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The NIMH Director’s Innovation Speaker Series: Diagnosing Resilience: A Multisystemic Model for Positive Development in Stressed Environments

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MICHAEL UNGAR: A topic could we have. So what I'd like to do quite briefly is bring you into the sort of the mindset of what resilience means these days to folks and to hopefully expose you to some of the current thinking. Now, the best way I can sort of bring you into my research program, which is on a-- we do research, basically, in over a dozen different countries. We have large studies. And sometimes it just boils down to a really good story. And certainly if you want to read more, there's certainly lots of materials that I can provide. But let me bring you into my world a little bit here. So a while back, I was doing some work with the human development branch of the World Bank. And I was going around the globe working with educators and educational researchers to try and develop programs that would bolster the resilience of very vulnerable populations, places like Colombia, etc., etc. And this is actually a picture from a meeting held in Nepal with folks from India, Bhutan, Afghanistan, Syria, etc. And I heard the most remarkable story from these two university professors who are sitting on the right side of my screen there. And what they were trying to do was get young women to go to university in Afghanistan, which you can imagine is quite a challenging affair in any context. So what they had to do was essentially promote the resilience of this population. And part of that, of course, was getting their mindset changed amongst these young women to see themselves as having a future in senior professions, to get an education, come to university, etc. So there was definitely a shift in mindset that they had to start with.

MICHAEL UNGAR: But of course, in a highly patriarchal society, they also then had to work with the systems around these young women, including changing the fathers' opinions so that they would agree to send their daughters to university. And then there was a matter of housing and making sure these young women were supervised by a kin male, etc., etc. And then once they got to the university, after just a few months, these women started, and then they all dropped out because they got sick. And these two professors explained to me that what happened was that these young women were basically coming to the university campus all day long, but the university had never built toilets for the women. So what was happening is these young women were getting ill because, of course, you cannot use the bathroom all day long. Cumulatively, the stress on your body takes its toll. So these university professors then had to go back and negotiate with the university to build toilets for the women students. Now, I know it might seem like a very strange example to start, but sometimes it's looking across a different context-- it shocks us into thinking about what it is that actually makes us resilient. And in part, yes, it is this factor of grit and perseverance, but it's also whether or not somebody builds you a toilet.

MICHAEL UNGAR: So this kind of notion of what the research now on resilience, whether we look at Ann Masten's work or Dante Cicchetti or Michael Rutter or others in the field, what we're clearly seeing is a move away from purely an individual or bounce back or pull yourself up by your own bootstraps kind of notion of resilience to one which is a much more dynamic process. One I've sort of characterized in this way is that we-- this isn't really positive psychology because what we're actually saying is-- we're focused as well on what risk exposures you've had and what is that protective process or [risk?] factors, if you prefer, that mediate that relationship between the risk and the specific outcomes that you're trying to seek. And I'm always thinking-- when someone comes to me and says, "How do I study resilience?" whatever, I'm always basically-- maybe because I'm very simple in this regard. I'm saying, "How do I get-- how we accounted for measurement or design of all three different columns?" And when you have, essentially, then you get an understanding of resilience.

MICHAEL UNGAR: And let me give you a very concrete example of this. So I'm working with a postdoctoral fellow, Dr. Raquel Nogueira from Spain. And what we've been doing is going back and looking at all the mindfulness-based stress reduction programs for children and seeing if there are patterns in those in terms of, first, are they effective? And two, for whom are they effective based on their level of risk exposure? And I mean, the good news is actually this, that if you look across many of these studies-- and this is not a complete summation of them. If you look at many of them, what you'll actually see is that, overall, there's a fairly good chance that a program like this will, in fact, have a positive effect on children's well-being, on a variety of different indicators. And that's good news. But what we did then was we've actually gone back to the data and said, "At what level of risk exposure do these programs actually benefit children?" And first of all, incredibly bad science in there, because most studies have not adequately accounted for risk exposures. But those that did, what we began to see a pattern of was that children who are in higher risk environments tend to benefit more from the intervention of a mindfulness-based stress reduction, some sort of program like that, which implies then that if we're going for universal programming for kids who are not under exceptional amounts of atypical stress, we may, in fact, be wasting our money when we begin to think about the impact of these particular programs.

MICHAEL UNGAR:So this is kind of the thinking of resilience; when we begin to sort of put a positive psychology bent into thinking but accounting for risk exposures and trying to find almost a hand-in-glove fit between the dangers that you face and what is actually protective. And if I could kind of tongue-in-cheek say, "Can we diagnose resilience?" which I know we tend to diagnose disorder, but as I've published this back in 2015 as a practitioner review, what we're actually understanding is, if we apply that idea, we can assess-- If you're going to assess resilience, you're going to have to start with adversity. You're going to need to know the severity of one's exposure to a risk factor, the chronicity. In other words, were you abused many times over a lengthy period of time or a single episode? And even then that's not a good benchmark because, of course, a single episode could just be as traumatic as a prolonged exposure as well. And at what level of exposure was it? Was it just an individual problem, like you have a learning challenge, or is it that you have a learning challenge and live in dire poverty with inadequately funded schools? What's your attribution of causality? People like Raffael Kalisch and others, out of Germany, are really talking about that how we attribute our experiences will definitely influence whether or not we perceive ourselves or have the capacity to overcome adversity. And of course, there's always cultural and contextual factors as well factor into this.

