Janet Lewis, 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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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 

 of this article briefly reviewed the literature on climate anxiety, presented the clinical rationale for moving climate-distressed patients into engaged action in concert with others, and listed numerous varied means of action.

 In this article, particular clinical situations in working with climate anxiety are discussed. The realities of climate change call upon a range of our skills, including our psychotherapeutic skills. Climate is both a public health and a psychological issue and these aspects are intertwined.

Most Americans are worried about climate change, and climate change may come up in various ways in treatment.

 The patient may explicitly make reference to it, or it may be an obvious aspect of their situation, such as having lost a home to wildfire. Sometimes the references are explicit. However, often these references are made by the patient in passing. As with any difficult topic, like sex or spirituality, the patient may be waiting, consciously or unconsciously, to see if the therapist can handle the discussion. It is the job of the therapist to be listening for possible references and to open these subjects for exploration.

Climate Change and Its Impacts on Mental Health

The Changing Face of Psychiatry in the Age of Climate Change

Patients may reference the state of the world, the news, a friend or relative dealing with fire, flood, or storm, or concern about their children’s future. Sometimes these references may be made quite dismissively or sarcastically, as though the patient is inviting the therapist to collude in ignoring the importance of our collective situation. It is important that the therapist not share in an unspoken assumption that climate is too big to talk about. When such references come up in treatment, the therapist should follow up: “I noticed you joked about the state of the world. Perhaps there are things about it that are frightening, so you don’t want to let yourself take them seriously. What is it like for you?” Then the therapist is in a position to explore the patient’s feelings and help him or her actively engage in response to his or her deepest concerns.

A discussion about climate involves a fresh appreciation of our relationship with the future. British psychoanalyst Rosemary Randall points out that we have defensively tended to split our appreciation for present and future, predicting future catastrophe while wrapping the present in gauze, as though the present is not connected to the future.

 She and Australian cultural researcher Lesley Head

 point out that some of this difficulty might relate to the enormously influential work of Kubler-Ross on grief.

Kubler-Ross was working with people who were dying, and therefore the final stage she described was an acceptance that did not include a future. As Leslie Head describes, in our current climate situation, we enter a future with necessary coexistence of grief and hope. She distinguishes hope from optimism, noting that optimism tends to push out negative feelings, whereas hope has room for grief also. Popular movements dealing with climate anxiety, the Good Grief Network, and Joanna Macy’s Active Hope Workshops emphasize this coexistence of hope and grief.

When therapists find themselves reluctant to discuss climate change, they should reflect on their own feelings about it. Most of us tend to use the defense mechanism of disavowal in dealing with climate, just as patients do.

 Therapists, like patients, have combinations of knowing and not knowing, acceptance and non-acceptance and are in various stages of emergence from disavowal. We may intellectually know that human made climate change is real, but the information has not completely penetrated emotionally, or we haven’t figured out how to best work at social change and how to change our lifestyles, given the social pressures to continue with business as usual.

We are all in the same boat in this regard. What is important is that we are each working on it, individually and together. Climate will require collective change, so none of us individually can have it all figured out. This may be a challenge for the therapist who is accustomed to working from the position of expert. Climate calls us to a more humanistic therapeutic stance, where we are talking with the patient about our shared human situation. “Here is the situation we are in . . . .” An understanding of this humanistic stance can undercut therapists’ feelings of guilt about their own carbon-imperfect lifestyles, which might interfere with their engagement in the topic.

Therapists may fear discussing a topic that has become politicized. The ethics of discussing climate change with patients have been explored in a series of articles in the 

. Given the enormity of climate as a public health crisis, it has been concluded that, in spite of its politicized nature, the benefits of discussing climate change with patients generally outweigh the risks.

Therapists may avoid discussing climate change because they themselves harbor pessimistic opinions about humanity’s future. We all need to understand that we are part of complex socio-environmental systems and uncertainty is inherent in complex systems. Hopelessness can be a defensive stance, an avoidance of uncertainty and of the realities of agency.

 While patients are unlikely to use the word “disavowal,” what characterizes much of the distress about climate is the difficulty of coming to terms with the existence of disavowal in oneself and in the world. Patients may express dismay, a feeling of alienation, of unreality, of impotent worry as they find themselves and watch others participating in relatively comfortable fossil-fuel–laden lifestyles while simultaneously knowing about the existing and future suffering wrought by climate change. This experience can be magnified in patients who grew up in circumstances of abuse or neglect, where collective family disavowal may have significantly shaped their development.

