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When engaging in professional discourse on controversial topics, how can psychiatrists respect the therapeutic boundary with patients when their own fears are heightened?
Editor's note: Click here for Furthering Psychiatry’s Necessary Conversation About Climate Change: A Response to Dr Elizabeth Varas, MD.
This article is not meant to disparage the climate change platform or diminish the importance of the role psychiatrists play as advocates for our patients; it is, rather, a commentary to provoke thought and open discussion regarding the scope of the changing ethical and social concerns of psychiatry in the age of climate change. Is there room on this topic for open discussion?
Psychiatrists have always been on the front lines helping survivors and their families cope with the devastation of the human spirit after a catastrophic event: the Haitian earthquake (2010); the Armenian earthquake (1999); the World Trade Center attack (2001). Psychiatrists have also been on the front lines to address far reaching social changes that have affected our patients’ lives: deinstitutionalization and the creation of the community mental health system (1963).
There is, however, a fine line between advocacy for our patients and activism. If we are to be foot soldiers in the climate change campaign, are our boundaries clear and our loyalty to the therapeutic alliance with our patients unencumbered?
We have been asked by our psychiatric educators to act as leaders in the climate change movement. In the article “Psychiatric Educators Issue ‘Call to Action’ on Climate Change,” Dr John Coverdale cites the fiduciary responsibility that every member of the psychiatry profession has towards the public.1 Dr Lise Van Susteren2 in her 2017 commentary on climate change calls for psychiatrists to use their skills of persuasion to confront denial and resistance in the public. This is a subtle shift as we move from the fiduciary duty and “duty to warn” our patients of a imminent threat to the much broader concept of our duty to warn the population at large of a looming diffuse climate-related process.
The climate change movement is a global issue with far reaching consequences not only for our mental health patients but also for citizens within and outside of our borders. The steps required for a meaningful reduction in carbon emissions are encompassing and will touch upon many ethical issues that have not been addressed by psychiatry in the past: population growth, migration, and redistribution of wealth from richer to poorer countries.
The steps required will have far reaching socioeconomic and political ramifications. Half of the world’s population does not have electricity and, as a result, the switch to alternative fuels will not be swift. Compounding the hurdles in the US is the political nature of the climate change movement. The Pew Research findings on “The Politics of Climate,” show that,
The political fissures on climate change issues in the US extend far beyond beliefs about whether climate change is occurring and whether humans play a role . . . these divisions reach across every dimension of the climate debate, down to people’s basic trust in the motivations that drive climate scientists to conduct their research.3
As psychiatrists embrace the mental health aspects of climate change, it is increasingly important to separate the advocacy for our patients from our own personal and social activism. The desire to understand more deeply the effects that climate-related disasters have on our communities and how to work to prevent them are well within the purview of psychiatric leadership. Looking to decrease consumption as well as utilize low carbon alternative fuels within our psychiatric environments is also laudable. However, how do we manage to respect the therapeutic boundary with our patients when our own fears for survival are heightened?
In her commentary Dr Van Susteren2 urges psychiatrists to use their professional standings and good will to access emotional barriers in the general population to activate behavioral change. The use of confrontation as the door to the unconscious to attack defenses and resistance is part of the psychotherapist’s tools. However, we are now being asked on a unified level to confront resistance and denial in the general population to bring about a societal behavioral change. First, is an ethical boundary crossed in this situation? And if so, does the severity of the threat of climate change mitigate boundaries? Outside of the psychiatrist’s toolbox, the implication of “one who denies” is pejorative; psychiatrists need to be wary of the use of their influence to label a certain subset of the population.
Now more than at any other time, climate change raises previously unseen moral and ethical challenges. The use of the terminology “duty to warn” which had a specific use in Tarasoff is openly used in the climate change movement to remind us of our duty to protect the public from harm. The transformation of the original intent of “duty to warn” to its present global use is daunting and may have unforeseen legal consequences down the road. Are we obligated as psychiatrists in the present climate of litigation to warn our patients of the threat of global warming?
As psychiatric experts in the field call for professional communities to embrace a greater role in the initiative of climate change, caution needs to be exercised to avoid the worsening of political fissures that extend throughout our political system. Psychiatrists must remain cognizant that climate change is indeed a political issue and avoid the mistake of alienating a percentage of the population.3 Respect and an attempt to understand the beliefs of others are necessary to comprehend the complexity of the ethical issues yet to be raised. Blind adherence to leadership without taking the time to work through the substantial moral and ethical issues independently is not the answer; independent thinking needs to be encouraged.
