it was stressful for our family, but I tried to be a supportive daughter during this time, so I would try to, like, meet him places.

And I started taking Vyvanse, which is sort of like Adderall, which was a bad decision.

You know, I probably.

I.

Maybe I should have known that taking a stimulant maybe wouldn't go well with my biology.

I mean, you're young, right?

Like, you don't know all of this stuff.

It's like, how are you supposed to.

Know all of that?

And I did.

I was struggling with attention because I was taking classes at a community college.

I was trying to work at the mall, which was really far away.

And then I was trying to support my father, and it was very stressful.

And I was trying to get through a math class.

It was just really hard to focus.

I thought I must have ADD or something.

And so I get prescribed Vyvanse.

I take it, and I stop sleeping.

And then here we go.

So this is lesson learned.

I will never take Vyvanse again.

I entered an extremely scary manic episode with psychosis.

I needed some sort of emergency intervention.

I did.

And actually we did go to the hospital.

I went to the hospital voluntarily with my mom.

My mom said, wouldn't it be good if you could go to sleep?

And I said, absolutely.

For those of you who don't know, Vyvanse, otherwise known as lis, dexamphetamine, is a central nervous system stimulant and affects the chemicals in the brain that contribute to hyperactivity and impulse control.

It's used to treat patients with adhd, or attention Deficit Hyperactivity Disorder.

One of the side effects is that it may cause new or worsening psychosis, unusual thoughts or behavior, especially if there's a history of depression, mental illness, or bipolar disorder.

And you didn't like, sleep at all?

No, I.

I was like, not sleeping.

And the thing is, is that eventually the psychosis, like I started being afraid that our house was gonna fill with gas and that people were watching us through these mirrors.

And it was.

It was really hard to go to sleep because I kept thinking about how it was filling with gas.

And then my thoughts were racing and racing and I'd go off on these missions where I felt like these spirits were pushing me to do certain things and I had to just do it no matter what.

So, like, I would go to hotels and say, can I swim?

Swim in your swimming pool to be baptized.

Is this like holy water?

Wow.

So, all right, hitchhiked.

I went to the Hard Rock once with no money and got up on the stage with some musicians and started like praying to gods.

And then security said you could not be up there.

And I'm like, oh, yeah, I totally understand.

I was very peaceful, by the way.

I was a very peaceful, docile person.

But like, I was putting myself in harm's way, like significantly.

And then it kind of escalated into a pretty serious episode.

But what I'll say is I ended up going to the hospital on a voluntary basis and it didn't actually help me.

And there was no follow up care post discharge.

How long were you in the hospital for at that point?

Probably only a week.

Then it escalated and then I ended up at a train station completely naked.

And cops were called and cops brought me to the hospital again.

I won't go into the details of all of that, but I was, I was completely naked.

Just to say things were pretty extreme.

And they brought me to the hospital.

I was petrified.

And I then at one point I asked.

I asked the psychiatrist, because I'm thinking that people are out to get me.

Like, it sounds almost like schizophrenia.

Well, I mean, that's the confusing part with bipolar.

Well, bipolar disorder or these sorts of manic episodes that have psychosis.

So there's psychosis, but the psychosis is really only there when the person's in mania and they're.

They're not sleeping.

So.

But.

But yes.

I mean, absolutely.

I feel like I have a lot of ability to empathize with people who have a schizophrenia diagnosis, Right.

Because for me, what I always reflect back on is mostly what I was experiencing was absolute terror and fear.

And the opposite of what I needed was to aggravate my terror, right?

And so I asked this psychiatrist in the hospital, and I was obsessed with Michael Jackson at the time, and he had died a year before.

And I said, are you going to kill me like you killed Michael Jackson?

And I was.

I just to emphasize I was pretty calm and I said a silly thing.

But guess what?

We're in a psych facility.

Everyone's saying silly things.

If there's any place that should be able to handle people saying silly things, it's a psychiatric facility, right?

So I said a silly thing.

I really needed reassurance.

Instead of reassurance, he said, that's it.

And maybe because I used the word kill, I'm not sure what happened there.

He called in the backup.

Why is there.

I don't know why there's backup.

Like these, like security.

These big, strong security men.

And.

And they come and there's a woman involved, too.

And they grab my body again and they pin me down on a table and they.

They inject me with something in my butt.

And I said, what are you giving me?

And this woman said, you know exactly what you're getting.

And so from my perspective, I thought they were killing me.

So I said, I thought, oh, it's lethal injection.

So then they put me in a cell.

It literally was like a cell.

