Awareness for mental health services in the U.S. has increased in recent years, but more work must be done. Over time we’ve learned how to talk about it – and just how important it is to speak up – as one in five people will experience mental illness. Sarah Cassell, the director of inpatient mental health services at Regions Hospital, joins the show for a conversation about the cultural connection to mental health stigma, the overall increase in the need for mental health services, mental health-related emergencies during the COVID-19 pandemic, and much more.
Awareness for mental health services in the U.S. has increased in recent years, but more work must be done. Over time we’ve learned how to talk about it – and just how important it is to speak up – as one in five people will experience mental illness.
Sarah Cassell, the director of inpatient mental health services at Regions Hospital, joins the show for a conversation about the cultural connection to mental health stigma, the overall increase in the need for mental health services, mental health-related emergencies during the COVID-19 pandemic, and much more.
Hosts: Kari Haley, MD, and Steven Jackson, MD
Guest: Sarah Cassell
HealthPartners website: Off the Charts podcast
Got an idea? Have thoughts to share? We want to hear from you. Email us at offthecharts@healthpartners.com.
Dr. Kari Haley:
He's a rehab doctor from Chicago.
Dr. Steven Jackson:
She's an emergency medicine doctor from the Twin Cities.
Dr. Kari Haley:
Together we're examining the health equity emergency.
Dr. Steven Jackson:
Inviting voices for change without the cue cards.
Dr. Kari Haley:
I'm Dr. Kari Haley.
Dr. Steven Jackson:
I'm Dr. Steven Jackson.
Both, together:
And this is Off the Charts.
Dr. Steven Jackson:
Welcome to the show. Today we are very privileged and honored to have Sarah Cassell, who happens to be the director of inpatient mental health services here at Regions Hospital, and a great leader, and passionate, and always ready to go. Sarah, welcome.
Sarah Cassell:
Thank you both. Thank you for inviting me.
Dr. Kari Haley:
We're so glad to have you here. One thing I'd love to hear more about is kind of your journey, so tell us more about you and how you ended up in this position.
Sarah Cassell:
Yeah. Thank you for that question. I have been at Regions Hospital for a total of 21 years. I started my career here... Well, previously I had a year or two exposure to long-term care, and then started here as a floor nurse. I had an associate degree, and I was curious to go back to school. Had a bachelor's, went back for a master's, went back for a doctoral degree, and completed all these education, let's see, around 2013 was the last time I've been in school. So it's been a journey. I've worked in several different areas including med-surg. I've worked in cardiology, I have some clinic experience, and now I'm in mental health. I've been in mental health since the beginning of the pandemic, so I've been there a couple of years now.
Dr. Kari Haley:
What a time to go into mental health, at the beginning of a pandemic.
Sarah Cassell:
I know, right?
Dr. Steven Jackson:
I have a feeling that a need for mental health services has probably gone up tremendously in light of the pandemic.
Sarah Cassell:
Absolutely. I'll have to agree with you on that. We've definitely seen an increase in the number of patients and also an increase in the length of stay. Patients are coming in when they are much sicker and so they are requiring longer, longer time with us. As far as the pandemic is concerned, think about the psychological impact on all of us. We've all been through a traumatic event, even if we don't want to recognize it. Some of us have coped better than others. Some people have decided to start new things: substance use, other things to just cope. And so we are seeing more patients that are coming to us in a really acute phase. And our staff too they've had to deal with a lot of things, a lot of medical patients that they have not dealt with in the past, so it's been a journey.
Dr. Steven Jackson:
So how are you holding up just personally?
Sarah Cassell:
Well, when your teams see you as a leader just running around and without composure, that negative energy kind of spills around, so it is important for me as a leader to maintain that calm, to be supportive, to be able to walk alongside my colleagues, my staff members. Check in with them, "How are you doing?" And if I'm struggling, I take time out for myself. We all need to recognize that mental health is important. Mental and emotional health are important. If I need a mental health day, as a leader I should be able to say without feeling stigmatized. And when my staff sees that I'm able to have those conversations, they feel comfortable having those conversations with their patients and also with their family members. And it's OK, it's OK to have those conversations.
Dr. Steven Jackson:
So you bring up an interesting word and concept, and it might be a good jumping off point in our conversation, and that word is stigmatized and/or stigma. Tell us a little bit about more what you mean by that.
Sarah Cassell:
I come from a culture where we don't talk about mental health. People don't talk about mental health. If you are struggling with your mental health, you are seen as weak. And we know that in other cultures there is not even a specific word for mental illness.
Dr. Steven Jackson:
Interesting.
