Michael A. Kalm, MD

Denial, politics, and delusions have played a role in our lives this year, from the pandemic to climate change. For instance, on November 16, 2020, the 

 reported, “Jodi Doering, an emergency room nurse in South Dakota, was overwhelmed Saturday night. Her patients were dying of COVID-19, yet were still in denial about the pandemic’s existence. Their last dying words are, ‘This can’t be happening. It’s not real.’”

We have a paradox. As knowledge, data, and treatment methods of coronavirus disease 2019 (COVID-19) expand and as potent effective vaccines are now available, acceptance should increase, and fear should be reduced. Instead, denial, fed by fear, is increasing in some quarters.

As effective vaccines achieve US Food and Drug Administration (FDA) emergency use authorization and become widely available, we will need as many people as possible to receive them to build herd immunity and save lives. Yet we know there is an ever-growing, conspiracy-based, antivaccine, anti-science movement in this country that will sabotage our best efforts if unchecked.

 What is true for COVID-19 is even more true for climate change.

When President Biden was sworn in on January 20, 2021, he announced one of the most ambitious programs for his first 100 days in history. This included rolling out this country’s most comprehensive plan to build a clean energy revolution: a modern, sustainable infrastructure with environmental justice, sometimes referred to (even in the title of this piece) as a “Green New Deal.” Using many proven concepts from great scientific thinkers, like Saul Griffith (

) incorporates how to fully decarbonize America. The plan will create 25 million new well-paying jobs that will be local and cannot be outsourced, cut our energy costs in half, repair our infrastructure, make our electrical grid more reliable, clean our air and water, and rally the other nations of the world to our global effort. The plan is detailed, thoughtful, and well laid out.

There is a catch, however. For this plan to work, it will require America mobilizing to a war footing, similar to World War II.

 It will also require a high adoption rate. While logically we should expect excitement and optimism readily fueling this, just as with COVID-19 and vaccines, we are unlikely to get it. In fact, we can expect quite the opposite response from a significant portion of the country.

Why is this? This paradox, this phenomenon of fear increasing when it should decrease, has been copiously studied. It has also been studied by political scientists and information scientists where it is variously known as “the Backfire Effect,” or the “Continued Influence effect,” and the “Illusory Truth effect.” The existence of the Backfire Effect is controversial in the information and political science world, in that despite hundreds of studies, replication of the effect is not reliably demonstrated—it happens sometimes and not others, with the possible implication that it may not have to happen when important information is handled well.

However, when it exists, the Backfire Effect is attributed to 3 sources, known as familiarity, overkill, and worldview.

 It has also been tied into fear of loss of self-identity,

 as well as terror management theory, ie attempts to suppress the fear of dying from terrorist attacks or other terrifying events.

 discuss “motivated reasoning,” or using emotionally-biased logic to find arguments in favor of conclusions we want to believe to be stronger than arguments for conclusions we do not want to believe, regardless of what actual evidence shows. Motivated reasoning is similar to confirmation bias, which stands in contrast to critical thinking.

All of these studies and theories have merit, but why then are the studies so inconsistent in replicating the Backfire Effect? One possible explanation put forth is the wording of the experimental design (the participants are given manufactured news items to read). Another is difference in the study populations. For example, the original Nyhan and Reifler study from 2006

 used only college students as participants. College students tend to respond differently to factual material that is offered as a correction to misperceptions. Additionally, none of the studies that I examined were able to control for when facts are dismissed in favor of counter-factual conspiracy theories from motivated and emotionally manipulative sources.

A huge issue is fear, which climate change provokes. President Biden has called climate change “an existential threat,” and this is not hyperbole. Species are going extinct. Habitats are being destroyed. The human race itself is threatened and there will be millions of deaths. People are already dying from climate change-influenced hurricanes, forest fires, droughts, and floods. Where I live in Utah, research was just published showing that “air pollution causes between 2,500 and 8,000 premature deaths each year in Utah, decreasing the median life expectancy by 1.1 to 3.6 years.”

How do people respond to fear? In the best-case scenario, they respond with courage and determination. That is why President Franklin Roosevelt said in 1933 during the heart of the Depression, at America’s darkest hour, ‘The only thing we have to fear is fear itself!’”

Unfortunately, the best case is not the common case. Many times, people respond with denial, saying things like: “Climate change is not real. It is only a normal weather cycle.” People also respond with anger, toward doctors who come with bad news or inadequate treatments, or scientists who talk about climate change and what is necessary to correct it. They accuse those scientists of trying to steal the way of life they feel both accustomed and entitled to.

