Beth Mark, MD, MES

The American Psychiatric Association (APA) meeting for 2021 was virtual again this year. Was this disappointing, a relief, or both? Disrupted routines offer us the chance to consider alternatives to long-standing traditions and seize new opportunities to change our habits for the better.

One observation about virtual APA meetings is that they have shown us the way to a more sustainable psychiatry. Remote work, decreased travel, and virtual meetings all substantially reduce GHG (greenhouse gases) emissions, and thereby contribute to needed environmental relief. For example, holding the 2020 APA annual meeting virtually saved the GHG equivalent of burning 500 acres of dense forest or 22 million pounds of coal.

 Similar analyses have shown that a single international conference can use as much COe2 (carbon dioxide equivalent) as a whole city for a year.

 We also see firsthand, however, that transferring activities online reduces the quality of interpersonal connection and can contribute to professional stress. Working towards a more sustainable way of living also includes caring for that which sustains us as individuals. We face a puzzle: how might psychiatry proceed with its conferences and maintain human connections while also promoting 

The Ethical Imperative to Alter Annual Conferences

According to current scientific consensus, rapid decarbonization of all activities is required to prevent the worst outcomes of climate change. The Intergovernmental Panel on Climate Change has projected that climate change will have severe mental health effects. These will include the traumas caused by natural disasters, violence, and heat; indirect effects of particulate matter and ozone; eutrophication of the water supply; environmental toxins; and other impacts on human health. Already 

disadvantaged populations will bear the largest brunt

The US healthcare system is responsible for 10% of all GHG emissions.

 While there is little data on the carbon footprint of US psychiatry as a whole, research in the United Kingdom, using national health system data, has documented the GHG emissions from various components of its own behavioral health activities. The largest portion of the carbon footprint comes from buildings and pharmaceuticals. Mitigation efforts there are focusing on avoiding unnecessary pharmaceutical use and waste, shared and smaller office use, and using more social-based and nature-based treatments.

psychiatric practices’ carbon excesses.

 estimated that the US healthcare system’s carbon footprint per year causes between 405,000 and 470,000 disability adjusted life years—about a year of disability for every 2275 visits to the doctor or hospital. If we really seek to do no harm, this is unacceptable hypocrisy in our practice. The APA has asserted its determination to respond to climate change’s health effects in its position statement,

, and its recent formation of a Climate Committee within its structure. As physicians and psychiatrists, we have an ethical obligation not only to participate, but also to lead the way in decarbonization efforts.

Another facet of our ethical duty to act sustainably involves social contagion: the phenomenon of unconscious imitation, deliberate adherence to new norms, and improved ability to behave in ways about which one had been ambivalent, as a result of the modeling of others. Social contagion has important effects on health, as has been demonstrated in obesity.

 In terms of sustainability, social contagion occurs with behaviors like adoption of clean energy technologies.

Decades ago, cigarette advertisements by the tobacco industry that depicted doctors smoking carried implicit, but powerful messages. Eventually cigarette advertisements were banned, and medical organizations vigorously distanced themselves from the tobacco industry. As with smoking, doctors are trusted sources of health-related information on climate change, creating additional ethical implications for our 

 It is likely that it will be easier for other medical organizations to overhaul their conferences if psychiatry has led the way. It will be easier for individual psychiatrists to alter their own practices after national organizations take these steps. And it will be easier for psychiatric patients to engage in sustainability when they see their doctors taking action, and so on. Through these social contagions, sustainable change is likely to occur.

How and Why to Increase Social Interaction in Virtual Conferences

Though we have a clear ethical mandate to mitigate climate change through decarbonization, we must work on both 

 to stressful circumstances. If mitigation efforts decrease our ability to adapt (eg decreasing our well-being and thereby our resilience), then we are not responding to climate change in a way that sustains both planetary needs and our own needs. Mitigation and adaptation, though often discussed separately, are in practice intertwined, and must be addressed together. The reduction of GHG emissions in psychiatry can only be usefully done while addressing the associated changes in work and life that may affect individual and societal resilience.

Another way of understanding this point is the concept of the triple bottom line, wherein effects on the environment, effects on people and society, and effects on financial viability are each considered to represent a bottom line that must be adequately addressed.

 Connection is a foundational component of wellbeing and resilience. So, we have to ask, “How are online activities affecting our human connections?”

From the perspective of knowledge acquisition, 2-way exchange promotes learning,

 with some aspects (eg asking questions) actually improved online.