MICHAEL UNGAR: Now, if I might, what we're actually understanding is that-- if I had to summarize this broadly, generally speaking, at lower levels of risk exposure, we could say that adapting individual strengths or qualities, adapting temperament or looking at personality traits, cognitions, generally speaking, those things are going to be effective when our risk exposure is lower, so if our ACE score is relatively low; if we're not being structurally disadvantaged by our race or our culture or ethnicity or by our status economically, etc., etc. Now, when you enter higher risk context though, no surprise, what begins to show up in the research is that it's which resources are there to actually help you to survive. So has someone, in fact, helped you to get to university, if you're a young woman growing up in a very structurally marginalized place where women do not typically go to university? Are those resources even if they're available, are they accessible to you? Do you have the funding, the transportation systems, etc., to get to them? And how much you use those resources strategically? Can you exploit what is actually available to you? In other words, can you make use of what is around you? And do others sort of reinforce your choices, or do they say that is a very odd thing for you to do and actually undermine your strategies to [cope?]. And of course, what is the capacity of the systems around you? Are there scholarships? Is there funding, etc., etc., to get you onto the next phase of your life?

MICHAEL UNGAR: Now, add to that as well, of course, in any particular context, you're going to have to account for the social and historical context. For instance, Ingrid Schoon, out of the UK, did some work earlier on in her career in which she basically looked at patterns of resilience if you were growing up under Margaret Thatcher's government or Tony Blair's government. And there's something about the different historical periods that you're living in and your own developmental phases and, of course, cultural factors that also have to be accounted for when you're trying to understand resilience. So just coming back to this, the question, of course, is which factors are going to most likely affect you for the better? Now, before I get into the specifics of those factors, might I just off for a definition of resilience, which is much more than just that notion of an individual bouncing back, that neoliberal agenda that says, "If you haven't survived, somehow it's your fault," right?

MICHAEL UNGAR: So where there's exposure to significant adversity, what I think the work I'm doing with all my colleagues around the globe is saying that it's our ability to navigate to all the psychological, social, cultural, and physical resources that sustain our well-being and our capacity to negotiate or to ask for those resources to be given to us in culturally meaningful ways. And in pure simplification again, it's really just about can we navigate? Do we have the compulsion to do it? Yes, the personal traits like perseverance and everything else. But ultimately, the world has to be able to provide us with what we need to do well and hopefully in ways that make sense to us so that we can actually negotiate for those resources.

MICHAEL UNGAR: Now, to explain this, let me be a little more specific. When we actually have been doing this research on a global scale-- this is actually based on some qualitative data from a 11-country study, 14-site study that we said, "Well, what is making kids who are extremely high risk actually surviving and thriving in different cultural spaces?" And we saw patterns there even though the actual expression of those patterns in particular context was very different. So obviously, young people who can nurture relationships, when they can negotiate a powerful identity for themselves, when they have experiences of efficacy, either politically or socially or just in their own sort of personal lives, when they experience some social justice, some sense that they're treated fairly in their lives, when they have access to basic material resources as well such as education, clothing, food, and indeed, when there's also that sense that they can promote social cohesion or they have a sense of belonging in their lives-- as well as, of course, we saw very clearly, because we were working mostly with marginalized populations around the world, that this kind of notion of cultural adherence, the sense that you had a sense of connection to your culture was also particularly poignant for this kind of work.

MICHAEL UNGAR: Now, if you begin to think about during a pandemic, for instance, what you begin to see is that these factors are incredibly important, not just for children, but for adults too. And we sort of-- in a pandemic, we get hit of two sides, right? We actually stack the deck on the stress or the risk exposures. We have more unemployment, more financial problems, more medical problems. We literally create all the conditions for unhealthy mental health conditions, right, on the one side. And on the other side, we actually remove all the protective processes, the mechanisms. Many of these things disappear. So we literally take away-- say, if you're talking about young adults-- we recently completed a large study in the US with Cigna, one of the HMOs. And what we found was very specifically that young-- it was young adults and older adolescents who were being most affected, in some respects mental health-wise, by the pandemic because their lives had been, in a sense, most dramatically changed. They weren't able to socialize. They weren't able to cope with the stressors. And in fact, they were hypersensitive to some of the social justice issues in terms of Black Lives Matters and the Me Too movements that these things were worrying them a great deal.

MICHAEL UNGAR:So when we begin to think about what it is that carries us through, whether it's a war or as a refugee or indeed during a pandemic, what we're actually saying is, "How do we as mental health professionals intervene to create the conditions so that people can find these particular resources?" And if I might, I think unfortunately we often thought about resilience as somewhat a predictable fit, right? Oh, okay. I go into a situation, and I give someone an opportunity for self-esteem. Unfortunately, the old thinking on resilience was this kind of very puzzle piece-like approach, right? You put one thing together with another. That's actually not what the science of resilience is showing. It's much more like a tangram in which you basically have all kinds of strengths. Indeed, I just showed you seven: a positive identity, a sense of efficacy, relationships. And people bind those all together in very complex patterns that satisfy certain specific contexts. So when you're under a particular kind of risk, if you're a refugee who's being racially marginalized, or perhaps you're simply a child who's living in a very upper-middle-class family, who has excessive expectations and an overprotective parenting style-- those are quite extreme examples, but what the individual does is they put together these factors into their lives to cope as best they can.