And I'm now convinced that I've been given lethal injection.

So I don't want to die.

Just to be clear, at no point has my lived experience and myself being hospitalized involves suicide or suicidality.

It's kind of been the opposite where I've been so afraid that I'm going to die.

So I'm in there and I'm like, I don't want to die.

I start doing jumping jacks and to keep my heart rate up.

And then I'm slowly kind of fading.

So I lay down and I say some pretty.

Pretty deep prayers and I.

I just.

I basically give up.

I'm like, I just have to let my spirit go, and that's it.

And I started hearing, like, Tracy Chapman music.

She's not dead, but I started hearing her music.

And I thought, well, that's my cue to die.

I didn't die.

I woke up.

But here's the thing.

Even though I know now that I didn't die, my body lived through the terror of thinking that I was dying.

And that has caused me significant pain.

I have developed PTSD from that episode that.

I mean, I have to say it has disrupted my life.

Like, it is something that I still manage this sort of sensation, these flashbacks to this sensation, this fear that I'm dying.

And that could have been avoided because it could have been avoided if, when I asked, are you going to kill me?

If the doctor said, absolutely not.

We're here to help you.

And it could have been avoided if, when they were pinning me down, if the woman just told me what they gave me, we're giving you a sedative to help you calm down.

And nobody answered my questions both times.

Instead, they answered my questions with violence.

And it.

And it caused a lot of harm.

And I find it quite upsetting that this is what we call treatment in our country, that this is how we are supporting people who are in a state of crisis.

For me, I was really scared.

The opposite of what I needed was to be terrorized even more.

Right.

That was my fear.

Wow.

Throughout these years, you touched on the inpatient psych experiences.

Have you had a therapist that you used to go to weekly?

Did you experience any of that?

You would hope, right, that after all of that, I would have had access to high quality mental health care.

At the time, we didn't have health insurance, so that's some context.

This was before the aca.

Some of the provisions of the ACA went into effect, so I didn't have health insurance.

I started seeing my dad's psychiatrist.

So there was some medication management immediately after, but no therapy, no psychotherapy.

I eventually moved to Kent, Ohio, from South Florida.

I moved to Kent, Kent, Ohio, to go to Kent State.

And I can say that I struggled a lot when I transferred to Kent State because I kept having these flashbacks and I kept having these episodes of panic where I would feel like I'm dying.

And I would text my really good friend Kelsey, actually, and I'd say, kelsey, I feel like I'm dying.

Do you think I'm dying?

And they would say, you're not dying, dude.

And I'd say, okay, thanks.

It was almost like an OCD thing.

Like I'd get an overwhelming flashback and I would need someone to reassure me that I'm not dying.

This was happening.

I was having this flashback and Kel said, why don't you go to your campus mental health center?

They can help you.

And I was like, brilliant idea.

So I go and this man, he meets with me and he says, you need to go to this other place on the other side of campus.

And they said, okay, I, I really want help.

So I walk to the other side of the campus and this woman greets me and I go into her office and she does, she has like an emergency session with me.

And I tried to start, I started explaining what happened right.

In Florida at age 20.

I started explaining all of it and then the trauma of it, and then I'm getting these flashbacks and maybe I overwhelmed her, you know, and she didn't really know what to do because this.

Was a on campus thing.

Right.

So I imagine the things that she usually deals with is like, oh, I failed my exam and I feel really depressed or something like that or.

Yeah, exactly, exactly.

This is a national issue on college campuses is their inability to support students who have mental health conditions or crises.

But that's like another conversation.

According to an article by the national education association, 90% of counseling center directors reported an increase in students seeking services.

Now this was before COVID 19 and at that time most of the wellness centers had waiting lists with timelines of several weeks to see an in person counselor.

Because of the demand for services, these counselors faced burnout, which then ultimately led to the rate of turnover to rapidly increase.

The article even mentions that some colleges have sought to cut spending by cutting counselors jobs and outsourcing the work, which then led to faculty and adjuncts having to pick up the load when they aren't even trained in counseling.

It seems like a mess.

So she then calls paramedics on me and the paramedics come and I called my mom actually, and I was like, mom, I'm really scared.

I, I went to get help and she called these paramedics and my mom just said, stay really, really calm, Morgan.

Now even my mom now knows the hospital is not avoid going there.

And, and so I stayed really calm and I, I answered their questions and they turned around to the therapist and they said, we cannot take her anywhere.

She's totally fine.

And so then the therapist became frustrated and decided to call police.

