Beth Mark, MD

“Alone we can do so little; together we can do so much.”--Helen Keller

The climate crisis presents unique and complex challenges to the mental health and wellness of individuals and communities.

 The need for interventions at a global scale increasingly leads mental health providers to look toward large group interventions. This article outlines a number of the more popular group approaches. It informs psychiatrists about the climate distress groups that our patients may access and advances our understanding of these groups’ methods, which may help psychiatry’s own public health response.

We can anticipate an increasing number of population-wide climate events, from disasters and social disruptions to existential concerns. Within disaster psychiatry, it is now suggested that

Beyond contemporary approaches of diagnosing and treating illness...there should be a transition to early screening and delivery of public health interventions that are evidence-based, cost-effective, readily accessible and community-focused with the goal of reducing distress, enhancing well-being and functioning, reducing the rate of progression to psychological disorders and, ultimately, improving the overall trajectory….

This is no small challenge, given the complexity of the problem and the wide range of individual responses.

 An objective exploration of the novel programs that have been developed to address eco-distress will help us offer better clinical approaches and guidance for these new types of distress.

In one approach, Climate Cafés (CC), were developed with the idea that diverse individuals will benefit from discussing their concerns about climate change in an informal supportive space, free of charge. There are several models of CC, some led by mental health professionals and others by non-specialists. One clinician-led model was developed by the 

Climate Psychology Alliance (CPA)/United Kingdom

 It is not a closed therapeutic group. The general structure of the CC is for group members to share what is on their minds about climate change, what prompted them to attend the group, and reactions to what others say. Leaders are there to listen for emotions and reflect them back, focus group process, and protect the emotional safety of the space. The leaders do not suggest any course of action, nor is there expectation that group members will take action regarding climate.

 has posted a suggested template for a CC discussion group, modeled loosely off the Death Café project and led by a non-clinician. (Death Cafés are gatherings aimed at increasing awareness of death and mortality as a means to becoming more engaged and fully alive within our finite lives.)

strives to “include equal doses of hope and action. If at all possible, participants should leave feeling empowered and energized, rather than hopeless and depressed.”

 There is, to date, no published information or research on the experience of CC participants.

 (GGN) is a nonprofit support group organization aiming to help people build resilience for living with climate change, as well as other systemic issues such as racism, classism, sexism and homophobia. The co-founders, Laura Schmidt, MS, and Aimee Lewis Reau, MFA, anchor their program in a 10-step model, similar to Alcoholics Anonymous (

). The purpose of the meetings is to gather with others in order to build community and to enhance one’s ability to accept and sit with climate uncertainty, pain, loss, and grief. They propose that personal resilience is built as a result of this process. The group meets for 10 consecutive weeks and is led by lay people who have received training from The Good Grief Network staff. Neither Schmidt nor Lewis-Reau are certified mental health providers.

Readings by climate change authors such as Joanna Macy, PhD, and Jem Bendell, and trauma experts such as Bessel Van der Kolk, MD, are recommended, as are meditation and yoga exercises. Group leaders do not prescribe any specific climate related action, but they do support members in personal discovery of meaningful climate action. Schmidt and Lewis-Reau do not discourage group members from discussing and processing past non-climate related traumatic events during group meetings, believing that processing past traumatic events can “free you from the extra weights that are tethering you from being a nimble actor” in dealing with 

 There is, to date, no published information or research on the experience of GGN participants.

The Work That Reconnects (TWTR) is an approach developed by Joanna Macy, PhD, and is described as a “transformative learning process.”

