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The Future of Healthcare: “We must build resilience rather than fix problems” with Dr. Michael Ungar

…Build resilience rather than fix problems. It is costly to fix problems after they occur. It makes a lot better sense to help people have in place what they need before they hit a crisis. In the field of healthcare, that means giving people easy access to annual check-ups to prevent more serious chronic diseases […]

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…Build resilience rather than fix problems. It is costly to fix problems after they occur. It makes a lot better sense to help people have in place what they need before they hit a crisis. In the field of healthcare, that means giving people easy access to annual check-ups to prevent more serious chronic diseases from overwhelming our healthcare system later. Diabetes, heart disease, obesity are all mostly treatable problems that, if caught early, needn’t cost our health care systems huge dollars.


Asa part of my interview series with leaders in healthcare, I had the pleasure to interview Dr. Michael Ungar. Dr. Ungar is a Family Therapist and holds a national Research Chair in Child, Family and Community Resilience at Dalhousie University. His work has literally changed the way we think about resilience all around the world, helping governments and mental health professionals change people’s environments so they can thrive when facing adversity. He is the author of 200 scientific papers and 15 books. His latest, Change Your World: The Science of Resilience and the True Path to Success, is ideal for both employees and employers in healthcare, social services, and the private sector.


Thank you so much for doing this with us! Can you tell us a story about what brought you to this specific career path?

I worked for years with young people in jails and in homeless shelters and learned quickly to never assume that a child who looks delinquent is a ‘bad’ child. More often, their behaviors were simply the best way they had to cope with a tough situation and the few opportunities available to use their talents in socially desirable ways. In an odd twist, their vulnerability helped me understand that our resilience is always an expression of both who we are on the inside and what we have on the outside. Even more profoundly, change the world around a young person or an adult and they change, regardless of the individual’s motivation to behave better. That means if we give a problem employee with a learning challenge the right on-the-job training and emotional supports and opportunities to show the parts of their personality where they excel (that might be in more physical aspects of the work, or maybe it’s manipulating others — think drug dealers who make great entrepreneurs or sales people and you have the idea), they will take us up on these opportunities to have more powerful, and widely recognized identities that bring them success. Change our worlds and we change. Make those worlds ‘resilience-promoting’ in all the right ways and people will become their best selves. My research and clinical work supports this simple truth. In practice, that means, for example, that when we live with someone to whom we really matter, and who relies on us for genuine support, and others see us a good person who contributes to the welfare of others, the net result is that these experiences turn us into more responsible and caring people. The source of change is not inside us. It comes from outside. Likewise, creating a work environment where our opinion counts and we experience a sense of efficacy (personal control) that comes with being able to influence decisions on the job also improves our mental health and our productivity.

Can you share the most interesting story that happened to you since you began leading your company?

I lead a large research center and hears stories of resilience from individuals and communities all around the world. It’s these stories that have inspired my innovative work on wellbeing. In particular, I’ve worked for years with a small town that relies entirely on the oil and gas industry, the farms and forests around the town dotted with pumpjacks for hundreds of miles in every direction. They invited me to visit during the last economic boom. The price of oil was over a hundred dollars a barrel and while there was plenty of money to improve the town’s infrastructure, the boom had also brought with it a great many social problems. Lots of single men had moved to town, housed in trailers provided by the oil companies. Every evening saw drinking on the streets and there had been a rise in prostitution and serious drug abuse. The town was looking for solutions, and to their credit they had discovered that if they made their town more family-friendly they were better able to attract men and women who would settle in the town and contribute over the long term. They built a 50-space subsidized daycare center. They built a new park, and hiking trails on the bluff outside the town. They even worked with local developers to build a dozen affordable housing units to help families that couldn’t afford the going price of $2500/month for a two-bedroom apartment. These efforts by a thoughtful municipal government helped. The Mainstreet merchants began opening coffee shops and gyms. The schools grew. The town flourished in ways that, as anticipated, cushioned it from a complete collapse when oil sank on world markets to less than thirty dollars a barrel a couple of years later.

