Janet Lewis, MD

 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. 

 Whitmarsh LE. Scepticism and uncertainty about climate change: dimensions, determinants and change over time. 

Overcoming Polarization by Evolving Both Right and Left: How Polarity Theory Provides a Path to Political Progress

. Boulder: Institute for Cultural Evolution; 2016.

 Australian Psychological Society. Coping with Climate Change Distress, Information Sheet. www.psychology.org.au/getmedia/cf076d33-4470-415d-8acc-75f375adf2f3/coping_with_climate_change.pdf.pdf. Accessed December 6, 2018.

Articles

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.

The text is well organized with take-home messages set apart in boxes. The phenomenon of treatment resistance is reviewed, as are data that support the positive results obtained at the Riggs Center. A variety of issues are addressed, including negative transference; the transmission of trauma; psychodynamic psychopharmacology; and working with suicidality, family resistance, and psychotic disorders.

We are urged to look beyond the phenomenon of “acting out” toward the notion of “enactment,” which implies clinician participation in the unfolding treatment-resistant behavior. From this point of view, treatment pivots around the empowering concept of authority-the patient as author of an engaged relational narrative previous-ly carried in action (and inaction) rather than in words.

The book is worth reading by all mental health professionals. Of particular interest is the chapter “What is psychodynamic psychopharmacology? An approach to pharmacological treatment resistance,” by Drs Mintz and Belnap. The 2 main subjects in this chapter are deserving of book-length treatment. These are “resistance 

medications” (including the nocebo effect) and “resistance 

 medications,” wherein use of medications and the medical model contribute psychologically to treatment resistance.

Another notable chapter is “System pressures, ethics, and autonomy,” by Marilyn Charles, PhD. Dr Charles emphasizes that for treatment-resistant patients, “the standard of care is a floor, not a ceiling.” She describes how various types of fear on the part of the clinician often create a tendency toward oversimplified thinking in the treatment of these patients.

The only shortcoming of this excellent book is its minimal discussion of the issues involved in applying its understandings to less intensive clinical settings. The reader feels this as an aching need. One is left with the disquieting implication that much of current treatment with some patients, because it is “deaf” to the communication in their behavior, may actually further entrench treatment resistance.

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.

Treatment Resistance and Patient Authority: The Austen Riggs Reader

I was very pleased to read Robert Langs' letter ("

Violence Against Mental Health Professionals

 July 2007), in the wake of Dr Fenton's death. Dr Langs discussed violations of the therapeutic frame in relation to risk of violence and voiced concern over our tendency toward a "one-sided thinking and approach to this problem" of patient violence. He is particularly qualified to weigh in on this discussion; his classic paper "Therapeutic Misalliances"

 described the interactional nature of therapeutic failures in general.

In his letter, Dr Langs pointed out psychotherapists' strong resistance to recognizing the possible contribution of a therapist to patient violence. In my experience, analyses within our professions of disastrous or even simply unsuccessful therapy outcomes usually reflect "one-sided thinking." Those involved in the discussion of such cases tend either to identify with the therapist and focus only on aspects of the patient's neurochemistry, psyche, and behavior that contributed to the poor outcome or to identify with the patient and focus only on objectionable aspects of the therapist's behavior, such as gross boundary violations.

A particularly narrow viewpoint I have witnessed involves a rigid employment of the medical model. I have seen colleagues who use this approach object to any analysis of the therapeutic relationship at all. For example, I have witnessed colleagues objecting to a discussion of the therapeutic relationship in the case of a patient's suicide. They argued that since a significant percentage of bipolar patients commit suicide, it is an outcome of the disease. They objected to psychiatrists "wringing our hands" over the consequences of illness, when those in other medical specialties would not. Of course, what is missing in such an assessment is an understanding of the nature of psychotherapy as an interactive therapeutic tool. Probably equally lacking is a tolerance for our uncomfortable existential position in being practitioners ofsuch a tool.

As psychotherapists, after a disastrous outcome we can never honestly say that everything possible was done. We may say that the therapist's behavior was reasonable, but we can never say that everything possible was done. On further reflection, with further consultation, and especially in retrospect, we should always be able to see new angles that could have been pursued in  psychotherapy and that may have averted disaster or even led to progress. We cannot know for sure, and this lack of certainty can be uncomfortable, but we have a duty to ourselves, our colleagues, and our patients to reflect on and learn from these cases. Such reflection must use multiple perspectives, including an interactional perspective.

I was very pleased to read Robert Langs' letter ("Violence Against Mental Health Professionals," Psychiatric Times, July 2007), in the wake of Dr Fenton's death.

Janet Lewis, MD

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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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