Sarah Cassell:
It is important for us in this specialty to recognize that mental health exists and it's OK.
Sarah Cassell:
One of the leaders in promoting mental health is an organization called Make It OK. As a hospital we have partnered with Make It OK to give our patients the resources that they need to have those conversations about mental health. Sometimes it's just knowing where to start. I'm struggling, or you have a colleague that's struggling and they tell you, "I had a rough day last night," or, "I had a rough night last night," or, "I had a rough day yesterday at work," and you hear them but you're afraid to say, "Tell me a little bit more about that. What does that mean?" And they might hit you with something like, "I have anxiety. I have depression." And you might feel uncomfortable not knowing what to say. You might think, "Why are you telling me this? I'm your colleague. I'm not supposed to know this." But again, it's giving you the resources to have these conversations. We all know that as health care providers we struggle, and when we don't have the right resources it could lead to worse issues, more complicated stuff could happen.
Dr. Kari Haley:
Yeah, absolutely. I mean, I think we've heard a lot of stories in the media even, and we've noticed with our own colleagues that during, especially this pandemic time as you've mentioned where a lot of mental health emergencies or a mental health has kind of surfaced, that it's really that discomfort with talking about it. And that's leading to burnout, that's leading to people leaving the profession after they've dedicated years to getting into this. So I think that ability to really talk about mental health is so important and something we don't ever really learn how to do very well.
Dr. Kari Haley:
Do you have thoughts more about how we can start having those conversation, and in particular with the lean of that we are serving a diverse population. So how do we have these conversations with people who we might not even feel comfortable talking to in general because we don't speak the language or we don't have the insights into their culture?
Sarah Cassell:
Patients that come in from different cultural backgrounds and they are struggling with mental health, the first thing that we do is identify the language barriers if they exist. One of the complications is that when someone has a disorganized speech or pattern of thought and you have an interpreter that is trying to interpret whatever language, that interpreter may not even have the words of that patient or what they're going through. So as mental health care providers we have to evaluate the situation. We have to evaluate what our patients are going through, what immediate actions can we take to just de-escalate them, get to the point where we can have reasonable conversation with them, if we can, or just figure out some interventions to make sure that they are heard. It is important for them to be heard, and sometimes it's your body language.
Dr. Steven Jackson:
Interestingly enough, I was reading basically an article on psychiatry.org, and I'm going to quote it. It says, "A lack of cultural understanding by health care providers may contribute to under diagnosis and/or misdiagnosis of mental health in people from racially and ethnically diverse populations." Then it goes on to say, and this was interesting, "Factors that contribute to these kinds of misdiagnosis include language differences between patient and provider, stigma of mental illness among minority groups, and cultural presentation of symptoms."
Dr. Steven Jackson:
So you go into a room and they are already within that interaction differences in culture, and now you add an element of challenges in the mental health and the specific cultural implications with those, and now there can be a lot of miscommunication and a lot of... I mean, that's a pretty interesting dynamic and one that is probably difficult. Can you tell us about any situations, I guess, on the wards with your personal experience?
Sarah Cassell:
Yeah. I think it's very easy to have those miscommunications when you're trying to help a patient who is going through a mental health crisis. And we know that these experiences occur at the most vulnerable times of their lives. They may have suffered really serious implications or lived experiences that they have endured that have brought them into our care. And so when you look at what's going on with the patient, there's bound to be miscommunication if you as a provider are not open to really listen and be there with them.
Sarah Cassell:
And we have a lot of experienced clinicians, psychiatrists, we have occupational therapists, we have social workers, we have mental health practitioners, mental health associates, we have nurses with a lot of experiences in taking care of patients. I think what occurs is that when these patients come together, or when our teams come together, I should say, to care for these patients, it's an interdisciplinary action. So they come together and they listen to the patient's story. It's important to listen to the patient's story. When you are able to put yourself in that patient's situation, you can empathize and be able to provide better care. So even though there may be miscommunications that may occur, I think the interdisciplinary approach to patient care really helps.
Dr. Kari Haley:
Yeah. I mean, I think almost more importantly with mental health than a lot of our other medical conditions there is still interdisciplinary work, absolutely, but when people are truly in a mental health crisis sometimes they are paranoid, sometimes they are so far removed from reality. They are psychotic. They have psychotic features to their depression or their anxiety that providing that safe space where multiple people can give their input to be able to kind of figure out the real plan of action, I think is so, so key in taking care of these patients, especially with the ultimate goal of getting them well enough to be discharged to an outpatient program or society, or wherever they end up, their disposition is. Can you talk a little bit more about any sort of community partners that we have available in our region at least to think about... What happens next after these patients need to be hospitalized?
