Janet Lewis, MD

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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The spread of obesity in a large social network over 32 years.

Peer effects in the diffusion of solar photovoltaic panels

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https://climatecommunication.yale.edu/wp-content/uploads/2014/12/Global-Warming-Public-Health-October_2014_FINAL-1.pdf

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 

 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.

 Lewis J. In the room with climate anxiety, part 1. 

 Leiserowitz A, Maibach E, Roser-Renouf C, et al. Climate Change in the American Mind: March 2018. New Haven, CT: Yale Program on Climate Change Communication; 2017.

 Randall R. Loss and climate change: the cost of parallel narratives. 

Hope and Grief in the Anthropocene: Re-Conceptualising Human-Nature Relations

 Weintrobe S, Ed. The difficult problem of anxiety in thinking about climate change. 

Engaging with Climate Change: Psychoanalytic and Interdisciplinary Perspectives

 Alame D, Truog RD. How should clinicians weigh the benefits and harms of discussing politicized topics that influence their individual patients’ health? 

 Ekholm S, Olofsson A. Parenthood and worrying about climate change: the limitations of previous approaches. 

 Benedek T. Parenthood as a developmental phase. 

 Hugger L. Mourning the loss of the idealized child. 

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.

Janet Lewis, MD

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