Fostering Human Connection in a Sustainable Virtual World

May 4, 2021
Janet Lewis, MD

Beth Mark, MD, MES

Elizabeth Haase, MD

Jeremy D. Wortzel, MPhil

How can psychiatry meet its ethical duty to mitigate climate change while also promoting collegiality at conferences?


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.1 Similar analyses have shown that a single international conference can use as much COe2 (carbon dioxide equivalent) as a whole city for a year.2 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 environmental sustainability?

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 of these effects.

The US healthcare system is responsible for 10% of all GHG emissions.3 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.

Patients pay the price of psychiatric practices’ carbon excesses. In a study, Eckelman and Sherman3 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,4 its decision to divest from fossil fuels, 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.5 In terms of sustainability, social contagion occurs with behaviors like adoption of clean energy technologies.6

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 sustainability behaviors.7 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 mitigation and adaptation 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.8 Connection is a foundational component of wellbeing and resilience. So, we have to ask, “How are online activities affecting our human connections?”

Networking and Experience

From the perspective of knowledge acquisition, 2-way exchange promotes learning,9,10 with some aspects (eg asking questions) actually improved online.11,12 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.13 Networking is also a common concern in the business sector, with 85% of Forbes Insight Survey indicating that they build stronger and more meaningful business relationships at in-person conferences.14 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.

Reward Systems. Redcay and Schilbach provide a useful review of neuroscientific understandings of the mechanisms of social interaction.15 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.

Presence and Mindfulness. In research on social presence, face-to-face communication is found to make contributions to individual well-being and relational closeness.16 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.”16

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.

When we enter a conference 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, Resident Jeopardy, virtual talent shows, or even karaoke events that can all be conducted remotely.11

Considering Psychiatry’s Options

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 climate change, 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.1 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.

Concluding Thoughts

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 both/and 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.

Dr Lewis 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. Dr Mark 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. Dr Haase 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. Mr Jeremy Wortzel is a medical student at the University of Pennsylvania School of Medicine.


1. Wortzel JR, Stashevsky A, Wortzel JD, et al. Estimation of the carbon footprint associated with attendees of the American Psychiatric Association Annual Meeting. JAMA Network Open. 2021;4(1):e2035641.

2. Klöwer M, Hopkins D, Allen M, Higham J. An analysis of ways to decarbonize conference travel after COVID-19.Nature. 2020;583(7816):356-359.

3. Eckelman MJ, Sherman JD. Estimated global disease burden from US health care sector greenhouse gas emissions. American Journal of Public Health. 2018;108.

4. Ursano RJ, Morganstein JC, Cooper R. APA official actions position statement on mental health and climate change. APA Off Actions. 2017:1.

5. Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. N Engl J Med. 2007;357(4):370-379.

6. Bollinger B, Gillingham K. Peer effects in the diffusion of solar photovoltaic panels. Marketing Science.2012;31:6,900-912.

7. Leiserowitz A, Maibach E, Roser-Renouf C, et al. Public perceptions of the health consequences of global warming. Yale Project on Climate Change Communication and George Mason University Center for Climate Change Communication. October, 2014. Accessed April 26, 2021.

8. Richardson J, Henriques A, eds. The Triple Bottom Line: Does It All Add Up. Routledge; 2004.

9. Rowe G, Frewer LJ. Public participation methods: A framework for evaluation. Sci Technol Human Values. 2000;25(1):3-29.

10. Abelson J, Forest PG, Eyles J, et al. Deliberations about deliberative methods: Issues in the design and evaluation of public participation processes. Soc Sci Med. 2003;57(2):239-251.

11. Antonoff MB, Mitzman B, Backhus L, et al. The Society of Thoracic Surgeons (STS) virtual conference taskforce: Recommendations for hosting a virtual surgical meeting. Ann Thorac Surg. 2021;111(1):16-23.

12. Chris W. Learning to love virtual conferences. Nature. 2020;582:135-136.

13. Oester S, Cigliano JA, Hind-Ozan EJ, Parsons ECM. Why conferences matter—an illustration from the international marine conservation congress. Front Mar Sci. 2017;4:1-6.

14. Koyen J. Business meetings, the case for face-to-face. Forbes Insights. Published online 2009:1-6. Accessed April 26, 2021.

15. Redcay E, Schilbach L. Using second-person neuroscience to elucidate the mechanisms of social interaction. Nat Rev Neurosci. 2019;20(8):495-505.

16. Hall J, Pennington N, Holmstrom A. Connecting through technology during COVID-19. Human Communication & Amp; Technology. 2021;2(1).