For these patients, a discussion of the nature of disavowal can be useful. Patients can be credited for their appreciation of reality, and the therapist should be confirming that the collective enacting of disavowal can be “crazy-making,” in that it is confusing and frustrating. The therapist should clearly lay out the current circumstances, eg, “Yes, we are in a serious urgent situation that most people are in various stages of waking up to.” “Yes, this is resulting in tremendous suffering.” “What helps people to bear this knowledge of reality is a bit different for different people. We can think about what helps you.”

For patients with histories of abuse and neglect, it is important to also explain that they may be particularly aware of our society’s disavowal because of their own experience with disavowal. For example, you might start the conversation with the following, “Wrong things were happening, but somehow people both knew and did not know; they knew it but didn’t fully appreciate it enough; they knew it but didn’t take it seriously enough to get help; they knew it but didn’t allow that knowledge in deeply enough to change their behavior. So now you are painfully aware of our lack of full awareness about climate change.” Patients can be encouraged to act in concert with others, having allies this time, as they work their own way out of disavowal and take action over what so deeply concerns them.

 Parents can be especially distressed over climate and may require extra support.

 Findings suggest that parents may have a psychological need to maintain the illusion of an omnipotent ability to keep their children safe.

 Awareness of climate change is a threat to that illusion. Parents can be assisted to connect with other concerned parents and to shift their activities into arenas that can actually help their children’s future safety.

Parents who wonder about how to address their children’s environmental concerns can be encouraged to engage with their children in pro-environmental activities. In that way the parent and child are given the experience of being able to engage actively together rather than the experience of paralyzed worry.

Patient dealing with disaster or threatened disaster.

 Psychiatry has a long history of understanding and working with psychiatric effects of disasters. Now, however, both we and our patients have a new larger context, that of climate change, within which we are understanding and experiencing individual disasters and threats of disaster. Now the patient dealing with disaster may also be dealing with the knowledge that, given climate destabilization, more disasters may follow. Clinical work with these patients involves a balance between the need for immediate trauma care while not ignoring the reality of future climate anxiety.

 When the topic of climate change arises, one might find oneself working with a patient who actively rejects the reality of human-made climate change. One-tenth of Americans are “dismissive” of global warming as an issue and another 11% are “doubtful.”

 We all tend to filter reality through our preexisting beliefs, a process known as confirmation bias.

 When working with a climate change dismissive patient, it is important not to collude with the denial of science while simultaneously affirming the underlying positive values that might be fueling the rejection. Understanding and appreciating the patient’s values can advance the therapeutic relationship.

There is an ongoing discussion within the political science arena about the importance of appreciating underlying worldviews and values. One version of this discussion is “polarity theory” described by McIntosh.

 According to this theory, “value clusters” exist within the political right and left. All value clusters are recognized as having both positive and potentially unhealthy aspects. This theory asserts that our way out of current extreme political polarization involves affirming the positive aspects of those values so that negative aspects can then get “pruned away” within the political camps themselves. This theory may bear some relationship to that of motivational interviewing where resistance is not directly confronted but underlying motivations are clarified.

Positive values that may underlie climate denial are often in the “liberty” value cluster described by McIntosh, which can lead to a worry about government overreach. When faced with a climate denying patient, these values can be uncovered with a simple question such as “What worries you about those who want response to climate change? What mistakes do you think they could make?” The clinician can then express genuine appreciation for the positive aspects of these underlying values, such as affirming the importance of personal liberty or small and local governance or cultural heritage.

As psychiatrists, when we work with climate change material clinically, we are both assisting in an urgent public health crisis and meeting our patients where they are. We can promote hope with room for grief. We can provide general recommendations to our patients for dealing with climate distress, including taking a break, having fun, maintaining routines, and focusing on only a few issues while simultaneously encouraging active engagement in response to deep concerns.

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Climate is both a public health and a psychological issue and these aspects are intertwined. In this article, particular clinical situations in working with climate anxiety are discussed.

In the Room With Climate Anxiety: Part 2

 The mental health effects of climate change are immediate, long ranging, and complex. As a premiere psychiatric publication, we were compelled to provide crucial information on the psychiatric sequelae of climate change, which was the genesis of this exclusive series from the Climate Psychiatry Alliance (CPA). We urge you to follow the series in upcoming issues and our website as we cover climate-change related issues such as ethical implications and denial as well as transformational resilience.