Sarah Cassell:
Well, you talked about their safety. Their safety is paramount. That's the first thing that we look at. How are we keeping our patients safe? And what sort of disposition do we have? Where are they going to when they leave our facilities? What's the next step? What's the trajectory and how can we figure out... How can we make sure that they are functioning as you and I in the community? They are at their best, they are functioning at their best in the community, how can we make sure? So given that transition, we have some facilities that we work with closely. Hovander [House] is one of them, a HealthPartners facilities that we work with, but there are several facilities that we work with in the community.
Sarah Cassell:
Having a plan and making sure that we communicate those safety plans with our partners is important. There are patients that are leaving our facilities that may require ongoing treatment. Depending on the patients and depending on their ability to stay safe at home, we have a partial hospitalization program that is called DayBridge that is here at Regions, and our patients that are well enough to be home safely, but sick enough to require ongoing therapy can stay at home using some sort of technology, whether it's their iPad or their phones, and we can have ongoing therapy for about three weeks virtually. We're going back to a hybrid situation where some of them will be able to come in and have three more weeks of therapy while they are still trying to heal from a traumatic event or from a mental illness that they're going through.
Sarah Cassell:
And what I always say is that mental health is really hard and it's tough, but people do get better, and as health care providers, keeping that in our minds really helps us see our patients as people and meet them where they are in their journeys.
Dr. Steven Jackson:
I think that's a great point, because when we think about health equity, and I always use the analogy or metaphor, if you want to call it that, of taking my glasses away. If you were to take my glasses away and have me take a standardized test, there's a good chance I won't do very well because you have now taken away my accommodation. You've taken away the thing that I need for the playing field to be, for the better part, equal or even. But if I have my glasses, now I have a fighting chance to be equally successful.
Dr. Steven Jackson:
And I think when we think about health equity and... A plug for the title of our podcast is examining the health equity emergency. We've already talked about that there are cultural implications to dealing with a mental health episode, or crisis, or even a mental health discussion. We talked about there was a stigma amongst families, maybe amongst minority groups, amongst communities, where in some instances it's not OK to talk about it. And so it seems like there should continue to be ongoing work in, well, how can we level the playing field in those situations, how can we make it OK, and it sounds like we're doing some things in this space to do just that.
Dr. Steven Jackson:
I actually have a daughter that deals with anxiety, and she has been probably for a while. She's now 14. I won't say her name on the air because my wife would probably kill me. It started off as early as maybe 3 or 4 years old and we thought it was just her being a 3- or 4-year-old who was acting out. And as we educated ourselves, and I can personally say, as I humbled myself I realized that there was actually something really going on here. This wasn't just a kid being a kid but she's having some difficulty. And once I realized that, it's OK, we made it OK in our family to talk about mental health and we got her the assistance that she needs. She's thriving and she's doing very well. She's an awesome young lady.
Dr. Steven Jackson:
But in my own personal life... I don't know if it was a stigma. Maybe it was a personal stigma in my own mind that I made up that, "No, I don't have a child that has difficulties with mental health. That's not going to happen here." And I had to realize that, "No, slow down, bro. This is what's going on." And again, once I got to that point I realized that it is OK to talk about it. It is OK to treat it. It's OK to be OK with all things mental health. And as I said, she's thriving, so thank you for everything that you guys are doing in this area, in this space.
Sarah Cassell:
Thank you. It's meaningful work because when our patients come in, and again, they're going through that acute phase, and then after a while, they're with us sometimes for a week, sometimes for two weeks, sometimes for a month or more, but when you see them leave... And we have a lot of letters that patients write and give us feedback. We strongly encourage feedback because that's the only way we can get better as health care providers. But when you see them leave and they're so grateful for the care they have received, then you really know that this is meaningful work. And it may not feel rewarding sometimes but it's work that needs to be done. And again, hats off to the great clinicians and the caregivers that are constantly being there to support community members that are going through a mental illness. Again, one out of every five of us will experience mental illness, and that's a reality that we have to accept. One in five of us would experience mental illness.
Dr. Kari Haley:
That's quite a stat. I mean, if you think about your room, just in your office or in the school building, that's a good number of people. And I think the big thing that I'm taking away from this is that importance of making it normal piece of conversation or normal piece of things that we address as clinicians in the outpatient setting. Do you have thoughts about how we can all do better at that as clinicians, as just people, honestly, to help promote the acceptance that mental health is real and it's OK to have mental health issues? Because it is just like any other health issue. We need to address it and we need to be OK talking about not being OK.