With the elevation of the importance of climate change, the emphasis has been shifted from the patient to the health of the planet. The earth has morphed into a giant but ailing planet that has failed its toxicology screen and needs our collective energy to nurse it back to health. Psychiatry, as well, continues to evolve. A new ecological psychology around climate change has emerged from the groundswell and gained popularity among its followers. New theories are emerging regarding the planet’s role in ego and personality development. The treatment of anxiety related to climate-related disasters continues to evolve as we learn to live with the threat of impending doom and sensory and media overstimulation.
The enemy/hero narrative in the climate-change movement is not an effective one; rather cooperation, a search for common aspirations and solutions, and the acknowledgement that we are all in this together is a more effective agenda.4 The global agenda of climate change will continue to advance; however, patience must be exercised until the political and economic shifts that are required emerge, driven by successful business models that lower our carbon footprint and improve the health and welfare of all citizens. The recent yellow jacket riots in Paris demonstrate the potential consequences of a less than carefully thought out plan regarding access to electricity or fuel in a financially stressed population.
Furthering Psychiatry’s Necessary Conversation About Climate Change: A Response to Dr Elizabeth Varas, MD.
By Robin Cooper, MD, Elizabeth Haase, MD, Janet Lewis, MD, David Pollack, MD, Alex Trope, MD, and Lise Van Susteren, MD
Leadership of Climate Psychiatry Alliance
Dr Varas challenges all of us to embrace deep conversations in the opening of her article, “The Changing Face of Psychiatry in the Age of Climate Change,”1 with the question, “Is there room on this topic for open discussion?” We answer with a resounding “YES.” Listening and actually hearing different points of view is a deep value often unspoken within our profession and at the core of being a good therapist. We must often help patients in conflict with these skills. Facing and attempting to have an impact on the many vexing health threats of our generation (climate change being only one, but one that carries apocalyptic threat) requires us to engage in these discussions and to work toward common ground.
Just as with our patients, the ability to actually listen, hear, and respectfully engage in discussions challenges us when the topics are of such monumental proportions and the issues touch on core values, fears, and opinions that are deeply held. These conversations call on the best parts of our character. Our professional skills in helping our patients tolerate uncomfortable and conflicting experiences and in avoiding splitting into opposing camps can offer some tools for these complex dialogues. So, let’s delve into the discourse.
Dr Varas rightly warns that the “enemy/hero narrative is not effective” in the climate change movement. We would add that splitting is ineffective any arena. The “enemy/hero” narrative, where the enemy is seen in other people pulls us into primitive psychic states. These primitive states may effectively rein in acute anxieties, but they create a false sense of psychic security through affiliative group identity, and they do damage to the need to hold multiple conflicting ideas, experiences, and opinions. Dr Varas calls for recognizing that “we are all in this together” and to do the hard work of “searching for common aspirations and solutions.” We wholeheartedly agree.
However, searching for areas of common ground must not cloud the areas of disagreement or differing perspectives. We tell our patients, “being able to listen and hear what your partner says, does not mean that you have to give up your thoughts and feelings.”
Dr Varas brings up the concern about boundaries in therapeutic work. We agree with her that in the therapeutic space of the consulting room, we have no business “attacking defenses and resistances.” Our task with any patient is to be present with their concerns and what brings them into the office. We, in the Climate Psychiatry Alliance (CPA), are not advocating sledge-hammer techniques.
At the same time, we also have within our tool kit the skills to identify and address what is not being said. This is the bread and butter of good psychotherapy. This does not give license for clinicians to turn the consulting room into a political soapbox. There is a distinction between proselytizing and appropriately understanding climate-related impacts on health and mental health and how these affect individuals and communities. Technically and scientifically addressing these issues in a non-politicized manner is our preferred approach. We balance our understanding with therapeutic assessment and craft delicate interventions all the time in our work with patients.
Often this does not require explicit mention of climate change. As a very simple example, bringing up with patients on psychotropic medications the information that “in this day and age when we are having more extreme heat waves” the warning of the increased risk of heat stroke while providing suggestions for prevention and early recognition is good clinical care and should be on the checklist for psychiatrists. How is this different than discussing safe sex practices with patients whose sexual behaviors put them at risk? Moreover, helping patients to prepare for inevitable extreme weather events should be a part of our engagement.
More complex therapeutic issues of boundaries are emerging more frequently as patients present with states of what is seen as “eco-anxiety.” Some patients spontaneously and explicitly bring up their fears of the changing world due to climate change. Patients who are in a panic about their limited ability to protect their children may regret or fear having children. We must be available to hear and engage with these patients.
When we convey unspoken messages that these topics are areas we do not want to consider, our patients sense our avoidance as dismissive or disapproving, and they may unconsciously or consciously retreat from these conversations. Our patients live in the real world with real world threats. We must be available to them as they negotiate the management of these fears. To do so, we must confront our own anxieties, so that we are able to be present for the range of experiences with which our patients contend. It is our job to help them manage gripping psychologic troubles while maintaining the “loyalities to the therapeutic alliance.”