I recall, though, trying to help the community think differently about their resilience. When times were good, they were incredibly philanthropic, with every child given the opportunity to play any sport he or she wanted. When I pointed out that maybe, to be resilient, the donors should let families pay their own way when times are good, and save for the inevitable “bust” that history told us was coming, local business people (always generous) just couldn’t see the sense in that. What I explained, though, was that children don’t need the extra support when the economy is good. When the economy turns sour, however, families become unsettled. One parent has to take work away from home. There is no money to play sports. Children lose their access to the very activities, homes, connections with peers and their community that they need to smooth over the turmoil going on at home. In other words, children’s resilience, and family resilience, depends on getting the right resources they need when there is a crisis.

That might seem obvious, but it’s not how we think. We think about increasing wellbeing when times are good, but seldom about what we will need to remain resilient when times are bad.

Can you tell our readers a bit about why you are an authority in the healthcare field?

My work on resilience has changed the way we think about “doing well” when we face significant challenges. It has had a profound impact on the way mental health care providers work with people and how governments design social policy. After 25 years as a clinican and researcher, and tens of millions of dollars in research funding, one gets to see patterns in the way individuals, institutions and governments think about health and where they need to invest.

What makes your company stand out? Can you share a story?

We know who we are as a research center. We are the group you find when you search for the term ‘resilience’ and then add a word like ‘context’, ‘culture’ or ‘research’. We don’t do studies on mindfulness and we’re not positive psychologists, though our work helps to explain why those approaches can work when we focus as much on people’s surroundings (the risks they experience) as people’s ways of thinking, feeling and behaving. We’ve actually been awarded several ‘sole-source’ government contracts because, quite simply, there is no one competing with us in the space we occupy. Organizations around the world often call me and my colleagues for advice based largely on our publications and international presence online. And we do all this without any fanfare or advertising. It really is a case of if you have a good idea people will find you.

Can you share with our readers about the innovations that you are bringing to and/or see in the healthcare industry? How do you envision that this might disrupt the status quo? Which “pain point” is this trying to address?

Have you ever really thought about the story of Cinderella? In my new book, Change Your World: The Science of Resilience and the True Path to Success, I retell the story with a devilish twist, explaining what it really teaches us about resilience. Cinderella is not the real focus of the fairy tale. The real star is the Fairy Godmother. After all, without the Fairy Godmother, Cinderella would wind up an abused child, living in an awful kingdom with no health and social services (just a selfish prince who spends all his money on gala balls for the wealthy), toiling away as a working child, with no opportunities to change her life except to run away to the street. If Cinderella was like most of the young people I’ve worked with, her life is more likely to wind up being one of drugs and an early pregnancy than that of a princess. Add a Fairy Godmother, and our stories can be changed (Cinderella and Meghan Markel have a lot in common!).

The moral of the story? Healthcare systems are Fairy Godmothers. That has been my message to leaders in the health and social services sector and policymakers. How we design systems and implement programs can literally change individual health outcomes. A good example is how we refer people for counseling. Many businesses make referrals. Very few follow up to see if people attended or to help them overcome the barriers to actually connecting with mental health professionals. This means thinking ‘systemically’. It’s never enough to design a service and expect people to use it. We always have to think about people’s culture, beliefs, and even whether there is public transit to reach a service (or money for gas). We have to also think about whether the person’s workplace remains socially toxic (when they come back ‘healed’, will the stress on the job cause a relapse?). When we think of the systems that surround people, and how we can be Fairy Godmothers and make good things happen for others, we are much more likely to design health and social services in ways that individuals and communities experience as useful.

What are your “5 Things I Wish Someone Told Me Before I Started” and why.

Over my career I’ve learned a few big lessons.

  1. People value personal relationships. My staff know better than to tell me “I’ve emailed three times and they still haven’t responded.” My usual response is to point to the old fashioned telephone on my desk and remind them that there has existed for more than a century an amazing technology that gets far better responses and keeps us connected to the people we want to work with.
  2. My expectations of others are usually too high. Though I share a lot of projects with colleagues, at the end of the day it is still my research center. My reputation. And to be truthful, I am a “happy manic” most days. Over the years I’ve had to acknowledge that in most cases other people will not meet my expectations. That means either better resourcing my staff so they can, as a team, accomplish everything I expect, or changing my expectations. I prefer the first option.
  3. People love to be inspired with a new idea. I present to thousands of people each year and I have learned to keep my presentations focused on just a few big ideas, and tell stories to make these ideas come alive. For example, I’ve begun to talk about “resilience to violent extremism” and the many community-level factors that predict why most people do not become violent despite legitimate grievances. For many in my audience, this simple twist (most people focus on why people radicalize) opens huge possibilities for interventions by health and social service professionals keen to help communities avoid all forms of violence.