Dr. Steven Jackson:
Absolutely.
Sarah Cassell:
I don't know if I have any great ideas but one thing I can tell you is that we are looking through our policies and our processes through the lenses of equity. We know that to get from inequity to equity is a journey. It didn't occur in a day, it took time. And so as leaders we are encouraging our staff to be open to talking about mental health, because if they themselves as care providers are comfortable talking about it, then it will put them in a better position to be able to be open to our patients and talk about their illnesses. So as we look at our policies and procedures and how we provide care for our patients, we want to make sure that we're including our Patient Family Advisory Council. We usually call that PFAC.
Sarah Cassell:
Recently we had one of our patients that was on our unit and after she had left she volunteered to serve on the Patient Advisory Council. She worked with our leaders to create something we're calling therapeutic listening. And what that is is finding time to really sit down without no busy work, no busy hands, sit down with your patient, really find out who they are and what they would want out of the care. As health care providers we're often very task-oriented. We want to get this done, get that done, get this done, but sometimes patients just want to sit down and say, "Listen to me, this is me. This is my story." And therapeutic listening is something that we are using to, again, connect more with our patients so that after we've kept them safe in giving them all the therapies that they need, make sure that they live here with a great experience.
Dr. Kari Haley:
No, I think that is great and I think that really helps build-
Dr. Steven Jackson:
Beautiful.
Dr. Kari Haley:
... a culture within the department, and hopefully then expanded with the culture within our organization or other people's lives who are living through this and experiencing this, both the providers and the care staff that are taking care of these patients. And then as the patients go home, to really build that active listening, that therapeutic mindset so we can continue the good work that you are doing of really trying to emphasize the need to be there for people who are having mental health problems.
Dr. Steven Jackson:
And I think it's about... Something you're touching on is individualized care. And obviously sometimes it feels like there's not a lot of time for that or we're task-oriented. I think every physician I know has some kind of list in one of their pockets, maybe with a empty box on the left or right waiting for a check mark to say, "Yeah, I've done that for the day. I'm good." And sometimes patients they need something more individualized given where they are, and I think this therapeutic listening is exactly what the doctor ordered. OK. That was bad. That was really bad.
Dr. Steven Jackson:
Something I wanted to kind of double back on. Now I had kind of mentioned that when my daughter was much younger than she is now, some of the behaviors that she exhibited was misinterpreted as, again, a kid being a kid, maybe acting out, whatever that means, and then we found out that she dealt with anxiety and we focused on that and got her treated and worked with her. And again, she's doing very well now. I read something that says that racial and ethnic minority groups or minority youth, I should say, with behavioral health issues are more readily referred to the juvenile justice system than to specialty primary care compared to white youth. And we're talking about disparities here in mental health today. It's interesting, if I can misinterpret the behaviors of my own daughter, how much more are the youth within society being, I guess, misrepresented and misunderstood and not getting the help that they need. And again, sort of thrown to the justice system. Let the justice system handle this. What's the solution? I'm going to put you on the spot, Sarah Cassell. What's the solution?
Sarah Cassell:
Thank you for that question. If I had the solution I think that I wouldn't be here. I'll probably be running my million dollar enterprise.
Dr. Steven Jackson:
There you go.
Sarah Cassell:
But you're right. We've seen research, we've looked at articles that have examined the disparities that exist in the care provided for mental health patients. For example, an article that we looked at quite recently showed that African Americans were being restrained and secluded at a rate twice as high as their white counterparts. In other words, the data showed that white patients were being restrained and secluded at about 8% to 9% whereas African Americans and other races were likely to be restrained and secluded at about 16%.
Dr. Steven Jackson:
It's more than double.
Sarah Cassell:
More than double. When we look at that information, again, we are not drawing conclusions, but we want to make sure that our staff have access to data like that, and look at what is our process? What are our policies? How are we trained on de-escalating patients? Is our staff doing an implicit bias? Do they have the resources they need? If they have patients that are coming from different cultural backgrounds and may not speak the same language and may not be comfortable or fluent in English, what are the resources that we're using? So we do look at the data and make sure that patients that come to our hospital for care receive equitable care. We do not want any inequity in the care, so we're looking at the data, we're talking about it, and we're looking at how can we make sure that our staff are ready and equipped to care for our patients.
Dr. Kari Haley:
That's so important. As we're talking right now, I'm just kind of thinking about with the data that Steve kind of talked about with African American Black youth referred to the juvenile system rather than primary care or mental health resources, and I'm just thinking about like the next step beyond. What are the social determinants of health out there that is maybe contributing to some of this and how can we help within our communities to build a healthy community, a healthy mindset in a way that youth can maybe get the right resources that they should be having rather than being referred into a justice system that is not going to address any underlying mental health and definitely not going to address necessarily any underlying social determinants of health?