I'm just so like, mind blown Right now because it's like, why, why would she ask, like, did she feel that you were a threat to her?

For me, I was telling my story, right?

Like these are the things that have happened.

And I don't know if it was like by sharing with her the, the capacity of where my brain could go in terms of psychosis, where she felt like, oh, you're, something might be happening with you.

And then I was sharing what I was currently feeling like my sensations in my body and that it felt like I was dying.

So I'm not sure if like from her perspective maybe she was worried.

Well, I don't, I don't know, maybe, maybe she is dying or I don't know, like where the miscommunication came in.

And I can imagine that there was a lot of bias and stigma and a lot of assumptions made where she was not able to kind of listen to me or connect with me once I kind of shared where I was coming from.

I just feel it's really hard sometimes for, for people to not default to their stereotypes that they have of, of people.

And, and she probably didn't have that much experience, to be honest, as you said.

And so she called cops and the cops come in and they really scared me, I have to admit.

And then they sort of tricked me.

They said, it's in the best interest of your family if you come with me.

And I thought, what do you mean my family?

Like, what's going to happen to my family?

And then they said, there's a place on campus and they can help you.

Let us take you to them.

And I said, absolutely.

Again, I'm like, take me.

I keep saying yes, give me healthcare.

They put me in their cop car and they drive me really far away.

They do not drive me on the other side of campus.

And they ended up driving me to a hospital that then observed me in a room for like, I don't know, eight hours and they decided that I was okay and they fed me some SpaghettiOs and then they just released me and I received no follow up care.

So it solidified for me that it's not safe to try to get help from the healthcare system.

So if I'm being completely honest, the reality for me is I did not receive any therapy up until I started my job as faculty.

Wow.

That's when I decided, okay, now I can try and get some therapy and, and process things.

And maybe the fact that I'm, I'm faculty will help prevent some of these bizarro like discriminatory assumptions about my Capacity to live a productive and happy life and who I am.

But yeah, I love to come on here and say, oh, go reach out for help.

There's help there.

But for me, in my lived experience, I did try to reach out for help many times.

And for me, each time I tried, it was quite traumatizing.

It made things worse for me, just to be clear.

Like, for me, I did need to potentially be given some medication that would have brought me down.

I did need some sort of safe landing pad, but I didn't find that necessarily at the hospital.

So you mentioned the regulations that were put into place for inpatient psych and how they weren't really met when you were experiencing that.

And then you say, I wish I got the high quality mental health care that was, you know, outpatient kind of setting.

Explain the difference between, like, why the quality and safety seem so different, you know, when it comes to inpatient and outpatient settings.

Okay, so I can answer this, but I can say is I'm not sure there's actually been much head to head comparison between outpatient and inpatient.

And so I'm going to sort of answer this from a place that is based in sort of conceptual and theoretical reasoning and describing differences in the features of care.

But I can't necessarily point to empirical evidence that says, you know, outpatient care is better than inpatient care per se.

First of all, inpatient psychiatric care is an institutional setting where it's.

You can kind of think of it as a black box.

Patients don't have a lot of choice in where they receive inpatient psychiatric care or whether or not they're going to be hospitalized.

And so these facilities don't necessarily face any sort of reputational or market consequences for providing care that is of poor quality.

There's not necessarily very clear feedback from the people that they're serving.

It's not like the people they're serving can just get up and walk away and say, this is bad, I'm not coming here.

And because it's inpatient psychiatric care, unfortunately it means that families do not have easy access to patients when they're hospitalized, as they might have in other hospital settings, but also certainly in outpatient settings.

In outpatient settings, a patient comes and then they go, right?

They're not trapped there.

They have agency.

They could get up and leave.

In the middle of a session in an institution, you are stuck there, right?

So that there's a huge power imbalance just there alone.

Lack of choice where you go, whether you go and when you leave and your Family can't easily visit, they can't easily observe what's happening or advocate for you.

If you're in a psych facility, it's assumed that your perception of reality must be a bit distorted.

And I think that creates a barrier sometimes for the providers, the staff within these facilities and regulators and policymakers to sort of prioritize patient centered principles and trauma informed care and to see the value in trying to address some of these power imbalances.

It's almost like the root cause of this is dehumanization and then the features reflect that dehumanization.

So these are people that don't deserve, you know, a clean facility or they don't deserve safe care.

They don't deserve to be listened to and to be treated with respect because there's something wrong with them.

So we dehumanize them and that way we don't have to feel bad about ourselves for providing care that's not that great.

I mean, the other thing is it's hard to find and retain staff.