 TWTR incorporates aspects of deep ecology, systems theory, eco-psychology, Buddhism, and activism. It was initially developed for adults, but it is also being applied to the late adolescent and young adult populations. A key premise of TWTR is that for humanity to respond adaptively to the problem of climate change, individuals must learn to shift from an automatic psychological response of withdrawal and defensiveness towards an active, creative, and collective response, termed “Active Hope.” TWTR workshops (conducted over 1 to several days) involve a 

, designed for exploring and tolerating emotional reactions to catastrophic world problems (

Instead of turning away from the problem, group members reframe and honor their feelings, and then develop fresh perspectives intended to bring about “The Great Turning,” a societal transformation from an industrial, growth, and consumer-based society to a more equitable and sustainable one. In 

, there has been an emphasis within TWTR on “revisioning the Work with the aims of decolonization, integrating a deeper anti-oppression framing and analysis, embracing marginalized perspectives and considerations, and generally making the Work safer and more relevant for non-dominant groups.”

 This effort is referred to within TWTR literature as the “Evolving Edge.” There are guidelines for individuals who want to become group facilitators, but no specific training or degree requirements. There is a variable fee to attend. To date there is no published information or research on the experience of TWTR participants.

The Deep Adaptation Forum was developed by Jem Bendell, PhD, after the publication of 

 “Deep Adaptation: A Map for Navigating Climate Tragedy,”

 which went viral. Deep Adaptation (DA) positions itself outside of mainstream work on climate adaptation in that it assumes inevitable societal breakdown and collapse due to climate change and intentionally challenges the idea that hope should be part of climate change adaptation.

An international DA online forum has subgroups: a Professions Network for professional collaborations exploring climate collapse; a Groups Network aimed at cross-pollination between groups focused on related topics; and Positive Deep Adaptation, a Facebook group for sharing the psycho-social-spiritual implications of climate collapse and practical knowledge to support individual, local, national and international wellbeing before and during social breakdown. The addition of “Positive” to the Facebook group’s name is intentional, as the group’s focus is not to detail and recount the collapse, but to support personal and community adaptation mechanisms to best live with collapse (

 (ie, creating an equitable system for distribution of life essentials such as food, water, energy, and health care) and 

 (fostering psycho-social-spiritual-cultural shifts to accept and live through collapse with some composure and stability).

There are no workshops or intervention templates in DA work. Rather, online forums promote international discussion and sharing action plans for societal collapse. There is an emphasis on the collective, in terms of both leadership and actions. There is to date no published information or research on the experience of DA participants. There are, however, comments on the 

 written by participants who describe the collapse-readiness and collapse-transcendence changes they have made in their lives as a result of engagement with DA.

Transformational Resilience (TR) is an approach developed by Bob Doppelt, who is trained in both counseling psychology and environmental science. This workshop approach focuses on building individual and community psycho-social-spiritual resilience to prevent or minimize harmful impacts of climate changes.

 The model is based on the premise of post-traumatic growth: that living through and with adversity can result in a more satisfying way of life. TR is tailored for diverse participants (different ages, demographics, communities, cultures and nationalities) and can also be tailored to specific occupational groups including mental health and social services workers, first responders, environmental scientists and policy makers, climate activists, businesses, and nonprofit organizations. A small number of highly trained and experienced clinicians lead the workshops, which involve a fee.

 are the 2 foundational skills taught in TR workshops. Attention is paid to presenting and teaching these skills in an age-appropriate, culturally-informed manner. Presencing involves integrating skills for self-regulation to decrease the fight/flight response. These skills include body-based techniques such as grounding and mindful breathing. Psychoeducation, reviewing the neurobiology of the acute and chronic stress response, is woven into the skill building. The maladaptive nature of the fight/flight response, when employed as the only go to response to climate stressors, is illustrated through its negative impacts on individual physical and mental health and harm to the social health of a community (eg, distrust, increased interpersonal aggression, and decreased concern for the other, which includes the environment.)

Purposing involves helping participants explore and consider their values and what matters most to them in life. Through the steps of Purposing, participants imagine and begin to create an intentionally meaningful life, in spite of unfavorable climate change conditions. The skills involved in Purposing include cultivating appreciation for insights of self and others in adversity, clarifying values to live by, and harvesting hope for the future by engaging creatively in relationships and activities that promote the wellbeing of self, others, and the environment. Purposing emphasizes the importance of nurturing and growing social support networks and developing more resilient core community infrastructure systems (eg, food, water, energy). Doppelt

 proposed that the TR approach can not only help individuals develop resilience, but also that the skills of Presencing and Purposing can help communities shift from being “trauma-organized” (fear-based, with rigid and punitive policies) to “resilience-enhancing” communities.