They also respond with depression and feelings of hopelessness: “We are going to die anyway. Let us just die in peace.” They respond with identification with the aggressor, a defense of the ego, in which the person aligns themselves with some powerful figure, often authoritarian, who promises salvation. With conspiracy theories, we see the rise of identification with an aggressor who fails to protect, like in the example of the patient in South Dakota, who staunchly proclaimed that COVID-19 did not exist even as she was dying from it. However, because of a quirk in psychiatric nomenclature, we do not call this kind of thought delusional.

Delusions are false beliefs based on incorrect inference about external reality that persist despite the evidence to the contrary; these beliefs are not ordinarily accepted by other members of the person's culture or subculture. Delusions can be classified as either “bizarre” or “nonbizarre.” Bizarre delusions are clearly implausible, for example, belief that one’s thoughts have been removed by an outside force, that alien thoughts have been put into one’s mind. A nonbizarre delusion is one that could actually occur in real life and may be difficult to distinguish from an overvalued idea. Although a bizarre delusion is considered more serious and may require antipsychotic medication, a nonbizarre delusion is referred to as a thinking error and may be amenable to correction, although the corrective effort tends to be very difficult to accomplish. This will be important as we discuss solutions to all of these problems later in this piece.

We do have another psychological factor that can work for us and that is acceptance. In this case, not acceptance of inevitable doom, but acceptance of our fears, along with acceptance of our courage to face our fears and find the will to solve our existential problems.

For Biden’s Energy Plan, we are already seeing fear, denial, and anger in statements like the following: “It’s a Socialist conspiracy! It’s too expensive! It won’t work! What about my job? What does it matter what we do without China, India and Africa?”

What can we psychiatrists do to overcome such reactions? A lot. We are uniquely trained and positioned to recognize and address all the psychological phenomena that are and will continue to occur in reaction to climate change, Biden’s plan, and conspiracy theories. We can recognize and respond to these thinking errors that will be running rampant through our communities.

As psychiatrists, our duties to our patients involve something of a paradox. On one hand, we are required to accept them as they are. On the other hand, it is our duty to challenge their thinking errors, and invite them to challenge their fears. We must do that politely, but unambiguously. We start by listening to them calmly and carefully, and then asking questions like: How do you know that to be true? How did you decide that some sources were all in error and others are correct? What is the risk for you in challenging your beliefs? In not challenging them? There is a whole host of therapeutic questions that may be asked. If one is convinced, as a psychiatrist, that adoption of a large-scale climate action plan is absolutely essential for our patients’ health, I believe we should encourage pro-climate actions from our patients’ minds and behaviors.

Also, as psychiatrists, our duties to our communities involve consulting with our leaders, our public health officials, our journalists, and our community organizations to acquaint and educate them regarding the fears and other symptoms we are likely to see among our citizens. We psychiatrists must not pretend that we or our patients live in a bubble that is somehow separate from the rest of the world. Political issues, especially in the area of climate change, directly affect our patients. They cannot be ignored.

On to the practical suggestions. Twenty-two researchers pulled all their findings and knowledge together to create the 

 at the George Mason University Center for Climate Change Communication. This is a handbook that provides a guide to correcting misinformation, disinformation, fake news, and both the “Continued Influence” and “Illusory Truth” effects. The whole handbook is well worth reading but there are certain key pointers that we would do well to keep in mind as we speak to our patients and communities about climate change.

 are geared toward helping people change from misinformation and disinformation to truth. In that way, while their suggestions are appropriate for people in general, they are also appropriate for our patients in particular.

By helping our patients to think critically, we will empower our patients to feel less alone, more connected to their communities, better able to discern truth from fiction, more confident in their ability to act, and better able to take part in building a healthier world.

The opinions expressed in this article are those of the author and do not necessarily reflect the opinions of

is a past-president of the Utah Psychiatric Association and clinical assistant professor of Psychiatry at the University of Utah.

1. Hotez PJ. Combating antiscience: Are we preparing for the 2020s? 

3. Maizland L. Global climate agreements: successes and failures. 

https://www.cfr.org/backgrounder/paris-global-climate-change-agreements

4. Haglin K. The limitations of the backfire effect. 

5. Lewandowsky S, Cook J, Ecker U, et al. 

. George Mason University Center for Climate Change Communication; 2020.

6. Trevors GJ, Muis KR, Pekrun R, et al. Identity and epistemic emotions during knowledge revision: A potential account for the backfire effect. 