Sarah Cassell:
I think that we know that your zip code determines your health outcomes a lot of the times, and so to your point about social determinants of health, depending on where you are and access to resources would determine how you go through a life. So for our youths that are in the zip codes and neighborhoods that are marginalized, we have to think outside the box. We have to think big. How can legislators and the legislature impact how our youths raised and what resources they have available so that they don't end up in the juvenile system as you're alluding to, Dr. Jackson.
Sarah Cassell:
It's important for us as a people to have a voice. I am a member of NAMI [National Alliance on Mental Illness]. I try to look at what's going on at the legislature and partner with other colleagues in the community so that as health care providers we can advocate for our patients, for our community so that these laws and regulations that are impacting them have a lens of equity. And we are looking at we as a people or as providers how can we support our patients. So again, looking at how we can make a difference. Finding out who your legislator is and talking to your legislator about things that you are passionate about, policies that you know impact your patients. We should be able to talk about it and call attention to the need in that community.
Dr. Steven Jackson:
So, Sarah, I want you to speak to two groups of people. The first group is the group that feels that mental health is not an issue in our land, in our world, and that we're doing too much and spending too much time and putting too much effort into addressing the issues of mental health. And I also want you to speak to our listeners and give us one or two takeaways to sort of ponder, sort of meditate on as we think about how we can join forces with you and your team to continue to fight and help those that need the help in this space.
Sarah Cassell:
Thank you, Dr. Jackson. Those are two great questions. First let me start with the question for those that think that mental health, we are putting too much effort into it. I think if you go back to the history, people with mental illness have really suffered, in the fact that in the past people did not want to deal with it, and still there are cultures, like I mentioned before, that are opting not to even address it. And for us as a community, for us as people to be able to move forward and give people with mental illness a chance and give them the treatment that they need, we first need to acknowledge that it is an issue, it is a problem that does get better, like I mentioned before.
Sarah Cassell:
But I want to use a phrase by George Santayana, and history matters, he says, "Those who cannot remember the past are condemned to repeat it." So if we don't know or acknowledge the struggles of racial inequity, of mental illness, whatever it is, that people have gone through, then we are bound to repeat it. And so I think as we look at mental illness and the care of our patients through the lenses of diversity and inclusion, it's important to know that we should have a voice, we should partner, we should listen to our patients with mental illness.
Sarah Cassell:
And for care providers or caregivers at home that have family members going through a mental illness and a mental crisis, it takes time. Be patient. Find the resources. Be open to talking about it. Get the help that you need. Don't wait until there's a crisis. It is harder to stabilize people in crisis than it is to actually help them when they are not in a crisis situation. So recognize the symptoms early, get help. And don't feel like you're doing it alone. There are so many groups out there that are for family members. Now that we have more opportunities for virtual groups, look and see what's out there. And again, be hopeful. Know that these folks will get better. Your loved one will get better. Just be there to support them and be there to help them and listen and figure out ways that we can promote their healing.
Dr. Kari Haley:
I think that that is a great wrap up to our conversation here. So many good key points in terms of really the listening, patience, and hope for the future. I love having that kind of thought that you're leaving me with when we think about our patients who are suffering from mental illness. And then also the disparities within it, so to try to actively listen, to actively be patient, and hope for a better future.
Dr. Steven Jackson:
Thank you for your time. I feel like I've been educated thoroughly. Just so appreciative of, again, your passion in this space and just the fight that's on the inside of you that you're taking into the ward and into the bedside. I know our listeners really appreciate what you've shared with us today, and I'll say this, we are joining forces with you and we'll continue to fight this thing together. So thank you so much for your time, Sarah.
Sarah Cassell:
Thank you. Thank you. And again, I have to say kudos to my team. I don't do this alone. I don't do this work alone. I represent a great group of staff. There's a African proverb that states, "If you want to walk fast, walk alone. If you want to go far, walk together." So we walk alongside each other as a team to care for our mental health patients. So thank you again for having me.
Dr. Steven Jackson:
Off the Charts is a production of HealthPartners and Park Nicollet.
Dr. Kari Haley:
It is recorded by Jimmy Bellamy, with creative by Peggy Anson, Tina Long, Tim Myers, and Jeff Jondahl.
Dr. Steven Jackson:
Production services provided by Matriarch Digital Media.
Dr. Kari Haley:
Our theme music is by Ryan Ike.