MICHAEL UNGAR: Let me give you an example. So I was working a little while ago with Dr. Keiji Akiyama in Japan, and he was looking at resilience after the tsunami that affected much of northern Japan. And he took me-- at one point, we went up to one of the towns that was affected. And this is a picture of Yamada. I just want to sort of walk you through what happened there for a second, right? So even though that they had prepared for a tsunami with a 6-meter-high seawall, the wave that came in around noon hour was actually 11 meters high and just completely devastated Yamada as well as other towns. Fires broke out, etc., etc. And by the time children returned from school that day, this was the kind of scenes that they were seeing. Now, what you may not have heard is that a lot of children actually survived, whereas many more adults died. And part of that seemed to be because the children were in school when it struck, and they were evacuated through the protocols when the tsunami alarms went off, whereas parents were down on the flood plain and many perished.

MICHAEL UNGAR: What caught my attention though, from a resilience point of view, was this. Now, this is 18 months later. They've cleared away much of the rubble. And what you're looking at is not a school. What you're looking at is what an NGO, a not-for-profit, put in to help children deal with the trauma of the incredible losses that they had experienced. And what that program was is this. It is an after-school tutoring program. Now, the concept here was that a Japanese child's life, much to the chagrin of my own children who I explained this story to and they were kind of incredulous, seems that-- you go to school all day, and then you go home briefly, and then you go back to these after-school cram schools, etc., etc., and on weekends as well. And if you're going to live the life of a normal Japanese child, this is your life. Well, that may seem a little bit odd to me sitting in my social location. What these children seem to be experiencing is one that the message from the external environment around them was saying that, "You are now normal again." Even if you've lost your parents, even if you're living in these very small, micro housing units while we're adjusting and figuring out what to do with you, etc., etc., your life at least can be perceived as going forward. To create a sense of optimism or expectations for the future, which are all components of resilience, they've actually created the structure of putting kids back into educational pathways that are predictive of a positive outcome. It also creates a social location. It creates a normal identity, and it gives them sort of all those sort of components, not to mention structure in their days, routines, and everything else.

MICHAEL UNGAR: In fact, there was just a study released recently in the Neurobiology of Stress that showed quite clearly that children during this pandemic do better, especially young children like age four, when families provide routines and structure. And that actually elevates their-- or prevents them from developing depression and anxiety or showing the signs of those particular disorders. So what I'm beginning to understand is if we can begin to see a bunch of conditions that are protective to a particular child, but it's always going to be culturally or contextually dependent how they are, well, manifested. You couldn't bring this to Canada. I can't take my kids after a major tsunami or something and put them into cram schools in the evenings. It's just not going to be protective. And it's kind of funny when I said to my colleague there-- I said, "Well, Keiji, what about all the other like right to play in soccer balls and all the other things that we use when kids are in traumatic experiences to help them heal?" And my colleague there says, "Mike, why would we want our kids wasting their time playing?" That is culture.

MICHAEL UNGAR: So what I'm actually getting at and which is coming out of a new book called Multisystemic Resilience with Oxford University Press-- this is my little plug, I guess I'm supposed to do here. But the whole point is that we're really now talking about complex, biopsychosocial ecological systems at multiple levels, all sort of working together. And this then puts the onus on us - well, if I can talk as a researcher first - to actually be thinking about and measuring these multiple systems. So we have a large study right now going on in two oil and gas communities, one in Canada and one in South Africa. And we're actually trying to understand the impact of, basically, the price of oil and the boom and bust economic cycles. And as we're potentially talking about moving away from a carbon-based energy system, what is all that going to do for the mental well-being and sort of the life choices of young people?

MICHAEL UNGAR: Now, when we start answering questions like that, what we're beginning to understand is we have to think about the impact on everything from our microbiomes, right, which is John Cryan's work, out of Ireland, and others that are looking at the relationship between our microbiome and our mood disorders. But we can even talk about hair cortisol or measuring cortisol effects, etc., etc., and our attribution styles or our cognitions of the psychological systems. We can look at our social environments and how we're interacting with others within our families, whether or not our parents have jobs and whether or not their caregivers are at home or are they traveling away based on the economy. We're also talking about the built environment and indeed even the natural environment. And the trick seems to be-- and this is what we're experimenting with is, how do you create models that can account for all those different systemic levels in one comprehensive understanding? And our belief is that if you can make robust one of these systems - so you can make it more resilient, say, the psychological system or maybe the built environment - that that would have a trickle-down effect or a trickle-up effect to actually make the other co-occurring systems also resilient.

MICHAEL UNGAR: Now, what that means in a very sort of practical way, of course-- what that means is that you want to, as a clinician even, be adapting multiple systems. So if you're thinking about someone's diet, then you're going to be thinking about food scarcity and whether or not they have access to a grocery store that they can actually get a ride to to actually get healthy food. If you're talking about psychological systems, you might also be thinking about the robustness of what kind of educational institution is a child actually going to and how can a positive teacher bring out the best in that particular child. Now, because I'm a scientist, you kind of kick around with all these theories and everything else, and eventually it comes right down to some hard, well, data.