Psychiatrists and other mental-health clinicians are being increasingly called upon to respond to patients’ worries about the destabilization of many aspects of our world. Within a longer series about the psychiatric aspects of climate change, this is the first of two articles dealing specifically with climate anxiety. The majority of Americans are now worried about climate change and a record 21%, one in five Americans, are 

 Recent hurricanes, floods, and wildfires have been reminders of climate change. Although no one event can be solely attributed to climate change, the trend to more severe storms, more heat, and overall destabilization of the climate is clear.

Our patients are exposed through the news, and sometimes via personal experience, to an increasing pace of climate disasters and species extinctions and to reports of inadequate response by leadership. Patients who are well informed also know that, because of the long existence of many greenhouse gases in the atmosphere and because of the many positive feedback loops in the climate system, we are not simply dealing with a “new normal” of increased heat, fires, flooding, and storms. Rather our collective situation is even more serious and urgent, in ways that are difficult to fully take in emotionally. Further adding to this large psychological task of grappling with the reality of climate change is the knowledge that we are all participating in the fossil-fuel–based social, cultural, and economic systems that have brought on and that are worsening this slow-moving disaster.

Understanding the anxiety resulting from this reality

Worry over climate change can be seen as appropriate and is usually not maladaptive. A quantitative and qualitative study done using online surveys showed that people who describe habitual worry about the environment can be functioning quite well. They tend to have pro-environmental attitudes and engage in “pro-environmental behavior.”

However significant distress over climate change is being described. Some of these descriptions are in populations that are being particularly affected. For instance, indigenous peoples have close relationships to the land and some are losing their lands-cherished aspects of their cultural identities-to climate change, producing significant distress.

From Australia, where there have been noteworthy droughts, came the first reported climate change delusion: a 17-year-old with delusional guilt about drinking water stopped drinking water.

 In a study of OCD patients in Australia, 28% of the participants in the study had spontaneous descriptions of OCD concerns related to climate change, such as compulsively checking to make sure that the faucets were all the way off or checking lights to make sure electricity was not being wasted.

 A quantitative study of Australians, half of whom lived in urban areas, documented significant distress over climate change, particularly among women, and in those aged younger than 35 years.

Distress over climate change is described in a cluster of related terms such as “climate anxiety,” “eco-anxiety,” “eco-paralysis,” and “climate grief,” all of which could be considered psychoterratic syndromes. The term “psychoterratic,” coined by the philosopher Glenn Albrecht, refers to mental conditions arising from our relationship with the natural world. One so-called psychoterratic syndrome is solastalgia, another term coined by Albrecht. The word “solastalgia” joins the Latin word for comfort with the Greek word meaning pain. It refers to the distress one experiences when a well-known environment has changed and no longer offers the same solace. It is a kind of nostalgia one can feel while still at home, an experience of loss that can be very difficult to put into words.

The concept of solastalgia is gaining a research base. A qualitative study of Great Lakes residents, using semi-structured psychoanalytic interviews of the residents, documented in their descriptions of their relationship with their environment an “arrested mourning.” Interestingly, these study subjects were individuals who were not particularly environmentally active.

Place-based distress has also been documented in Australian family farmers, and in Australian residents of an area changed by mining.

 A quantitative study of emergency room visits in Kentucky suggested a greater risk of depressive and substance use disorders in areas where there was mountain top removal mining, a process that drastically changes the landscape.

 The study controlled for other demographic factors such as socioeconomic status.

Another proposed psychoterratic syndrome is the so-called nature deficit disorder, a term coined by the journalist, Richard Louv, best known for his book, 

. He defines nature deficit disorder as the human costs of alienation from nature, claiming that there is a “diminished use of the senses, attention difficulties, and higher rates of emotional and physical illness” as a result of our being alienated from nature.

There is some support for this concept. There are many documented salutary effects of nature exposure, including effects relevant to psychiatric disorders and treatment, such as effects on attention, rumination, and social bonding. This topic of the mental health benefits of involvement in the natural world will be explored in a future article in this climate series.

A growing psychoanalytic literature is also exploring our relationship to climate change. In addition to other psychoanalysts, Sally Weintrobe, a British psychoanalyst, editor of the book 

, has recognized that climate change can be seen as a developmental issue. As Weintrobe describes it, just as in the development of the small child, we are collectively seeking to move from a relationship with nature as a “breast and toilet mother” to a more mature relationship where we recognize that Mother Earth has limits.