Let’s jump to the main focus of our interview. According to this studycited by Newsweek, the US healthcare system is ranked as the worst among high income nations. This seems shocking. Can you share with us 3–5 reasons why you think the US is ranked so poorly?

The US is ranked very near the bottom of high income countries on health outcomes because so many of the decisions that are made are ideological rather than driven by science. How about we think about healthcare in the US as a series of myths.

  1. Myth 1. A for-profit health care system produces better results. It does, but only for those with access to the system and good benefits. Remarkably, only half of children in the US have access to health care under regular insurance plans. The rest, if they can get care at all, rely on government funded programs. And because those programs only see the most ill, and are not adequately funded through a tax base, their care is substandard and health outcomes overall suffer. A system that is serving just half the population is a failing system.
  2. Myth 2. A for-profit health care system is cheaper. Not one study anywhere at any time has shown that the US healthcare system is cheaper to run or even cost effective than systems in other countries. The most privileged get great access to care, but in truth, they also pay far more than they would in a public health system. If one actually calculates what one pays for healthcare, and then compares it to the higher rate of taxes in other countries where healthcare is included in the tax burden, one quickly sees that Americans are paying more for the care they get. And that is before one considers annual deductibles and the limits placed on individuals to change employers and those with pre-existing conditions. Other countries just don’t have these problems or these costs.
  3. Myth 3. American’s receive the best care in the world. Not true. There is little money in the American system for prevention services, nor incentives to provide them. Despite the splashy news stories of that one individual in, say, the Canadian healthcare system received a lousy diagnosis, the truth is that in every other G7 developed country, if one has a complicated pregnancy, or falls and breaks a leg, the care they receive is exceptional, regardless of whether that person is homeless or a corporate CEO. What is also true is that if you need elective surgery (bad knees from running?) that kind of care can put you into a very long queue. But at least everyone will be healthier. Sadly, even a country like Cuba has better health outcomes than the US.

You are a “healthcare insider”. If you had the power to make a change, can you share 5 changes that need to be made to improve the overall US healthcare system? Please share a story or example for each.

If I think again about the key message of Change Your World, it is that we need to think about the resources we need to be healthy. In other words, it’s not enough to be a rugged individual. We also need to be a resourced individual. We need help accessing the resources we need to succeed, mentally and physically. Here’s a few ideas:

  1. Proportional universality. It’s a mouthful, but it is a really great idea that builds resilience across a population. The idea is that we all need the same supports, like safe streets, a family physician, and opportunities for training and education to be our best selves. Proportional universality reminds us that people with more challenges, like a disability, need these same things but in bigger quantities to make up for the problems they face. It is the difference between equality (everyone gets the same) and equity (everyone gets what they need to reach the same level of achievement).
  2. Build resilience rather than fix problems. It is costly to fix problems after they occur. It makes a lot better sense to help people have in place what they need before they hit a crisis. In the field of healthcare, that means giving people easy access to annual check-ups to prevent more serious chronic diseases from overwhelming our healthcare system later. Diabetes, heart disease, obesity are all mostly treatable problems that, if caught early, needn’t cost our health care systems huge dollars.
  3. Changing individuals is so much more difficult than changing systems. Enough with the personal development plans and self-help gurus! As I show with some very convincing numbers in Change Your World, if individual self-betterment plans worked then why at a time when there is more free advice online and more yoga mats being sold than ever before are our health outcomes getting worse and worse? Individual change needs to be supported by changes to the world around us. Want to get more fit? Walk more, which could mean using a public transit system or parking your car further from the front door of your place of work. It might take a little motivation to initiate a change, but it takes a world that nudges us towards change to really create better health outcomes. It also takes a world that provides us with the opportunities we need to succeed (like public transit, or a gym near to where we work).

Thank you! It’s great to suggest changes, but what specific steps would need to be taken to implement your ideas? What can individuals, corporations, communities and leaders do to help?