MICHAEL UNGAR: Okay. Cinderella, right? And this, of course, is the Disney version of the fairy tale. So you have Disney's version of Cinderella. She's incredibly white and very, very gender normative. So my apologies for the image, but this is the most popular image of her. The story always bothers me because we always talk about Cinderella as a resilient kid, right? Her mother dies; father dies. Evil stepmoms, poor stepmoms always get a bad rap. And then she's got so many great traits. And the fairy godmother turns a pumpkin into a golden carriage, [takes?] her off to the ball. She meets the Prince [Charming?], and basically, we have Meghan Markle story. Okay. But back to Cinderella, the story is always told about her. But really, don't you think that the story has very little to do with Cinderella? It has everything to do with fairy godmothers, because who would not do better in life if you didn't have someone who could turn a pumpkin into a golden carriage? And frankly, without the fairy godmother, Cinderella is just a kid who eventually becomes abused, lives in a kingdom where the prince spends all of his money on gala balls for the rich and famous and does absolutely nothing for the people who are most harmed in that particular community. I mean, there's not a mention of a social worker or a mental health therapist anywhere in Cinderella at all. And this kid probably just runs away at age 14, if she's like the kids I've worked with and made my career out of. Then basically, she probably ends up on the street swapping sex for a place to sleep at night and is not the princess that she eventually becomes.

MICHAEL UNGAR: So I know I've ruined the bedtime story for you, but essentially, what you can do then is we have to begin to think about how do we measure resilience? Do we just measure that internal concepts inside the individual, their grit, or do we measure somewhat more the contextual factors? And this is a free measure that it's open source on our website, so you're certainly welcome to take a look at it. It's a Child and Youth Resilience Measure. There's an adult version as well called the Adult Resilience Measure, well-validated across many different cultures and contexts and languages. And we've been finding a pattern in the factor structure of it, which includes, of course, these individual items. And you can read some of those. There's also relational factors to account for resilience. And of course, there's contextual factors as well, like getting education is important to me, and certainly, I am treated fairly in my community.

MICHAEL UNGAR: So what this actually looks like-- I've kind of talking, if you notice, about this risk protective factors and outcomes. And I'm talking about very much emphasizing in a much more equal way this idea of being rugged and externally resourced. And when you put it all together, you begin to get research that looks something like this. And this is a study we published a little while back, but I think it just bears out what exactly I'm trying to say. We looked at for just under 500 kids who are incredibly needy. These are kids using multiple services, mental health, child welfare. They're having problems in school. They're involved in corrections, juvenile corrections, etc., etc. And what we found is when you actually looked at the context from where these kids came, their neighborhoods, and you assessed them for individual risk factors, psychopathology, etc., etc., and then you looked at, at the very far side, how many services they used and what was their experience of those services, what we clearly saw-- I'm not going to go through too much of this, but just very clearly, the kids from the highest risk environments-- if you look at that minus 03 line, which is not significant to lifetime service use, that should be a positive and strong association because, of course, we'd expect the kids from the most dangerous environments, most threatening environments to have more services. But that's not what we found. And we've replicated this study in four other countries as well.

MICHAEL UNGAR: So very clearly, kids who are coming out of the most risky environments are not getting services. And when they are getting services, they don't like them very much, which is that sort of service use experience line, the minus 21, across the top of the parachute. And of course, I guess what we actually found was that when a child had a really good experience, say, with a mental health therapist, that was a vehicle for them to find those seven factors: a sense of efficacy, a powerful identity, a new relationship, a sense of their cultural adherence, their roots, a sense of cohesion, belonging. In other words, whatever the service was, as that service helped kids build those resources, both internally and externally, then they would change their behaviors.

MICHAEL UNGAR: Now, again, I want to make this as concrete as I can. So another manual, another free material that we have, we produce this manual called What Works. And it's available online for free download. And I produced several videos of interviewing people who were building resilience programs around the world. And I met this colleague of mine, Dr. Masego Katisi from Botswana, and what an amazing program that she's-- I mean, it's so far in advance of what we have-- often I've seen in Canada, the United States. She was working and trying to help children who whose parents had died of HIV and AIDS. And she wanted to do that by building their capacity. So she would basically team them up with local paraprofessionals, professionals in their communities who would create sustainable relationships for many years with these kids. And she wanted to give these kids a rite of passage that would help them to sort of grow and feel normal again. So she actually invented this program that involved a sustaining relationship and then a camp experience for two weeks where the children were provided with a sort of a trauma-informed therapeutic intervention offered by the same people who are their support people in the community. So the people come with the kids to the camp, do the work, and then return back to the home. We screw it up in Canada all the time, right? We have a therapist in the community. The child is sent away to a trauma-informed therapy camp or some sort. And then the child goes back as if somehow the child has to do all the work of bridging the continuity of the relationships and their learning. So let me show you what Dr. Masego Katisi is actually talking about.

MICHAEL UNGAR: We've called the program a resilience program not because I'm talking to you, but because, yeah, it is a resilience program in that-- the central problem here is loss of parents. But when children have lost their parents, consequently, they lose a lot of other resources. So what the program does is it helps rebuild those resources. First of all, to build the capacity of the child themselves, to check in what is it inside you. What I'm going through? How can I use the resources around me to help me? And then what do I lack? What resources are available that I link with that can support me throughout this experience?

MICHAEL UNGAR: So what the program does, therefore, is, number one, according to what the community came up with, is that it uses cultural resources of working together as teams. So young people, in the olden times and in some communities today, would be taken out for initiation to be trained as a group. So what the program does is it gathers those young people as groups to say, "Come." And for the first time, they camp in the wilderness, and they are given a platform where for the first time they can share their experiences of loss together in a team, which is what the community recommended. And then the program also links or supports the caregivers of these young people to be able to care for these young people, because they are also going through grief; they also have their challenges. So we have a way of running workshops for them on how to handle a grieving child. And they meet together with these very children in groups and discuss their challenges and come up with solutions on what to do.