There are a number of TR workshop participant testimonials describing benefits of workshop participation. Survey results describing participants’ responses to a 2014 TR workshop are also available online. The majority of participants rated the workshop as 

, one which increased their “personal resilience skills and their ability to help other people develop resilience skills and practices.”

 To date, there is no other published information or research on the experience of TR participants.

 concludes, “The phenomenology of the effects of climate change differs greatly” between individuals and communities. Given the variety of timing and type of climate change insults, there is likely no 1 psychological method or intervention that fits the bill for eco-distress, and there is little specific data regarding the efficacy of these group approaches. They do, however, incorporate interventions that are based both on evidence and expert consensus. For example, some of the basic steps in Psychological First Aid, a widely used intervention that is 

 are incorporated in a number of the groups described. Some of the 6 recommended techniques for addressing climate distress advocated by Clayton et al

 are also utilized: confirming climate concern as normal stress response to a real threat; psychoeducation about the human stress response; cultivation of coping, self-regulation skills, and resilience; fostering meaningful behaviors in line with values; and promoting meaningful social connections. The benefits of the behavioral techniques promoted, such a diaphragmatic breathing, are well established,

 and there is growing evidence that yoga and mindfulness decrease stress responses and anxiety.

How participation in the groups may impact psychologically vulnerable people is of concern. Group members are likely to experience strong emotions while participating, and it is unclear what procedures would be taken if a group member deteriorates psychologically. Potential psychological vulnerability of attendees may be particularly considered in TR, which is designed to acknowledge and help decrease psychological activation. Other approaches encourage participants to more fully connect to and experience distressing emotions. These experiences may be psychologically destabilizing, and it falls to group leaders with varying degrees of training and no mental health degree to assist. Given the paucity of outcome data, we must use our experience as psychiatrists to determine whether it is appropriate to recommend these treatments for our more vulnerable patients.

For individuals and communities experiencing ongoing, chronic environmental disasters such as drought, crop failure, and sea level rise, we would want approaches that provide practical supports and hold space for grieving, reevaluation, and reimagining of the future. These are potentially provided by GGN, TWTR, DA, and TR. For individuals who are somewhat distant from feeling the physical impacts of climate change, we want programs that assist in processing and managing anticipatory anxiety, fear, grief, anger and distress. They are potentially provided by CC, GGN, TWTR, DA. For individuals most in need of specific coping techniques and self-regulation skills TR provides both psychoeducation about the stress response and the teaching of specific stress reduction and coping techniques. Cultivating resiliency, something we would wish for all our patients, is an explicit goal in GGN, TWR, DA, and TR, though the definition of resiliency is not consistent across approaches. Fostering meaningful behaviors in line with values, a therapeutic intervention well-known to us from ACT, is a stated goal in GGN, TWR, DA, and TR as well as some of the CC models. Promoting meaningful social connections is a key element of GGN, TWR, DA, and TR and is implicit in the shared, experiential nature of the CC.

Despite our belief that these programs can be recommended at the current time, studies investigating participants’ experiences are needed. Does participation increase resilience and well-being? Are certain programs better suited for particular individuals or groups? The answers to these questions would assist mental health providers who are considering recommending a group to a patient, allowing for more precise risk-benefit analysis. Even though there may not yet be comprehensive research on eco-distress epidemiology or evidenced-based treatment, mental health providers have a responsibility to respond to distress within our shifting circumstances. Familiarizing ourselves with these various programs is an important step towards climate change competency for mental health providers.

 is a staff psychiatrist at the Counseling and Psychological Services of the University of Pennsylvania, and a student in the Masters of Environmental Studies Program at the University of Pennsylvania; she is on the Steering Committee of the Climate Psychiatry Alliance. 

is clinical assistant professor, Department of Psychiatry, University of Rochester, NY, and in private practice in Penn Yan and Ithaca, NY.