Dr Varas implies an inappropriate slide into politicization noting a “subtle shift” from Dr John Coverdale’s identification of fiduciary concerns to Dr Lise Van Susteren’s call for “duty to warn” and “confronting public denial.” We do not agree. This is not a case of either/or, but rather an opportunity to recognize and address the many arenas that climate change impacts within the multiple realms of psychiatric work: clinical, administrative, advocacy, research, and education.
We are not simply individual clinicians. We have obligations to understand and address public health and mental health issues within our domain. Dr Van Susteran is in very good company when she advocates for this collective action. Many of our professional colleagues in health organizations have issued clarion calls for action to address the health impacts of climate disruption.2,3 Acting at every level from direct patient contact, community mental health systems, larger health systems, and advocacy for policies are all relevant and necessary tasks and should not be reduced to “either/or” status, but held in the context of the “everything/ many”.
Macpherson and Wynia4 explicitly address the ethical dilemmas of speaking out as physicians on climate and health related concerns. They formulate a series of seven criteria or factors by which one might determine the relative degree of necessity, benefits, and justification for speaking out either to individual patients or the general public. Their criteria include expertise, proximity, effectiveness, low cost or risk, uniqueness of opportunity, severity, and public trust.
Dr Varas raises important concerns about overpopulation, poverty, and other social determinants of health. She correctly addresses the complexity of providing energy to impoverished communities worldwide and identifies the slow transition to clean energy as a concern for bringing people out of abject poverty. Additionally, she identifies the resistance seen in recent “yellow jacket” demonstrations and riots in France. She seems attuned to political and socio-economic complexities. However, debating about the correct strategies and policies for addressing these issues is a political and strategic concern that is an insufficient reason to resist the degree of engagement we recommend. Fear, including fear of complexity, is a maladaptive and ineffective reason for inaction.
The use of climate change to promote an overly politicized and partisan conversation is and would continue to be a tragic and enormous disservice. In reality, we live in a very divided, somewhat tribalized, world. That should not prevent psychiatrists and our professional organizations from robust engagement in efforts toward solutions. Dr Varas calls for “caution to avoid worsening political fissures.” We worry that this call for caution subtly promotes restraint, avoids or denies the urgency, and unconsciously supports avoidance and inaction. We strongly believe that all of our professional knowledge, actions, and collaborations to face this impending public threat, the ultimate social determinant of health, are essential and would benefit from broad and immediate participation by our colleagues.
1. Varas EA. The changing face of psychiatry in the age of climate change. Psychiatric Times. 2019;36(2):20.
2. Global Climate and Health Forum. A Call to Action. https://www.globalclimateandhealthforum.org/call-to-action. Accessed March 8, 2019.
3. Canadian Association of Physicians for the Environment. Call to Action on Climate Change and Health. February 2019. https://cape.ca/wp-content/uploads/2019/02/2019-Call-to-Action-Feb-5-2019-FINAL.pdf. Accessed March 8, 2019.
4. Macphereson CC, Wynia M. Should health professionals speak up to reduce the health risks of climate change? AMA J Ethics. 2017;19:1202-1210.
Dr Varas has been in solo private practice in Westwood, NJ since 2007. She is a veteran in the US Navy Reserve, having recently completed her 8-year commitment as an officer in the Medical Corps. as a critical wartime specialist in the field of psychiatrist. Before starting her private practice, she was the Medical Director of a mental health center in Paramus, NJ for more than 10 years and served as the director of the PACT program for patients with chronic psychiatric illness. Upon completion of her fellowship in consultation/liaison psychiatry she was an attending psychiatrist at Bronx Lebanon Hospital in New York City in the consultation/liaison service.
Dr Varas reports no conflicts of interest concerning the subject matter of this article.
1. Moran M. Psychiatric educators issue “call to action” on climate change. Psychiatric News. 2018; https://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2018.9a7. Accessed January 15, 2018.
2. Van Susteren L. Climate change: a call to action for psychiatry. Clin Psychiatry News. 2017. https://www.questia.com/magazine/1G1-488965440/climate-change-a-call-to-action-for-psychiatry. Accessed January 15, 2019.
3. Funk C, Kennedy B. The Politics of Climate Change. Pew Research Center. 2016. http://www.pewinternet.org/2016/10/4/the-politics-of-climate/. Accessed January 15, 2019.
4. Marshall G. Climate-change activists are playing a dangerous game with their ‘enemy’ narrative. The Guardian. 2013. https://www.the guardian.com/commentisfree/2013/nov/16/climate-change-dangerous-game-enemy-narrative. Accessed January 15, 2019.