MICHAEL UNGAR: I'm going to pause there. That whole video and indeed that whole manual is available, as I say, for free download of-- for free to link to it on my website. But if you look closely at what Dr. Katisi is actually talking about, she designed this amazing program that is, in a sense, checking many of the boxes I'm talking about. She is helping by making resources available and accessible to very vulnerable children, in a low-resource context, by the way. What she's been doing, of course, is making it possible for these children to find the supports that they need in culturally relevant ways. And the program is effective. It decreases trauma, it seems to promote mental health or at least prevents children from sliding deeper into problems.

MICHAEL UNGAR: Now, this is all done in a context. We're talking about grief, and the loss of your parents is not always culturally appropriate in Botswana, in a sense. But what she's done is she's sort of negotiated to find a way to do trauma-informed therapy in that particular context by using these rites of passage, this idea of a child needing a rite of passage and taking the child out into the wilderness to actually go through that rite of passage. I had the honor of visiting this program, and it's quite exceptional to watch. But then again, I've seen in the United States amazing programs as well as, an educational program like Northwest Collegiate in Baltimore that takes all the children who basically have been expelled from all the other schools in the region and basically creates a very welcoming, safe, secure environment that relies on relationships and building relational spaces for kids to actually feel like they belong at school. Every child who wants to play basketball can actually get on the team and play basketball. They've kind of gotten rid of some of those hierarchies, some of those barriers to participation.

MICHAEL UNGAR: So the more we begin to think about policies and how-- I know that we're mental health therapists and people directly in mental health care, but I do think we can have conversations with people about their transportation systems, etc., etc., their housing. We can have people talk about their experiences of being mistreated in terms of social justice movements, Black Lives Matter, Me Too movements. We can have those conversations with people as well because those are factors in their resilience. And that's why I'd like to say-- so one thing we've been doing anyway is developing an actual program, because so many times I see programs-- when they say I'm going to promote resilience for a particular population, whether it's in a workplace setting or in a school setting, you see them kind of focusing in on, say, one narrow factor, say, mindfulness. And I say, "That's great." But it works so much better when you also have the resources around people. It's a bit like saying to somebody, "If you're going to go and sit on a-- you buy your Lululemon yoga mat, and you race down to the to the yoga studio. And you're a parent with two kids that you've just had to rush to get to their day care. And now you've gone to your job, and now you've gone to your lunch hour. And now you've kind of rushed over to the yoga studi,o and you've taken 45 minutes of deep breath like that. And you see these people. Then they rush back to the office, and they rush back home to cook meals for the kids and everything else. And you see them-- hang on. I get you're focusing on the rugged qualities, but the research is working against you. The chances of that affecting your life long term is about zero. However, if you were to turn to-- say, you have a spouse and say to your spouse, "Can you get the kids to the daycare? You do that. You pick them up on the days that I'm actually going to the yoga studio." Theoretically at least, that sort of more systemic approach is much more likely to increase the likelihood that this program works.

MICHAEL UNGAR: So what I'm sort of getting at is-- and this is some some really interesting conceptualization from Dr. Linda Theron in South Africa, a colleague of mine at University of Pretoria. And I really like the simplicity of how she sort of said this. She said, "We can think about resilience as like high capital or low-resilience capital." You have those seven things, or you don't have them. And we can think about whether or not you find them in socially desirable or socially undesirable ways. And, of course, what will happen is sometimes people move to antisocial means to just cope. So you have someone who's socially withdrawn, socially anxious, in quadrant two. They're not doing anything wrong. They're just not getting on with life. And they start doing drugs as a way of coping with that particular situation. Or maybe they move up to anti-social but high-resilience strategies. So it's not as we're seeing. Sometimes kids who are really feeling displaced socially and awkward, these are often the profiles of young extremists who join violent extremist movements to identify-- like the incel movements, etc., etc., right? And of course, what we're actually hoping, if you think about what we're-- I think what we do as clinicians is try and elevate people from this lower resilience or low-resilience capital and try and get them to find socially more desirable ways of expressing or finding connections. That could be an online community, a gaming community that's doing something or maybe a volunteer activity or a faith community, etc., etc., etc.

MICHAEL UNGAR: Now, those are the patterns. Now, there's a couple of caveats to this, okay? I definitely seem to be presenting resilience as almost a one-way track to success, right? There's these factors. You help people navigate to find what they need, to negotiate for what they need in ways that make sense to them and their culture and their context, right? And you think about both helping people to become rugged as well as resource. So in the workplace, that means you focus on helping your employees during the pandemic, for example, remaining calm, dealing with the stress of having two-year-olds crawling under their feet while they're trying to talk to their boss and all that other stuff. Yes. There's definitely a cognitive element here. But you also help them and support them through feeling like you offer them times for the social cohesion within their group experience, scheduling not just work-related calls but things that maintain the team effect.

MICHAEL UNGAR: I recently worked with a large, large financial management firm; it was just before Christmas. And they sent gingerbread house making kits to these large work teams. And they got them together in sort of work teams of about 60. And simultaneously, they had all the families on a Zoom call building their Pinterest-like gingerbread homes. It's a silly little example, but what it was, is a really wonderful idea of how an employer was trying to create a sense of community within a team that had become fractured by everyone working online instead. And again, the programs I keep seeing that work are those that have this consistent pattern.