Psychoanalysts are documenting climate distress. Rosemary Randall describes distress over the experience of ecological debt. Once someone becomes deeply aware of the fact that, in their ordinary Western life, they are engaged in activities that are negatively affecting the environment, harming both the people of today and future generations, it can be a crisis for the individual. She describes that sometimes this understanding of debt can lead to depression, masochism, or bitterness. She recommends “a sense of proportionality” about one’s guilt, including understanding the social problems that contribute to our situation, and describes how engaging in reparation in response to the sense of ecological debt can potentially reframe one’s identity.

Psychoanalyst Susan Bodnar describes cases of climate distress in young adults who engage in self-destructive lifestyles because they feel hopeless about their future lives on what they see as a damaged planet. She recommends the “environmental metaphor” as a helpful therapeutic intervention. This involves linking the patient’s self-neglect and self-destructiveness to the behavior of humanity towards the Earth and emphasizing the importance of not perpetuating this pattern but instead fighting this neglect and abusiveness. For these patients, she emphasizes the importance of working on respect for limits, boundaries, and space within their own lives. These cases are explained by understanding that the environment functions as an internal object, just as parents or siblings do. Therefore, when the environment is being treated destructively, this can influence personality development in sensitive individuals.

It is generally agreed that the mental-health effects of climate change, including climate anxiety, require more research. The astute reader will recognize many possible causes of climate-related distress in the above review, including the direct traumatic effects of extreme weather events, economic effects, possible physiological effects of heat, vicarious traumatization, in addition to concern for current and future generations and ecosystems. For research purposes one might wish to parse out the multiple pathways by which climate change affects mental health. However, when we deal with a patient in our office we must accept that the multiple pathways are often overlapping and intersecting.

Anxiety about climate change is a bit different than other anxieties we often treat, in that our goal should not be to eliminate what in this case is usually an appropriate anxiety. As therapists, we know the importance of exploring and validating people’s feelings in a process that can help them come into a clearer relationship with reality. This is no less important when patients are distressed about climate.

Many patients experience deep distress as they contemplate the suffering wrought by climate change and the circumstances their children and grandchildren are facing. Such patients require witnessing in a manner that does not minimize the real basis of their distress. In our work with these patients, witnessing and validating feelings is essential and also insufficient.

Given the threatening nature of climate change and its complexity, paralysis and hopelessness can easily occur. Throughout the literature on climate distress, experts counsel that we should foster active hope, emphasizing engagement. Whereas fear can produce a freezing response, action may overcome freezing via known neurophysiologic pathways.

 Failing to help the climate-distressed patient figure out what actions they can take may reinforce paralysis.

From a psychological point of view, engagement in concert with others should be recommended for two reasons. Relationships help provide containment for potentially overwhelming feelings. The second reason for doing this work with others is the phenomenon of disavowal.

In our awareness of climate change and its implications, we are all emerging from various degrees of disavowal, a defense mechanism described by psychoanalysts, whereby one both knows and does not know something at the same time. Being actively at work with others can foster ongoing engagement and mitigate discouragement. Otherwise one’s own tendency to disavowal can easily impede efforts, leading to further discouragement and distress.

What we can do to fight and prepare for climate change

Many communities and faith groups have climate-related organizations. The Climate Psychiatry Alliance website (

) also lists many organizations that a concerned individual might join. Actions can be taken in many realms, including:

• Engaging in political activity to challenge corporate and political leaders out of their denial or complacency

• Financially divesting from fossil fuels and encouraging organizations with which one is affiliated to divest from fossil fuels

• Contributing to the building of strong resilient communities and to the preservation of ecosystems

• Helping others reconnect with nature to experience our good-enough mother Earth

• Helping raise awareness of climate change in the general public and in specific groups

Moreover, there are many specialized climate related projects within particular areas and professions that psychiatrists or patients can volunteer for or professionally pursue. An upside of the complexity of climate is that there are uses for everyone’s interests or skills. Any climate-anxious patients can be encouraged to engage in a way that feels right and empowering for them.

In part 2 of this discussion of Climate Anxiety, specific psychotherapeutic and countertransference issues in dealing clinically with climate change will be described.

See last month’s climate change coverage: 

Dr Lewis is Clinical Assistant Professor, Department of Psychiatry, University of Rochester, NY, and in private practice in Penn Yan and Ithaca, NY.