And so unfortunately I think that then what happens is sometimes facilities don't feel like they're able to have high expectations for their staff, especially if their staff are in a union.

I think unions can be excellent.

Right.

But unfortunately, sometimes advocacy for staff well being comes at the cost of patient well being.

I don't think it has to.

If you actually implement trauma informed care models, those, there's empirical evidence for this, they benefit both patients and staff.

If you de escalate, if you treat patients with respect and dignity, there's going to be less conflict, there's going to be less restraint episodes.

Staff are not going to be injured as much.

It's a win win.

But unfortunately staff, and maybe unions view efforts to reduce the use of restraint and seclusion as, as threatening to the frontline staff.

It's sort of potentially reducing a tool at their disposal to protect themselves.

So there, so these sort of competing forces where sometimes or maybe oftentimes in these facilities there's an us versus them mentality that develops staff versus patients.

And staff, by the way, often don't ever see patients recover.

You know, they are just constantly seeing patients in a state of crisis.

So they may not know their capacity to recover.

And it's this very dehumanizing view of patients and there could be moral injury where, you know, they're, they're in these facilities and they may not feel that great about having to restrain a person.

I mean, who would feel good about that?

And so in order to feel okay about it, unfortunately, sometimes what, what develops is this a dehumanizing perspective of the patient.

And then of course, burnout leads to that as well.

Staff don't feel supported or well paid, et cetera.

So it's staff against patients and then it's administrators against payers and regulators.

And so whenever a payer or regulator says we want to try to improve accountability, we want to measure this better or we, we expect you to do something better, unfortunately, then providers feel threatened.

You're not paying us enough.

Right.

You know, you don't know how hard it is to treat these patients.

They're just so complicated.

Patients are just constantly being thrown under the bus.

Then there's that tension between leadership, the providers and the payers and the regulators.

There are places in the world, and I love to kind of go on and on about it, but there are places in the world where they have almost totally deinstitutionalized their population, where maybe they have just a few psych beds in their entire sort of proximity.

They buy into a value of rights based, person centered, recovery oriented.

What seems to support the viability of these approaches is an environment where everyone sort of buys into those values and those principles.

A strong social welfare state where you don't have people experiencing homelessness.

Unfortunately, the healthcare system does end up absorbing a lot of the failures of the rest of our social fabric and our services.

So in these places, they have strong social welfare system.

People are not struggling to live.

They have community like clubhouses where people with mental health conditions can go.

They have agency in how the clubhouse is managed.

They work, they're respected, and there's accountability and there's value in accountability.

And if someone does have a crisis that they try very hard to negotiate with the person, you know, well, what if, can we take you to so and so and see if we can try this medication?

And if they refuse, then it's okay?

Well, what about.

It's a constant negotiation and relationship building and trust building as opposed to being pinned down.

And then.

Yes, and, and then what happens is the folks with mental health conditions really trust the system.

They've developed trust, they developed relationships.

And then they're more likely to maybe go along with some of the suggestions in the future because they have been shown dignity in the past.

And so I just wanted to throw that out there, that it is possible.

I'm not sure if it's possible in the United States.

Oh, so this is, this is outside of the States?

Yeah, this is like in Italy.

I see.

Dr.

Shields is referring to a community based approach to mental illness that is modeled in the small Italian city of Trieste.

There, the approach to mental health care is anchored in kindness and agency where people are not defined by their mental illness.

It seems to be starkly different from practices in the United States and as you can probably tell, we're basically at the end of the episode.

But have no fear, there is a part two because to be honest, we have hardly scratched the surface in this episode.

We learned a lot about Dr.

Shields own personal journey and honestly I didn't want to edit any of it out.

There were some hard truths that were told.

Living with someone with bipolar disorder is one thing, but then experiencing the state of inpatient psychiatric care herself was eye opening and made her empathize with the way that her father was treated.

There's a lot of work to be done.

Next week we'll be diving into the polarizing ideas that people have around how to reform inpatient psychiatric care in the us, how we can improve accountability within these settings, the differences between for profit and non profit psychiatric facilities, and finally, what Dr.

Shields has found in her research of it all.

Thanks for listening to this episode.

If you have any questions for Dr.

Shields, make sure to comment them down below.

If you're listening on YouTube or Spotify or shoot me an email at hetallobalhealthpursuit.com learn more about Dr.

Shields by checking out her research at Washington University in St.

Louis.

All of the links and information is in the show notes.

Make sure to hit, subscribe or follow and leave a review if this episode resonated with you.

I'll see you in Part two.