MICHAEL UNGAR: Now, there is another caveat I really want to offer here, and that's this kind of notion, if I could, that these efforts to help do seem to show a pattern of what I've called differential impact. And yes, it's kind of riffing off the Thomas Boyce's and Michael Pluess's and others' idea of differential susceptibility. But as a social scientist, I'm less concerned about the genome or one's epigenome, I guess, and more concerned by the impact that programs have on people. And when we actually gathered papers in a special issue of child abuse and neglect a couple of years ago, what was really interesting was you see the pattern when you actually look for it. And this is what the pattern looks like. If we could all agree, for instance, that children who are in mentored groups where there's an adult to mentor them-- in generally speaking, we would think that that would produce over time some good results, especially if those children have been abused, sexually or physically or otherwise. And in general, you would be right. The depression drops for kids when they're being in a group with an adult mentor, whether that's a choir or a boys and girls club, a faith-based community or something like that, right?

MICHAEL UNGAR: Now, that makes a lot of sense. Especially in this case, the kids who most benefited from those seems to be kids who experience neglect. But what if you go and disaggregate your data--? Or as clinicians, we actually look a little deeper. Sure enough, what we see is this, that the children who'd been sexually abused in their past actually became more depressed when they were in these mentored groups. So in other words, a protective mechanism like an adult mentor, depending on your risk profile of abuse, produces quite a different outcome. And the pattern shows up for delinquency where actually the children who'd been sexually victimized, actually their delinquency decreased - I don't know - maybe because they were more depressed. But the kids who had other forms of neglect in their lives, they actually became potentially more delinquent, maybe because now they had more confidence to act out. The why is difficult to answer. But clearly, we need to be thinking about these kinds of more dynamic models.

MICHAEL UNGAR: And if I could switch the conversation yet again to just kind of broaden where the science of resilience is going-- and particularly Bruce Ellis and his colleagues who are looking at things like hidden talents in harsh environments, what I think Dr. Ellis and others are getting at is this notion that we have this kind of adaptive intelligence, right, that we can adapt to unpredictable or challenging circumstances, that, in fact, some stress is actually teaching us to cope. And that's why this overprotective parenting or being excessively cautious can actually undermine children's developmental pathways into becoming more resilient. They kind of lose their-- they're not psychologically inoculated, the term of the day perhaps-- psychologically inoculated to stress by never having been exposed to it. So Bruce Ellis and certainly others are talking about the need to to find our hidden talents within our harsh environments.

MICHAEL UNGAR: And Anthony Mancini at Pace University has actually been talking about psychosocial gains from adversity. And this I find also particularly interesting, especially during a pandemic, because what Mancini is showing-- by looking at studies and sort of aggregating the data, he actually found that within most of the studies that he was looking at, whether it was with people who'd experienced a shooting, soldiers who'd been deployed and were suffering from PTSD, people with cancer and how they experienced the course of the cancer, or indeed people with some sort of ambiguous loss or serious loss in their life, the death of a loved one, there was always about anywhere from like 7 to 11 percent of any sample that were actually better on measures of things like depression and PTSD. In other words, what's also being called post-traumatic growth-- there's a slight nuance in the two definitions, but I think the onus is on us as clinicians or indeed researchers too to not make the assumption that these things are always bad.

MICHAEL UNGAR: And indeed, during the pandemic, I can say with some confidence that we are seeing children, a lot of children doing a lot better during the pandemic, staying at home and having the attention of the parents, even if that's fractured attention, than many children who were in that constant churning of, "Okay. It's Tuesday; it's piano. It's Wednesday; it's hockey. Tomorrow, I have to go skiing. And then I have to do this. And then I have all these high expectations. And then I have this." There's a lot of kids dealing with that plus the bullies at school who are going, "Time out. Bring it on. I'm at home." And there are actually, I'm going to argue, employees too-- that there are people who are actually finding no longer the stress of the long commutes into an office incredibly beneficial. Now, of course, there are many people who've lost their jobs. This is a pandemic, a recession that's disproportionately affecting people who are much more marginalized. But my point is that when-- again, the dynamicness of resilience is always to ask the question not just what is the individual factor, or what is our individual program going to do, but which program, for which person, at what risk profile, and who with what resources is actually going to produce the desired outcome? And indeed, it's interesting. Here's some just recently published data from the UK that's showing actually rates of anxiety and depression are actually going down, not up throughout the course of the pandemic, which astounded the authors and, by the way, also astounds me as well.

MICHAEL UNGAR: So what am I trying to say? Well, I guess what I'm trying to say is that resilience looks very different for different populations in different contexts with different levels of stress. And the best way I can show you that is this picture. This was taken maybe a dozen or more years ago when my daughter was a lot younger. And I was working with my colleagues in Tanzania and developing some ideas. I have colleagues, of course, across the United States as well in Canada. And my daughter came with me during that trip. And at one point, she went to school with some of the children of my colleagues as we were looking at developing a study of resilience there. And I went back when lunch, and I took this photo. And I just love the photo because, well, as you can see-- my daughter, who, by the way, is the fifth one in from the right, if you couldn't sort of pick her out; you never know. My daughter though is outnumbered on that bench. And I remember I when I looked at the photograph after how profoundly it affected me that this is exactly what I was trying to say, was that we know a lot about her resilience, but we know far less about the resilience of the other children on that bench.