 Leiserowitz A, Maibach E, Roser-Renouf C, et al. Climate change in the American mind: March 2018. Yale Program on Climate Change Communication. New Haven, CT: 

Yale University and George Mason University

 Walsh J, Wuebbles D, Hayhoe K, et al. Climate change impacts in the United States: the Third National Climate Assessment. Melillo JM, Richmond TC, Yohe GW, Eds. US Global Change Research Program; 2014.

 Verplanken B, Roy D. My worries are rational, climate change is not: habitual ecological worrying is an adaptive response. 

 Cunsolo Willox A, Harper SL, Ford JD, et al. From this place and of this place: climate change, sense of place, and health in Nunatsiavut, Canada. 

 Wolf J, Salo R. Water, water, everywhere, nor any drop to drink: climate change delusion. 

 Jones KJ, Wootton BM, Vaccaro LD, Menzies RG. The impact of climate change on obsessive compulsive checking concerns. 

 Searle K, Gow K. Do concerns about climate change lead to distress? 

 Albrecht G, Sartore GM, Connor L, et al. Solastalgia: the distress caused by environmental change. 

 Lertzman R. The myth of apathy. Weintrobe S, Ed.

 Engaging With Climate Change: Psychoanalytic and Interdisciplinary Perspectives

. London, New York, NY: Routledge; 2013: 117-133.

 Ellis NR, Albrecht GA. Climate change threats to family farmers’ sense of place and mental wellbeing: a case study from the Western Australian wheatbelt. 

 Canu WH, Jameson JP, Steele EH, Denslow M. Mountaintop removal coal mining and emergent cases of psychological disorder in Kentucky. 

 Weintrobe S. The difficult problem of anxiety in thinking about climate change. Weintrobe S, Ed. Engaging With Climate Change: Psychoanalytic and Interdisciplinary Perspectives. London, New York, NY: Routledge; 2013: 33-47.

 Randall R. Great expectations: the psychodynamics of ecological debt. Weintrobe S, Ed. 

Engaging With Climate Change: Psychoanalytic and Interdisciplinary Perspectives

. London, New York, NY: Routledge; 2013: 87-102.

 Bodnar S. Wasted and bombed: clinical enactments of a changing relationship to the earth. 

Denying to the Grave: Why We Ignore the Facts That Will Save Us

Psychiatrists and other mental-health clinicians are being increasingly called upon to respond to patients’ worries about the destabilization of many aspects of our world.

In the Room With Climate Anxiety

Contemporary psychoanalysts know that behavior is a form of communication.

Treatment Resistance and Patient Authority: The Austen Riggs Reader,

edited by Dr Eric Plakun, describes the work being done at the Austen Riggs Center, a psychodynamic institution in Stockbridge, Mass. Specializing in work with treatment-resistant, usually highly comorbid, and often high-risk patients, the Center’s intensive multimodal psychoanalytic treatment program considers the most passive, disturbed, or disturbing behavior of treatment-resistant patients as cause for hope rather than pessimism.

Treatment resistance, defined as a failure to respond to customary psychiatric treatment, is now considered a fairly common occurrence that can involve substantial suffering and disability. Almost all mental health professionals have had contact with complicated, severe cases that tax resources and discourage clinicians. Given the magnitude of the problem of treatment resistance, the impact on patients and those who care about them, and the consumption of health care resources, the subject of this book is very important indeed.

To explain the practicalities of treatment resistance, the authors of each chapter describe contemporary psychoanalytic work and transmit the attitude required for this work. Furthermore, they keep in mind an audience that may be accustomed to approaching difficult clinical problems with a very different state of mind.

Aptly titled a “reader,” the book seems designed for the ongoing development and use of certain basic skills. Like the best of “readers,” it contains elements for the ambitious student. “The Third,” for example, which is discussed throughout the book, is a term currently at the cutting edge of psychoanalytic theory. Therefore, its inclusion may be a drawback for the inexperienced or less ambitious scholar.

Contemporary psychoanalysts know that behavior is a form of communication. This book describes the work being done at the Austen Riggs Center, a psychodynamic institution in Stockbridge, Mass.

Janet Lewis, MD

Articles

Group Interventions for Climate Change Distress

In the Room With Climate Anxiety: Part 2

In the Room With Climate Anxiety

Treatment Resistance and Patient Authority: The Austen Riggs Reader

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