7. Nyhan B, Reifler J. When corrections fail: The persistence of political misperceptions. 

https://www.dartmouth.edu/~nyhan/nyhan-reifler.pdf

8. Swire-Thompson B, DeGutis J, Lazer D. Searching for the Backfire Effect: measurement and design considerations. 

9. Errigo IM, Abbott BW, Mendoza DL, et al. Human health and economic costs of air pollution in Utah: an expert assessment. 

10. Schott B. Utah’s attorney general joins multistate effort to sue President Joe Biden over climate change order. 

https://www.sltrib.com/news/politics/2021/03/09/utahs-attorney-general/

11. George Mason University. Debunking handbook 2020. Center for Climate Change Communication. Accessed March 9, 2021. 

https://www.climatechangecommunication.org/debunking-handbook-2020/

Articles

Resistance to climate change often comes from the same place: denial. 

How a Biden Green New Deal Will Affect Our Patients and What We Can Do to Help

There’s an old joke about change: How many psychiatrists does it take to change a light bulb? Just one, but the light bulb really has to want to change.

One of my teachers ruefully described working for change as a “sandwich board” concept. Poor people during the 1930s earned money as walking advertisements, wearing sandwich boards with messages on the front and back, like “Eat at Joe’s,” and “Open for Breakfast From 7-11 AM.” My teacher used to say that our patients came to us wearing sandwich boards, with the front saying, “Please help me to change,” and the back, saying, “Over my dead body.”

Our patients do come to us for help. They want to feel better. But they also come to us with fear that makes change difficult. They come to us with psychological defenses, like denial, which stop them from facing what they fear most. They also come with prejudices, beliefs, anecdotal evidence, confirmation bias-all designed for feeling better but perpetuating the same distress.

Our duty as psychiatrists is to build trust, to provide a safe environment where our patients can be open; reveal their darkest thoughts, feelings, and fears; try out new things, and use their new skills out in the world if they so wish. When we do our job right, our patients can return to, or achieve for the first time, a healthy state where they can be in the world confident, thriving, and able to sustain healthy relationships.

But this is not easy. Sometimes fear runs too deep and denial is too great. Many years ago, I had a patient with paranoid schizophrenia. With therapy and medication, she recovered from psychosis and was a full-time student heading towards a full, thriving life. However, before her illness, she had been an accomplished pilot. At the time I was treating her, the Federal Aviation Commission (FAA) had a rule that prohibited renewal of a pilot’s license as long as the person was taking prescribed medications. I appealed to the FAA on her behalf, asserting that I would trust my life flying with this patient, because, with her medication, she was completely stable and competent. But rules are rules. No license.

My patient decided to discontinue her medication. I urged her not to do so, emphasizing the risk of relapsing into psychosis, and that she would risk losing her license anyway and probably much more. But the license was too important to her. She stopped the medication, and, as predicted, relapsed into psychosis. She resisted treatment and ran away. I received a letter from her family some years later that she never finished school, couldn’t hold a job, and had become homeless.

This is the paradox of psychiatry. We are agents of change with a patient population that often fears change. We suffer the “Curse of Cassandra.” Cassandra was the subject of Greek mythology, a princess who was cursed by the gods to always tell the truth but never be believed. It was Cassandra who warned the Trojans that the Greeks were hiding within the wooden horse and that it should be kept out of the city, but she was not believed. In her wonderful book, 

, historian Barbara Tuchman defined political folly as behavior exhibited by leaders of countries who ignore the advice they are given by their “Cassandras,” people whom they have trusted and had hired specifically for their advice. This is not just true of political leaders. It is also true for many of our patients as well as many communities.

This brings us to climate change. Our planet is in the grips of global warming, bringing massive climate disruption, creating mega-storms, floods, droughts, heat waves, and the beginning of climate migration. If unchecked and not reversed, we are headed towards a bleak future of species and habitat extinction, mass migration of people, hundreds-of-millions dead from starvation, and warfare over dwindling resources.

We are now hearing about a “Green New Deal,” a comprehensive restructuring of governmental, environmental, and economic policies, including ambitious technological innovation and massive transformation of the workforce, in order to save the planet and secure the future. While public support for clean energy is nearly 80%, the “Green New Deal” is being seized upon to create fear and suspicion of unacceptable costs, personal sacrifices, and lost jobs. While these proposals are being endorsed enthusiastically by many, they are met with outright derision by others.