There are at least a dozen resources that people need to be resilient. I discuss all of them in Change Your World. Here is the list in brief:

  1. Structure: We all do better when the world around us provides routines and expectations, whether that is showing up at work or walking the dog twice a day. During a crisis, structure is even more important as it offers a buffer against chaos. It makes us feel like our lives are predictable.
  2. Consequences: Making mistakes is a prerequisite for success. The consequences we suffer, however, must offer manageable opportunities to repair what we have done wrong and integrate what we have learned into future efforts. A facilitative environment that improves resilience holds us accountable for our actions.
  3. Intimate and sustaining relationships: Having even one person who loves us unconditionally is an important foundation for resilience. Even if that person is not in our life at the moment, we can do just fine with the memory of having once been well-loved.
  4. Lots of other relationships: We all need a clan, a tribe, extended family, colleagues at work, or an online community where we feel we are needed. With loneliness becoming a public health crisis in many high-income countries, these networks of relationships have become more important than ever.
  5. A powerful identity: How we are seen by others is crucial to our sense of self-worth. Our identities are co-constructions. We can tell others who we want to be but a good identity always depends on how others see us and whether they value what we have to offer.
  6. A sense of control: Whether one experiences personal efficacy or political efficacy, we all do better when we are given the opportunity to make decisions that affect our lives.
  7. A sense of belonging, religious affiliation, spirituality, culture and life purpose: The list of things that give us a sense of belonging is long and culturally nuanced. Regardless of where we feel connected, we are more likely to succeed (especially during a crisis) when we feel our life has a purpose and others depend on us as much as we depend on them.
  8. Rights and responsibilities: It is very difficult to experience success unless we experience social justice. It is also important that we are given genuine responsibilities for our own and others’ welfare.
  9. Safety and support: Knowing our homes and communities are safe and have in place the right supports to help us find the resources we need to cope when problems occur are crucial components of our environments. Without these, we would be constantly overwhelmed by stress.
  10. Positive thinking: People who succeed have a positive future orientation that is grounded in a realistic assessment of the opportunities they have been given. If we have plenty of resources and are still unappreciative of the advantages we enjoy, positive thinking can help us to see that our problems are more in our heads than in the external world that surrounds us.
  11. Physical well-being: Our environments provide us with everything from affordable, healthy food to sidewalks that encourage us to walk instead of drive. The better our environment is at keeping us physically healthy, the easier it is to maintain a lifestyle that improves our capacity to succeed.
  12. Financial well-being: A strong economy, fair taxation, and poverty reduction strategies can all make us financially successful and impervious to changing economic conditions. How much money is enough is a question of social norms and the stigma that comes when we do not fit in with those around us.

If we want people to use healthcare services less, we need to help them find as many of these resources as they can. The science here is very clear. When we design a program or intervention, the outcomes are much better when people get more of these resources at the same time. Healthcare leaders need to think about this. The more they think systemically, and the more they design systems to meet people’s multiple needs, the healthy patients will be.

What are your favorite books, podcasts, or resources that inspire you to be a better healthcare leader? Can you explain why you like them?

I like Psychology Today (my blog, Nurturing Resilience is also there — http://www.psychologytoday.com/blog/nurturing-resilience), but I find myself spending a lot of time with Child Trends (https://www.childtrends.org/child-trends-news-service) and reports from the Centers for Disease Control in Atlanta. I also read The Lancet. If you want an insight into other ideas like those in this column, look at work by Tim Caulfield who wrote Is Gwyneth Paltrow Wrong About Everything?and Malcolm Gladwell’s Outliers. For inspiration on leadership, I’d recommend Chris Hadfield (the former Commander of the International Space Station) and his book An Astronaut’s Guide to Life on Earth.

How can our readers follow you on social media?

Happy to connect:

www.michaelungar.com

www.resilienceresearch.org

Twitter @MichaelUngarPhD

Check out my new books and blog:

1. Change Your World: The Science of Resilience and the True Path to Success http://sutherlandhousebooks.com/project/change-your-world/

2. What Works: A Manual for Designing Programs that Build Resilience (free download) http://www.resilienceresearch.org/whatworks

3. Blog-Nurturing Resilience-hosted by Psychology Today http://www.psychologytoday.com/blog/nurturing-resilience

Thank you so much for these insights! This was so inspiring!

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