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1. Cianconi P, Betrò S, Janiri L. The impact of climate change on mental health: a systematic descriptive review. 

2. Cunsolo A, Ellis NR. Ecological grief as a mental health response to climate change-related loss. 

3. Morganstein JC, Ursano RJ. Ecological disasters and mental health: causes, consequences, and interventions. 

4. Berry HL, Waite TD, Dear KB, et al. The case for systems thinking about climate change and mental health. 

5. Climate Psychiatry Alliance. CPA Newsletters. Accessed November 17, 2020. 

https://www.climatepsychiatry.org/cpa-newsletters?rq=climate%20aware%20therapist

6. Climate and Mind. “Climate Café International.” Accessed November 17, 2020. 

https://www.climateandmind.org/climate-cafe

7. The Good Grief Network. Accessed November 17, 2020. 

8. Klivans L. It’s hard to think about climate change during a pandemic. Here’s how to stay engaged. 

. April 22, 2020. Accessed December 7, 2020. 

https://www.npr.org/sections/health-shots/2020/04/22/808853706/this-earth-day-is-like-no-other-heres-how-to-grieve-and-stay-engaged

9. Hathaway MD. Activating hope in the midst of crisis: emotions, transformative learning, and “The Work That Reconnects.” 

10. Work That Reconnects Network. Accessed November 17, 2020. 

11. Essay Contest. The Work That Reconnects. Accessed December 1, 2020. 

https://workthatreconnects.org/community-conversations/essay-contest/

12.Bendell J. Deep adaptation: A map for navigating climate tragedy. Institute for Leadership and Sustainability (IFLAS) Occasional Papers, Volume 2. University of Cumbria, Ambleside, UK. (Unpublished) Accessed November 17, 2020. 

http://insight.cumbria.ac.uk/id/eprint/4166/1/Bendell_DeepAdaptation.pdf

13. Deep Adaptation. Accessed November 17, 2020. 

Transformational Resilience: How Building Human Resilience to Climate Disruption Can Safeguard Society and Increase Wellbeing

15. The Resource Innovation Groups. Accessed November 17, 2020. 

http://www.theresourceinnovationgroup.org/tr-workshops-valuable-skills

Psychological First Aid Field Operations Guide. National Child Traumatic Stress Network

https://www.ptsd.va.gov/professional/treat/type/PFA/PFA_V2.pdf

17. Clayton S, Manning C, Krygsman K, Speiser M. 

Mental Health and Our Changing Climate: Impacts, Implications, and Guidance

. American Psychological Association and ecoAmerica; 2017.

18. Ma X, Yue ZQ, Gong ZQ, et al. The effect of diaphragmatic breathing on attention, negative affect and stress in healthy adults. 

19. Wynn G. Complementary and alternative medicine approaches in the treatment of PTSD. 

Articles

From disasters and social disruptions to existential concerns, climate distress groups may not only provide much-needed support to patients but may also help psychiatry’s public health responses. 

Group Interventions for Climate Change Distress 

There are moments in history that require us to step back and refocus, to view the issues before us through a new lens and from a different vantage point. We are all now sitting squarely in such a moment.

Trevor Noah, comedian host of the Daily Show, who regularly offers commentary on current events, spoke recently and with a serious tone, setting aside his usual comic repartee. He constructed a narrative in which stories that seem separate—COVID and race, Amy Cooper, George Floyd, the protests, and the looting—are, in fact, connected, the resulting forces surging together to form 

We face multiple interconnected crises: the worldwide pandemic of COVID, the crashing economy and the overarching and crushing impact of systemic racism. And unrelentingly, the climate continues to change and the effects of climate dysregulation continue to roll out and roll on.

 has taken the greatest toll on communities of color; specifically African-Americans, Hispanic, and Indigenous communities. These communities have suffered the greatest number of deaths. These community members are losing their jobs at higher rates than white workers. Black workers able to keep their jobs are often likely to be categorized as “essential” workers in service sector jobs. In such positions, people are often forced to choose between risking their health and trying to maintain the often-tenuous economic security of their families.