MICHAEL UNGAR: And I think the onus now is to allow the science to explore children who are indigenous, from other ethnoracial groups, peoples who are-- experiences much more marginalized and indeed now during a pandemic, children's experiences during the pandemic and let the complexity of those stories really shine. So on that note, I think it'd be great to take some of your questions and see what you're thinking about this. I hope I've sort of sparked your imagination about what resilience is and some of the concrete things that you can do to help people navigate and negotiate and indeed some of the factors which are likely in different cultures and contexts to spark people to be better prepared for the next challenge in their lives. So on that note, I'm going to pass this back to the moderator and see what people think.

JOSHUA GORDON: Alex, I think you're muted.

MICHAEL UNGAR: Do we have a--? Alex, are you okay?

JOSHUA GORDON: No. He's still muted.

JOSHUA GORDON: There he goes.

ALEXANDER DENKER: There we go. Sorry. I had to reset my headset, which is not something I expected. Thank you so much for an excellent talk, Dr. Ungar. We do have many questions, and I'll do my best to combine them as much as possible and get through them. We do have many questions that get at the notion of how resilience changes across the lifespan and from children to the elderly. And one of those questions is, what is the role of emotional intelligence in children and adolescents when managing adversity and building resilience?

MICHAEL UNGAR: So there's lots of studies across the lifespan. We're beginning to get those studies. And of course, there are some very famous ones like Emmy Werner study, etc., etc., out of Hawaii, etc. But the factors I've gone through tend to be pretty consistent, like positive relationships, sense of efficacy, sense of one's heritage or culture. I mean, these factors reappear across the lifespan, but they manifest both because of one's gender, one's opportunities, and indeed one's age as well in the setting that those things are in. So you'd look at how do you get seniors in a seniors' residence to exercise more, especially if there's a park across the street where you create the opportunities for them to go to the park. You create green spaces. You create the sense of efficacy. You inspire them to believe that they can do that. So there's, again, those personal rugged qualities and those actual resources as well. What was the second part of that question?

ALEXANDER DENKER: So as children and adolescents and then also there's a question about how this work is translated to seniors, to senior population, to the elderly, so how it could be translated or how resilience might change.

MICHAEL UNGAR: And there's also a notion of emotional intelligence. And again, can we begin to think more in terms of both sort of maintaining a robust cognitive style of attribution that doesn't blame yourself for mistakes and stuff? They talk about positive aging. Of course, there's some wonderful studies of that that says if you have a positive attitude towards, "Oh my gosh, that knee is all creaky. I guess I'm 80. It's called aging. The alternative isn't great, so I'd rather the creaky knee." That kind of attitude actually seems to have a benefit in terms of giving people a longer lifespan. So there's something about those attribution styles. But there's also something about whether or not you have a safe sidewalk outside your seniors' residence to actually go for a walk, or if indeed, as we've seen during the pandemic, people are actually able to visit you and to sort of maintain your social networks around you. So the more that we have both those resources and those rugged qualities embellished-- and that, of course, brings you back to emotional intelligence, which is just one of those qualities. What's the point of having emotional intelligence if you're walking down the street and the police pick you up because you're black? You're Hispanic and you're denied a job. You're turned away at a border, or you're given extra harassment.

MICHAEL UNGAR: I mean, I'm always amazed by us-- let's get really concrete about this, right, is that are our individual skills are only up to a point going to get us through a tough time unless systems around us also adapt. Let's face it. What is vaccine efficacy? It's not just the biological measure in a trial of whether or not the vaccine actually produces the immunity response we're expecting. It's now we're understanding that this vaccine efficacy is going to be far lower because a lot of people are going to resist taking it because of spurious beliefs, a lack of faith in our media, and leaders who, frankly, are undermining the faith in our institutions. That decreases the efficacy of the vaccine. In other words, our ability to resist stressors are always this complex story of external factors and internal politics.

ALEXANDER DENKER: Can you speak to how researchers identify their measures? We have a couple questions, both on how researchers define positive outcomes and also how researchers identify resources. And how would you identify what a helpful resource would be for those positive outcomes?

MICHAEL UNGAR: Yes. So actually, I recently published something in Lancet Psychiatry, which is an open-access paper, if you want to read deeper into this. But what I was getting, very succinctly, is I think we really got to be careful when we're looking at resilience processes that we don't assume resilience is the outcome. We want an outcome which is past the process. We want to identify and measure are people engaging in processes that are, in fact, protective? Do they have relationships? So the relationship isn't the outcome. The outcome is that then they feel better, or they're better connected in their communities or something like that, or the next time there's a food shortage that they can rely on somebody else to bring them over some groceries, that type of thing. So the outcome is often very, very concrete and measurable, at least in the studies we design.

MICHAEL UNGAR: We also like to assess the risk exposures, because otherwise, if someone says to me, "Here's a protective mechanism," I say, "I don't know." If people use my own measure, the CYRM or the ARM version of it, and they don't also account for the risk exposures, it's very difficult to actually say whether or not the outcomes are attributable to that. Like what does it actually mean that if people have higher self-esteem, they tend to exercise more? Well, my question always from a resilience point of view, "Yeah, yeah. But who, living in what kind of housing development, with what sort of advantages does that particular model--?" Can we all agree that more studies of university students is probably not the best path forward for resilience studies? Can we just all agree that they may not represent enough diversity of the population, right? It's not that we shouldn't start there. I agree with those studies when they start there. But they need to be replicated in context where we can account for much more variability in what we're trying to show. And I think that's what we really-- the field is going.