 Perhaps the most difficult component of a conference to simulate in the virtual setting is the social networking experience. Over 80% of APA conference attendees value networking opportunities, as well as the opportunity to collaborate and understand new science, technologies, healthcare opportunities, and treatments, according to the unpublished Annual Meeting 2019 survey. This reflects widespread experience in other sectors. A recent study conducted by the International Marine Conservation Congresses (IMCCs) surveyed 100 participants at 2 of their conferences.﻿One of the major takeaways from this survey was that respondents generally felt that networking, communication, and brainstorming are more successful when done in person.

 Networking is also a common concern in the business sector, with 85% of 

 indicating that they build stronger and more meaningful business relationships at in-person conferences.

 Many of the papers cited particularly mention chance social interactions that have a more spontaneous, intimate, and creative quality than other professional exchanges. Perhaps the greatest difficulty with virtual meetings comes from the decrease in spontaneous reciprocal interactions and the shared social exchanges that occur so easily face-to-face, whether in full conversation or impromptu moments of social engagement.

Mechanisms of In-Person vs Virtual Interpersonal Effects

The mechanisms underlying differences between in-person and virtual experiences can be considered in terms of biologic systems, and understandings of presence and mindfulness.

. Redcay and Schilbach provide a useful review of neuroscientific understandings of the mechanisms of social interaction.

 Studies have demonstrated that the mentalizing, mirror neuron, and reward systems are important in dynamic (second-person) social interactions. Through these interpersonal exchanges, studies show that participants build up a shared representation in these neural systems that brings them into conceptual alignment over the course of an interaction. Social interactions have been shown to automatically coordinate synchronous movements, mimicry of facial expressions, and eye contact, and to guide language development and linguistic learning. They have also been shown to promote turn-taking and agreement about what to call things.

Interpersonal interactions have been studied in social interaction science through both second-person and third-person techniques. In a third-person technique, the brain is studied as someone observes a social image such as a video of someone waving. In second-person techniques, there is a social engagement between 2 people, whether real or perceived, that is reciprocal and in real time. This may take the form of an avatar that is gaze responsive, or a live partner in person or by video.

The networks involved in social exchanges are not as activated by third-person (listener or observer) social interactions unless the observer is asked to think about the mental states of the other. When there is greater perception of the other’s responsiveness to oneself in a human way (eg, when an avatar responds with eye movements that are contingent on the participant, but not in perfect alignment), the reward system is engaged in the social exchange to a greater degree. Joint attention, mutual gaze, and motor synchrony have also been shown to be important for such mutual social engagement. Those with larger social networks engage the reward network during joint attention games, while those with smaller social networks engage the mentalizing network more in social exchanges that involve rejection, supporting the idea that interpersonal interaction, whether positive or negative, builds reward responses and mental representations.

From the point of view of social communication science, virtual meetings may bend towards placing the participant in a social observer status, because there are fewer opportunities for mutual social exchange. The ways in which dynamic modes of exchange lead to visual-motor stimulation, behavioral synchronization, activation of language centers, and greater activation of reward networks may provide some explanation for why individuals generally believe live meetings provide greater collaboration and networking.

At the same time, those with different neurological profiles may do worse in the live setting. Many anxious individuals find live conferences overwhelming. A study of adults with autistic spectrum disorder shows hyperconnectivity in social processing areas during spontaneous conversation compared with vocal repetition. For those who may experience unpredictable or spontaneous social interactions as more difficult due to this overload, a remote experience may facilitate engagement.

. In research on social presence, face-to-face communication is found to make contributions to individual well-being and relational closeness.

 Interestingly, video chat is associated with more loneliness and greater difficulty with relationship maintenance than phone call communication. While technical issues that interfere with conversation flow and physical immobility are possible reasons for this, another is that “the heightened cue environment might render what is missing more salient.”

It is undeniable that the sense of presence is different in person than over a computer. In a conference room, our senses are overwhelmed with noise, temperature, smell, the look of the place and the attendees. This occurs in 3 dimensions and in the entire conference room at once: the feel of the carpet or the hard chair; the act of our physical body movement as we are engaged in choosing where to sit or moving across the room; the taste of stale bagels and bad coffee, etc. While this experience can be stressful, it can often be a positive stress. In the actual conference room, we are pulled by our senses to be in the present moment when we walk in. The growing literature on mindfulness, reflected in dialectical behavior therapy, somatic experiencing, and other methods, shows that being in the present moment feels good and helps us navigate challenging feelings and emotions.

 room virtually, we are not pulled into the present moment, nor do our senses snap to attention, making us as alert and present as possible. In our tiny boxes, often with a virtual background, often with our video and audio off, we are present only as a digital marker. Unless we are the speaker, we can surf the web, multitask, and daydream in a way we would be less likely to do if we were attending in person. What kind of individual and collective focus is lost as we participate from our own private cells? If we do put energy into being present, how well can we connect to others on the screen? Even if we decide to focus on one face amidst the scores of faces on the grid, that individual will probably not be directing their attention to us at the same time. Trying to engage in the nonverbal communication dance, likely orchestrated by our mirror neuronal system, probably does not compute in larger group virtual meetings.

