Psychiatry in the Courtroom: Climate Disruption and ACEs

Psychiatric TimesVol 40, Issue 10

climate disruption, afraid


Supported by psychiatrists, a group of 16 Montana youth brought forward a constitutional climate lawsuit against their state, fighting to protect their rights to a healthy environment, life, dignity, and freedom—in the first ever youth climate case to go to trial. And they won.1

Psychiatric Testimony

“A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient… A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.”2

Present in the courtroom as an expert witness was Lise Van Susteren, MD, a psychiatrist and expert on how the climate crisis affects the physical and mental health of youth. Van Susteren shared more with Psychiatric Times about the importance of her crucial testimony.

“The extreme weather events will increase in intensity and frequency. Youths know this and know, because of their age, they are likely to suffer the cumulative toll. Kids are powerful witnesses on the stand. You can feel their fear, anger, and despair, and hear them say in their own words that they feel abandoned and betrayed,” Van Susteren explained. “If you are a mental health professional, and you are asking yourself, ‘What does climate change have to do with me?’ The answer is everything. From our ethical duty to protect public health to our mission to alleviate individual and collective suffering, taking action to warn of the urgent need to address the climate crisis is at the very epicenter of what we do. Psychiatrists have a pivotal role in addressing the problematic behaviors driving climate change and helping to drive the rapid social change that is so urgently needed.”

Van Susteren believes that taking action is the key to addressing climate distress. She recommends mental health clinicians—and everyone—engage in 5 different ways related to climate, what we call here the 5 Van Susteren P’s (Table).

Table. The 5 Van Susteren P’s

Table. The 5 Van Susteren P’s

“There are not enough serotonin reuptake inhibitors or therapists in the world to deal with the breadth of emotional challenges that come from the climate crisis. Only a systemic-oriented process that addresses not just symptoms but also the causes—and provides the means to work together—will restore the health of the planet,” Van Susteren told Psychiatric Times.

The American Psychiatric Association agrees climate change poses a threat to mental health, and that, furthermore, those with mental illness are disproportionately affected by climate impacts.3 The challenge remains: How can you as a mental health clinician treat a patient who has climate anxiety?

“We cannot reassure our young patients that there is no monster under the bed; there is. The best that you can do with a child who is struggling, and what is absolutely key, is to make this a family situation,” Van Susteren said. “Ensure the family acts together in ways that contribute to a healthier planet. Let the child know you are doing it because their concerns prompted it, as this is empowering for the child and reduces the sense of vulnerability. Refrain from eating meat as often as possible, plant a garden, reduce airline miles for vacations, put up solar panels. If a teenager is on their way to a peaceful protest, consider saying, ‘Go with my blessing. Do you need me to drive you or want me to go with you? I want to validate the reality of the problem and the need to act urgently by showing my respect for you and what you are doing. I will do my best not only for our family but to motivate other families to do the same.’ That is treatment for a child.”

The Case

Article II, Section 3 of Montana’s Constitution states4: “All persons are born free and have certain inalienable rights. They include the right to a clean and healthful environment…”

Held v State of Montana argued that the state government promotes and supports fossil fuel extraction and burning, which worsens the climate crisis and harms the lives of youth. The plaintiffs, aged 5 to 22 years, were represented by attorneys with Our Children’s Trust, a nonprofit that helps youths file similar lawsuits across the United States. They did not ask for compensation in the form of money; instead, they asked the court to find unconstitutional a provision in the Montana Environmental Policy Act that prohibited state agencies and policy makers from considering the climate impacts of potential projects that might affect the environment.