As psychiatrists, do we have a role to play here? Some would say no, for a number of reasons. First of all, the population at large is not our patient. We have a rule in psychiatry-a good one-that says, “No therapy without a contract.” Secondly, we ordinarily do not discuss politics or world affairs with our patients. Thirdly, we ordinarily do not tell patients that they have to change.

But there are exceptions-when a patient is caught in a hopeless marriage, we sometimes say to them, “I’m afraid that you will be depressed for the rest of your life if you don’t leave this marriage.” If they are stuck in an addiction-whether it is alcohol, drugs, gambling, or even overspending, we sometimes say to them, “You are suffering from addiction. It is a disease, and it is a disease that will kill you if you don’t find the courage to face it openly.”

Even with psychosis, in which the patient appears to be divorced from reality, we sometimes say, “Your thinking is a delusion, and as difficult as it is, you must fight your way through to reality.”

What does climate change and a Green New Deal have to do with these clinical situations? Everything. Climate change has come about for multiple reasons that scientists and economists will debate for a long time. But the bottom line is-we currently have a global economy that is built on the consumption of fossil fuels. That model no longer works. The longer it continues, the more damage is done, and the harder it is to find a solution.

Sex therapists tell their older patients, “You can’t have sex at 70 the way you had sex at 25. You have to redefine what sex is so that you can not only continue to enjoy it, but even increase your enjoyment!”

And so must we-thus the Green New Deal. We can’t stop burning fossil fuels. We have to replace that part of our economy with something that will not only diminish climate change but will also improve our lives. This means innovation, new ideas, alternate forms of energy, job training, infrastructure repair, wider education, urban planning, water management, and on and on. As I said, the details of what properly constitutes a Green New Deal is a subject to be debated by scientists, economists, sociologists, and ordinary people everywhere. Our job as psychiatrists is to provide the crucial hope in a better future and the necessary courage to take the steps to get there.

Nothing prepares us more for this momentous task than what I call the second paradox of psychiatry: psychiatrist as “happy warriors.”

What is a “happy warrior”? I must share a story about one of my heroes, Jacob Javits. Javits was a long-time Senator from New York, elected to office from both the Republican and Liberal parties. Neither party was particularly happy with Javits running on the other party’s ticket, but Javits believed in the principles of both parties, so he felt no conflict. He was considered one of the Senate’s “happy warriors,” always willing to take on a fight for a cause in which he believed, no matter how unpopular, always in good spirits while doing so. After retiring from the Senate, he continued to fight for the causes he believed in, even after he was virtually incapacitated with amyotrophic lateral sclerosis, and to the end, always of good cheer.

Late in Javits’s life, a reporter asked how he remained in perpetual sanguinity, even when faced with such tremendous adversity. Javits responded that, when immigrating to this country, his family was very poor. To get food on the table, his father, Morris, became a Golden Gloves Boxer. This was in the era before weight classifications in boxing-no flyweight against flyweight or heavyweight against heavyweight. They just drew two names out of a hat, and you got into the ring. So, here was Morris, five foot four inches tall, just over 100 pounds, getting into the ring with a six-foot four 200 pound behemoth. Javits said, “My father had only one rule about that-’Hit ‘em with what you’ve got.’ Fair or unfair-didn’t matter. Win or lose-didn’t matter. Just ‘Hit ‘em with what you’ve got.’ That was my father’s rule and I made it my rule. It’s still my rule-‘Hit ‘em with what I’ve got,’ and I’m still doing it.”

We in psychiatry are happy warriors. We don’t give up on patients. We recognize and accept their fears, their denial, their prejudices, their disbeliefs, and we stick with them as long as they’ll let us in order to find ways to make it easier for them to accept painful truths and make courageous changes that will provide them a better future.

Although the population-at-large are not our patients, they are our fellow citizens. They are part of our community, and, as citizens, we owe it to them to apply our knowledge and skills as much as we can to build a healthy environment in which improvements and innovations can be made for the benefit of all. We must help those who are already striving for a Green New Deal to be happy warriors themselves!

Dr Kalm is Clinical Assistant Professor of Psychiatry, University of Utah. He is past president of the Utah Psychiatric Association. Trained at Duke, Dr Kalm is committed to the welfare of his patients, and by extension, to all people and all species of the earth. 

Dr Kalm reports no conflicts of interest concerning the subject matter of this article.

Michael A. Kalm, MD

Articles

How a Biden Green New Deal Will Affect Our Patients and What We Can Do to Help

Cassandra or Happy Warrior: How Paradoxes of Psychiatry Can Sustain the Green New Deal