How can we connect better in virtual space? Based upon what we know, continued innovation is needed in our use of virtual environments, finding ways for the machine to cue and engage the participant, to add unexpected fun things to being online. Respecting the mirror neuron system, we can create opportunities within the larger meetings for very small meetings. For example, the break times can be expanded to include 10 to 15 minute slots, where 2 participants are randomly assigned to a breakout room and get to know each other a bit. Or, if some resist that amount of spontaneity, the breakout rooms could be arranged in advance, maximum of 4 participants, based on common professional interest, location, or hobbies. Some other efforts to improve upon the virtual networking are including social activities such as virtual Peloton group rides, 

, virtual talent shows, or even karaoke events that can all be conducted remotely.

What is our profession to do? We have a tradition of large in-person conferences that have provided education, networking, collegial bonding, impromptu educational exchanges, a break from the day-to-day work environment, opportunities for new perspectives, and a crucial financial influx for the APA—but it all contributes to 

, the most serious public health offender of our time. How do we maintain and further support the positive aspects of conferences while doing our duty to decarbonize?

An important consideration is the location of conferences. In their analysis, Wortzel et al calculated the optimal location for an APA meeting using a statistical model that plots exactly where the meeting should be to generate the least amount of carbon, even if that point turns out to be a location in the middle of the ocean, as well as an analysis of the carbon footprints of the last 40 APA locations using the demographics of current attendees.

 They found that the Northeastern US is the most environmentally sound place to meet, even accounting for those who must fly cross country to be there. Emissions can be reduced over two-thirds if meetings are held in this corridor, easily fulfilling the level of emissions rollbacks suggested by the Paris Accord.

However, this solution has its drawbacks. Even with an optimal location, non-US attendees at the APA conference must generate significant emissions to attend in person. Clearly, we must get away from a one-size-fits-all way of thinking and be innovative. A virtual option can help mitigate this concern. It may become unsustainable for western US psychiatrists to come to the meeting if they must fly 5 times further than their peers, so accommodations in terms of carbon offsets, reduced meeting costs for this group, and intermittent meetings might meet the needs of all.

As travel is the largest carbon emission component of conferences, an additional solution is the use of more regional conferences. These would provide all the advantages of in-person interactions—social collegial contact, networking, impromptu learning—while also drastically reducing the GHG emissions. Perhaps these conferences could have something of a hybrid model, with big name speakers being virtually included. These multiple conferences might even benefit the APA financially, and may even attract more participants, if they can be made sufficiently attractive.

Another possibility is buying carbon offsets, whereby air flights are offset with financial contributions to other sustainability activities such as planting trees. But the purchasing of such offsets would not reap the benefits of behavioral contagion. We would still be setting the problematic example of routinely flying to distant cities for conferences. If we only undertake the buying of offsets without further evaluating our systems of behavior, we would be turning a blind eye to the extent of the problem and the need for extensive systems change.

The decarbonization of psychiatry cannot be delayed. At the same time, we have responsibilities to do this in ways that preserve or even strengthen the interpersonal and professional connections that are so necessary for individual health, group cohesion, and individual and collective resilience. In order to meet these obligations, we must deepen our understandings of bonding, of coregulation, and of shared purpose, particularly as applied to our uses of remote and in-person activities. Holding a 

 perspective, we are called to focus both on mitigation (reducing GHG) and on healthy adaptation (strengthening connections). Understanding this can help us to innovate means of preserving and strengthening the most important aspects of our activities while accepting the challenge of psychiatry’s decarbonization.

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

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

is associate professor of psychiatry at the University of Nevada School of Medicine at Reno and acts as medical director at Carson Tahoe Health, Outpatient Behavioral Health Services.

is a medical student at the University of Pennsylvania School of Medicine.

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Peer effects in the diffusion of solar photovoltaic panels

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The Triple Bottom Line: Does It All Add Up

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Articles

How can psychiatry meet its ethical duty to mitigate climate change while also promoting collegiality at conferences?

Fostering Human Connection in a Sustainable Virtual World

“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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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. 

On Climate, COVID, and Race

A person’s a person, no matter how small


	                            – Theodore Seuss Geisel

It’s not that I did not believe in climate change-I could sense the subtle changes in the seasonal norms, and I forced myself to read the increasing number of articles offering scientific proof of it-but it was an unsettling, nagging insight that I could generally pack away. I would recycle my plastics, make some donations, and get on with my busy day. My defensive structure was shaken four years ago when my son sent me a link to an article with the title “When the End of Human Civilization Is Your Day Job,”

 which described how climate scientists were struggling emotionally with the burden of facing the facts and trying to communicate them to the public.