MICHAEL UNGAR: Now, one other thing though, mental health folks are very good at measuring the psychological and the internal. If you look at most studies, they tend to quickly operationalize the external environment. One question, do you adhere to your culture? Like not what that culture means. We have very monochromatic kind of ideas around, "Oh, are you a racialized person?" Tick. Well, hang on a minute. Are you a rich racialized person, or are you a poor racialized person? Are you living in a community with other people who look like you, or are you living as the only person of that racialized group in a community that excludes you? And there's plenty of research to suggest that when we get a little bit more nuanced for the external variables, the better we'll understand the internal, to the point where now we are actually-- when we do a study in a community dependent on oil and gas, we are actually looking at the variable of the economic conditions or the world price of oil. And we need some more fine-tuned detail on that to actually be able to answer questions of significance.

ALEXANDER DENKER: Thank you. Is there a way to assess capacity for resilience? Along the notion of looking at other populations, we have an individual who asked a question about impacts of burnout and how populations that experience burnout, like healthcare workers, may or may not-- one may or may not have more capacity for resilience than the other.

MICHAEL UNGAR: That's right. And if I might then, just to sort of tweak that, I think what the question's saying is, does the person have in place the capacity to access or have available to them the resources that they need to cope with situations where they are going to feel burnout? I'll give you a simple example. When we did this large Cigna study in the US during the pandemic, what was clear was that people reported less anxiety and depression or propensity for that when their employers were much more transparent with them about what the actual economic conditions that were impacting them were. Now, in other words, the transparency of the employer and saying, "Hey, we're really struggling here economically," or, "This really is knocking us off our feet," or, "We're really worried about paychecks." Those conditions basically created a better cognitive space for the individual. So when you're looking at this kind of question, what we're actually, of course, talking about is, is somebody ready for resilience, or is somebody going to show more resilience is going to partly be predicted by the quality of their relationship with their employer, the social justice that they experience in their lives, which is why--

MICHAEL UNGAR: If you look at, say, Susan Cutter's work in the US, there's almost like taxonomies of what we need to understand resilience at a community level. And we know that the better communities will produce better individual resilience, a more cohesive environment. When more people own-- there are studies in Chicago that show that when more people own their own homes, that the communities tend to be a little bit safer. Now, that's not true all around the world necessarily. But those kinds of patterns say to me-- if someone says, "Will this individual has a susceptibility to resilience?" I would say, "Yes. As a biological genetic predisposition, potentially." But ultimately, it's about what resources do they have and what habits have they formed cognitively over time that have been reinforced which is going to get them through a crisis.

ALEXANDER DENKER: Thank you. Can you talk about how the concept of post-traumatic growth plays into resiliency, if if it's part of the same; if it's a different construct?

MICHAEL UNGAR: Yeah. Well, Mancini seems to be talking about that we gain from-- there's always a percentage of people who-- in that adverse circumstance, they seem to accommodate to it better. So the child who is bullied at school during the pandemic and has to stay at home is just going, "A1," right, "this is great." Post-traumatic growth is different, and it's somewhat controversial as well whether or not-- but without going into the controversy, the idea is that you go through the hardship, and the hardship creates a steeling, S-T-E-E-L-I-N-G effect on you. You learn from it. So the best example I have, Mothers Against Drunk Driving. You had a group of, in this case, women who lost a child to a drunk driver. And through that incredible-- that is the worst possible crisis a person can go through. And they took that, and they used that to start a national, international movement to prevent something that-- to benefit all of us. Would they have done that without the loss of the child? Now, I'm not trying to-- that is not where-- you don't want to go there. But the idea is that sometimes we go through a great hardship, and we learn something new about ourselves. There's communities that have gone through wildfires that have come back, where people have revisited their values, have taken their cellphones and said, "I'm going to spend more time with my kids." I'm not making that-- there's some data for some studies like that. That for me is what post-traumatic growth is about.

ALEXANDER DENKER: Thank you. I'm going to turn over the rest of the talk to Dr. Gordon.

MICHAEL UNGAR: Thank you.

JOSHUA GORDON: Well, thanks again, Michael, for a really wonderful talk about really illustrating the richness. I was thinking of saying complexity, but that has a negative connotation, I think-- the richness of resiliency and the need for us to think about applying the same sort of precision medicine approach that we think about trying to work towards with our treatments to prevention and thinking about the fact that individuals with different capacities for resilience or facing different stressors, different traumas might require different approaches. I think that's really important for us to keep in mind. I also appreciate everybody's questions. I want to let people know we had 589 participants at peak today. It's remarkable, way more than would have been able to come in person. So there is a silver lining to the-- and this is yet another silver lining to the forced virtual experience. So I want to thank everyone for joining. I also want to thank people for their questions. In addition to the one that Alex managed to ask, we had 31 more that we did not get to. And I saw participants raising their hands, wanting to ask even more. So I apologize to all of you who had questions and didn't get the opportunity to have them answered. I also want to just let everyone know, as was said in the Q&A, that this was recorded and will be posted on the web. So if you missed pieces of it, look out for announcements from NIMH when it does become available on the web. So thank you again for joining us and hope to see you at the next NIMH Director's Innovation Series. Bye-bye.