Although almost every state has environmental provisions in its constitution, Montana is 1 of 6 states that explicitly lists a right to a quality environment. Of those 6 states, 4 treat this right as judicially enforceable; Montana is one of them and has a well-established body of case law to support it (Figure).5

FIGURE. States With a Right to Quality Environment

Figure. States With a Right to Quality Environment5

The Ruling

On August 14, District Court Judge Kathy Seeley ruled in the plaintiffs’ favor. In the 103-page written opinion, Judge Seeley stated that although the state’s inaction on climate change is not enough to constitute an issue,

“[The plaintiffs’] mental health injuries stemming from the effects of climate change on Montana’s environment, feelings like loss, despair, and anxiety, are cognizable injuries.”6

A spokesperson for Montana Attorney General Austin Knudsen, Emily Flower, declared the ruling “absurd,” and the entire case a “taxpayer-funded publicity stunt.” Flower also said the office plans to appeal.7

On the other hand, Yale legal experts are calling the ruling a “milestone in climate change law,” and likely to encourage others who seek to force climate action via the legal system.8

Other Climate Well-Being Cases

Snapshot of Psychiatric Impact

Snapshot of Psychiatric Impact

According to a report from the United Nations, climate lawsuits have exponentially increased in the past 5 years, from 884 in 2017 to 2180 in 2022.9 Here are some of which to take note.

Juliana v United States. In 2015, 21 youths filed their case against the government, asserting that “through the government’s affirmative actions that cause climate change, it has violated the youngest generation’s constitutional rights to life, liberty, and property, as well as failed to protect essential public trust resources.” As of June 1, 2023, the case is on the path to trial.10 Van Susteren will serve as an expert witness in this trial as well.11

Natalie R. v State of Utah. In March 2022, 7 youths filed a case arguing that Utah, through its policies promoting the development of fossil fuels, is contributing to the dangerous air quality and other climate crisis impacts, and harming the youths. Like Held v Montana, the plaintiffs also argue the state is violating their state constitutional rights to life, health, and safety. Oral arguments before the Utah Supreme Court are expected in late 2023.12

Layla H. v Commonwealth of Virginia. In February 2022, 12 Virginia youths filed a case that states the commonwealth’s historic and ongoing permitting of fossil fuels causes and contributes to the climate crisis, and once again, violates the plaintiffs’ constitutional rights. Furthermore, they claim that Virginia has violated its public trust duty to protect elements of the public domain, including atmosphere. Additionally, by relying on fossil fuels as its main energy source, the state is exacerbating climate change via greenhouse gas emissions. Parties will be notified of dates to appear for oral argument by the Court of Appeals soon.13

Concluding Thoughts

As research has shown, the effects of climate change will exacerbate social determinants of health and lead to increased risk of neurological and psychiatric problems.14 Psychiatry is uniquely posed to help not only the environment, but the youths of this country, as this landmark case demonstrated.


1. Historic climate trial: Held v. State of Montana. Youth v. Gov. Accessed September 5, 2023.

2. The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry. American Psychiatric Association. 2013. Accessed September 5, 2023.

3. Ursano RJ, Morganstein JC, Cooper R. Position statement on mental health and climate change. March 2017. Accessed September 5, 2023.

4. Section 3: Inalienable rights. Montana Code Annotated 2021. Accessed September 5, 2023.

5. Dernback JC. The environmental rights provisions of U.S. state constitutions: a comparative analysis. Environmental Law Before the Courts. April 13, 2023. Accessed September 5, 2023.

6. Montana First Judicial District Court Lewis and Clark County; Rikki Held v State of Montana. Mont CDV-2020-307 (Mont 2023). Accessed September 5, 2023.

7. Rott N, Bayram S. Montana youth climate ruling could set precedent for future climate litigation. August 23, 2023. Accessed September 5, 2023.

8. Yale experts explain climate lawsuits. Yale Sustainability. August 16, 2023. Accessed September 5, 2023.

9. Global climate litigation report: 2023 status review. United Nations Environment Programme; Columbia Law School. Accessed September 5, 2023.

10. Juliana v. US Government. Youth v. Gov. Accessed September 5, 2023.

11. Expert report of Lise Van Susteren, M.D. Kelsey Cascadia Rose Juliana; Xiuhtezcatl Tonatiuh M., through his Guardian Tamara Roske-Martinez v The United States of America; Donald Trump, in his official capacity as President of the United States. Accessed September 5, 2023.

12. Natale R. v. State of Utah. Youth v. Gov. Accessed September 5, 2023.

13. Layla H. v. Commonwealth of Virginia. Youth v. Gov. Accessed September 5, 2023.

14. Climate change and mental health connections. American Psychiatric Association. Accessed May 2023. September 5, 2023.

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