The article forced upon me the realization that, in the face of impending catastrophe, I had not only resorted to repression (trivializing the magnitude of the problem and thereby diminishing the intensity of my fear and anger). I had engaged in regression, manifesting a remarkably childlike consciousness with respect to authority.

Of the generation whose formative experiences included the Vietnam War and Watergate, I generally thought of myself as an adult who had a healthy skepticism about the competence and morality of those in power. The fear of climate change had evoked my childish trust that the adults in charge would “take care of things.” To my surprise, I realized that I (or some part of me) still retained the belief that scientists impersonally discern the facts and those in charge make the appropriate policy changes to keep us safe, and that’s just the way things work. Yet, the scientists featured in the article were distraught about what they were finding. Even more intense was their agonized frustration that no one seemed to be listening to their important and dire message-this was acutely painful to me.

Perhaps not surprisingly-given my job (I work in a college counseling center) as well as my childlike consciousness with respect to climate change-I became interested in how actual (ie, chronological) children and adolescents are responding to climate change. As it turns out, there is little research in this area.

One of the central insights of those in the field of climate change is that the scientific and psychological challenges confronting the climate crisis cannot be severed from politics, economics, ethics, and even religion.

 In part, this is because our treatment of each other and our treatment of Mother Earth reflect the same ethos.

 The allocation of money and attention with respect to research on children’s emotions and attitudes toward climate change reflect colonialism and racism. Eighty percent of the world’s children live in the developing world, ie, those countries that did the least to create the climate crisis while suffering the most from it.

 on and accentuates inequality. The inequality, for example, between the inhabitants of the present and those of the future whose legacy is being squandered; between the countries that have emitted the most carbon and those that are paying the price of those emissions; and, within nations, between the fortunate and the have-nots who are already undernourished or living in unsanitary conditions.

Childism, prejudice against children, is evident in the amount of research in this area on children-whether from the developing or developed world.

 Children are uniquely vulnerable, both physiologically and psychologically, to the direct and indirect effects of climate change. For example, children not only have greater biological sensitivity, they literally interact with their environment-as a percentage of their body weight, with the air, food, and water-more than adults.

Children are uniquely at risk for exposure to environmental contaminants while playing on the ground and putting their hands, dirt, and other objects in their mouths. Extreme weather events-occurring more frequently in the context of global warming-disproportionately disrupts childhood, a period of relatively more limited adaptive capacities (eg, children are less able to digest the psychological and physiological traumas of migration).

 Despite all of this, there is very little research on children’s emotions and attitudes. In contrast, there is a relatively robust body of literature examining adults’ emotions and attitudes with respect to environmental issues in the US.

As another manifestation of childism, there is a top-down quality to the research insofar as it is concerned with how adults can help children cope with their emotions and how adults can facilitate children’s “pro-environmental behavior” (ie, reducing one’s carbon footprint). I wonder if our current emphasis on getting children to reduce their carbon footprint reflects the condescending belief that, until children grow up and gain more sophisticated skills and power, this is the only way they can contribute to mitigating the climate crisis.

Of course, I believe that adults have the responsibility to help children regulate their emotions. And, while reducing one’s carbon footprint is a laudable goal, it is not for the reason I had thought while I was busy recycling my plastic. The material benefits of recycling is no longer terribly meaningful; many believe the goal of sustainability is no longer feasible.

Nevertheless, children’s participation in efforts to recycle can acquire the character of a needed, vital ritual. It becomes a mindfulness practice that re-orients our relationship with the environment from one of exploitation to one of mutual care. Recycling mindfully can also open up opportunities for children to become curious about what we use, where it goes, and how much do we really need. Rather than a top-down lesson to be “learned,” a more mutual, naturally occurring conversation between parent and child can take place.

Children, less wed to existing political “realities” and economic structures than adults, may provide the more radical and urgent perspective that is needed in times of crisis. It is the children who are listening to climate change scientists. They believe in the fact of human generated global warming more than adults.

 Students are suing their governments, organizing marches and school strikes around the world, and creating student-led environmental activism groups. Children are sounding the alarm and calling for more fundamental changes in our ways of being.

Children, it would seem, are angry and feel betrayed. They are increasingly putting these feelings and their unique perspective to adaptive use-pushing us out of our complacency. As adults, we too can make unique contributions, including sharing our wisdom and defining core values, and a capacity to regulate our own and our children’s emotions in the face of crisis.

A radical and urgent perspective about the realities of climate change.

Beth Mark, MD, MES

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