We have known for some time that communities of color, often lower income, are exposed to environmental risks at a much higher level when compared to more affluent, white communities. These more vulnerable community members have a higher rate of exposure to environmental toxins and climate-related diseases and the least access to quality health care. These community members are often living in buildings and in locations that cannot withstand the increasing fury of extreme weather events resulting from the changing climate. And yet, because of structural racism, these same communities get the least amount of attention and support to redress these environmental injustices.

As mental health professionals, we have a responsibility to more fully appreciate the corrosive impact of structural racism on individual and societal psyches. Ruth Shim, MD, addressing the social determinants of health, offers a graphic representation of the multiple forces coalescing into adverse mental health outcomes. Of note, climate change is now recognized as one of the social determinants of health.

Perhaps some of us have enjoyed a kind of psychological comfort by keeping safe within our climate silo as we work on issues related to global warming. Is there a degree of protective privilege conferred by focusing so narrowly on climate change? Have we held a kind of hopeful expectation that in focusing just on the climate change part of the equation, it would naturally address the systemic injustices by a kind of ripple effect? That fantasy has been rattled. White, privileged people are positioned in a more “experience distant” manner from both the effects of climate change and racism than are communities of color. The events stemming from George Floyd’s murder have shown us a “here and now,” raw and bleak reality. The curtain has been pulled back, revealing the agony that has been present for centuries and is being expressed again on the streets of American cities. We must hold all things at this painful moment; the pernicious impact of systemic racism, the crisis of the COVID pandemic, and the immense threat of climate change.

Sam Grant, executive director of MN350.org in “

Black Environmentalists Talk About Climate and Anti-Racism

” suggests that we must “help people see the connection between that issue [racism] and the broader climate crisis. . . . So it’s not choosing this or that. Or this, then that. It’s this 

We must change our lens and see how these all weave together: the issues of the pandemic, the economic downturn, structural racism, as well as the degradation of our natural world caused by climate change. The classic figure-ground, vase and profile picture, familiar to us from psychology, is an apt model that allows us to toggle back and forth between a foreground focus upon the impacts of structural racism or upon the environmental crisis. Neither is more prominent or important but together reveal a fluctuating change in perspective. Both must be viewed to make the picture whole.

 captures the potential of this historic moment in a second way. We must focus on the foreground—the tattered and frayed aspects of our society now so harshly exposed. Yet, we must consider the background that is always present in a crisis, the possibility of transformational change. Both must be viewed to make the picture whole.

For climate advocates, we must make environmental justice core to our efforts, while simultaneously holding the awareness that climate change is progressing and threatens the habitability of this planet for us all. The real challenge is to bring new creativity to our efforts and forge multiracial coalitions to address the mental health and public health impacts of inequity, racism, and the climate crisis.

Read Up on the Links Between Racism and the Environment

 Race, Racism, and Mental Health Resources

The Link Between Climate Change, Health, and Poverty

 is in private practice and she is Assistant Professor, Department of Psychiatry, University of California, San Francisco; she is on the Steering Committee of the Climate Psychiatry Alliance. 

 is a staff psychiatrist at the Counseling and Psychological Services of the University of Pennsylvania, and a student in the Masters of Environmental Studies Program at the University of Pennsylvania; she is on the Steering Committee of the Climate Psychiatry Alliance. The authors have no conflicts of interest concerning the subject matter of this article.

1. Conrinthios A. Trevor Noah Relects on George Floyd Protests: “Police in America Are Looting Black Bodies. Yahoo Entertainment. June 1, 2020. 

The social determinants of mental health: psychiatrists’ roles in addressing discrimination and food insecurity

3. Sengupta S. Black Environmentalists Talk About Climate and Anti-Racism. 

Beth Mark, MD

Articles

Group Interventions for Climate Change Distress

On Climate, COVID, and Race