Psychiatry and Stigma: How one Canadian psychiatrist uses design thinking to reimagine mental health care and combat taboo


November 12, 2020

Dr. Thomas Ungar is an associate professor of psychiatry at the University of Toronto and the psychiatrist-in-chief at St. Michael’s Hospital, part of Unity Health Toronto. In this interview, Journal editor Nada Dorman talks with Dr. Ungar about prostates, the pandemic and how design can change the future of mental health.

Nada: Let’s start with the basics; tell me about you. Where are you from?

I was born and raised in Toronto. My parents were Holocaust survivors with Jewish background from Hungary. They escaped Budapest in 1956 during a revolution by crossing borders with my older brother, who was three years old at the time, and getting on a boat and arriving at Pier 21, which is Canada’s version of Ellis Island. Like every immigrant community, they started in the immigrant ghetto as refugees. My father started a business and worked his way up.

My older brother was an artist-filmmaker, and immigrant parents often want to see a professional, so I kind of had to become a doctor. I actually started out in family medicine for two years in a variety of locations in Toronto, but I was always fascinated and upset by my colleagues’ lack of comprehension that mental illness is really an illness. The way they treated patients, they just didn’t get it… so I went back to school to become a psychiatrist.

A Director and a Psychiatrist Walk into a Bar

Nada: Let’s jump right in with something I’m eager to understand. You created an online series aimed at helping people address sexual and mental health issues. How does a practicing psychiatrist decide to create and produce a reality show?

When I shared the idea with colleagues in my department, they thought I was wacked. I saw a call for innovations grants from the Men’s Health Foundation (Movember) and got awarded close to $150,000, and we did it. Initially, we focused on men’s sexual health, prostate and testicular cancer. It was not exploitive; it was tactful, humorous. It needs a little more development, and I’d love to find a professional production company. I’m just a physician with a day job, but we wrote it up as a creative experimental vehicle for public health education leveraging edutainment. This is the most professional fun I’d ever had. On so many levels, it was working; we even published a proof of concept study.

Nada: Tell me about how you tackled mental health with the web series.

We did four mental health episodes. The most dangerous one we did was the suicide portrayal. You don’t see people talking about or disclosing much on suicide. Everyone is scared to do that, or they might sensationalize it and exploit it. That took us into the ethics of portraying mental health using media and this crazy format. This was around the time that 13 Reasons Why came out. We did a commentary in the British Medical Journal on their blog sharing how human-centered design can be used to portray mental illness and reduce suicide. It’s not that you can or can’t use media for portrayals of suicide – that’s old school as you come up against the traditionalists. It’s how you do it. It’s been a pretty lonely place in my work, but I keep at it and get fabulous feedback here and there.

Where Buildings and Bias Collide

Nada: Share what you’ve experiencing in Toronto with respect to race, access and equity.

The focus of my work over the last ten years has been about overcoming the attitudinal barrier which people often called mental health stigma and structural stigma. We’ve reframed this as an equity issue, the stigma of inequitable care and access and implicit bias and systemic bias. Everything right now is about this in the U.S. and in Canada. We’re getting at the deep structures, funding formulas, creating quality dashboards. This web series is designed to leverage entertainment and creatively get at the stigma and attitudinal level using creative entertainment and a pop-culture design.

Nada: You’ve been at this for a few decades now. Are you seeing that this next generation of doctors is at least more aware of the inequity and the need to treat mental health more comprehensively?

It’s really great. At the attitudinal and personal level, the awareness is up, the receptiveness is up, the desire is there, they’re totally engaged. What I don’t yet see is an awareness of the structural inequity. That’s not there yet.

Nada: Can you explain further?

In Toronto as with other places, we have a separate main mental health hospital. And we also have psychiatry programs and in-patient units in every general hospital. Everyone thinks it’s great, but how come one disease has its own hospital? It’s a segregation model. People don’t see it as that, but I see it as structural segregation that’s not even noticed. This type of segregation exists throughout health care.

I’m using a sneaky, subversive way to get in there to hack and change the rules of the game from the inside out. I’m not going to be an activist screaming from the lawn of our equivalent of the White House on Parliament Hill. As part of a five-person research team with the Mental Health Commission of Canada, we’re creating an implicit bias training module for mental illness and substance abuse. That’s the structural stuff that’s there. There are these weird, unconscious, implicit segregations of unfair quality in treatment in mental health.

I’m using narrative and creative story-telling and observational culture of healthcare insights and turning them into rapid prototypes to change standards to capture the implicit bias. That’s what’s limiting the quality of care for people. It’s not purposeful; I’m not accusing health providers of personally being aggressors or oppressors. That’s an off-putting misconception, and you have to gracefully bring them there. Story and narrative are a wonderful vehicle. I like the comedy and getting cheeky and playing with words. Not everyone receives it well. They don’t see the intent; it’s the intent that’s important.

Design Thinking and Mental Health

Nada: Tell me about how you were introduced to design thinking.

My interest in design thinking came from my frustration because the wonderful biomedical research that medicine does was very, very rigorous but conservative. It didn’t allow for the freedom the way I came at things: laterally, being multidisciplinary, borrowing ideas, creative narratives, playfully educating. This was going really well for me, but I still don’t have an academic center or home – people don’t think I’m a real academic.

I attended a lecture with the founder of IDEO and the heads of Parsons and the Rotman School. I went to this lecture and instead of being the fish out of water, there were people there that think like me. I’m not so weird after all. I just got into it. I read about it, learned it, and feel very validated by it. It gave me permission to use my analytic knowledge but also take the best of creative design and free thinking, which isn’t so weird for psychiatry, right? It just makes sense to me.

Comedy in a time of COVID

Nada: How have you applied design thinking to helping support patients with the pandemic?

I’ve been asked by a few media outlets to do some interviews about COVID-19, and I’ve done some writing on this topic. First of all, I use non-medical jargon when I can. “This really sucks,” is an example. I try to get a good metaphor. Also, let’s not blur normal worrying and anxiety with an anxiety disorder.

Now people are getting COVID fatigue. The human factors field of quality of care accepts human limitations such as developing fatigue and expects them and designs for them. The old model of medical error doesn’t do that – it says you can’t make an error. The human factors method builds in and expects human limitations and error.

What I’m not seeing is using talented influencers and social media merged with the scientific world to get the word out. There isn’t anything yet that’s influencing them other than “be well.” To encourage mask use, I’d like to see an image or video of a pirate telling someone to “cover your blowhole,” at least the ones on your face, maybe with a whale icon?

There is a lot of room for COVID design. You’ve got scientists and public health officials in charge. You don’t have designers and the creative media and youth doing wacky things. That’s a huge gap with COVID right now.

What’s Next?

Nada: In 5 years where do you hope to be? What do you want to be doing?

There better not be a pandemic! Another year or so and things will ease up, and we’ll have a vaccine out by then.

I think we will shift about what we value, and that will have a generational impact. Same way that my parents surviving the Holocaust and then being refugees always leaves a different world view of what’s really important. We will shift away from our materialism and appreciate more. We will work from home more, prioritize our relationships more and recognize more around what has meaning. We’re part of a society that does look out for one another, and I think there will be even more hopeful consideration of that after the pandemic.

As for my work, I hope that the great work to improve structural elements of stigma and mental health and implicit systemic bias will spill over from the racial issues into other equity issues, specifically mental health and substance abuse at a structural level. And personally, I hope I can just build more design into my career. My dream would be to have the web series picked up. I’d keep my clinical role always, but if I could be a part-time TV/video producer, wouldn’t that be a riot?!

Nada Antoun Dorman is managing editor of the Journal of Design and Creative Technologies. She serves as Assistant Director of Communication in the School of Design and Creative Technologies at The University of Texas at Austin.

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