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.
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Part one 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.1 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.2 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.
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.3 She and Australian cultural researcher Lesley Head4 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.5 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 AMA Journal of Ethics. 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.6
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.
Disavowal. 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.
My children’s future. Parents can be especially distressed over climate and may require extra support.7 Findings suggest that parents may have a psychological need to maintain the illusion of an omnipotent ability to keep their children safe.8,9 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.
The climate denier. 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.”2 We all tend to filter reality through our preexisting beliefs, a process known as confirmation bias.10 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.11 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.12
1. Lewis J. In the room with climate anxiety, part 1. Psychiatric Times. 2018;35(11):1-2.
2. 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.
3. Randall R. Loss and climate change: the cost of parallel narratives. Ecopsychol. 2009;1:118-129.
4. Head L. Hope and Grief in the Anthropocene: Re-Conceptualising Human-Nature Relations. London: Routledge; 2016.
5. Weintrobe S, Ed. The difficult problem of anxiety in thinking about climate change. Engaging with Climate Change: Psychoanalytic and Interdisciplinary Perspectives. London: Routledge; 2013: 33-47.
6. Alame D, Truog RD. How should clinicians weigh the benefits and harms of discussing politicized topics that influence their individual patients’ health? AMA J Ethics. 2017;19:1174-1182.
7. Ekholm S, Olofsson A. Parenthood and worrying about climate change: the limitations of previous approaches. Risk Analysis. 2017;37:305-314.
8. Benedek T. Parenthood as a developmental phase. J Am Psychoanal Assoc. 1959;7:389-417.
9. Hugger L. Mourning the loss of the idealized child. J Infant Child Adolesc Psychother. 2009;8:124-136.
10. Whitmarsh LE. Scepticism and uncertainty about climate change: dimensions, determinants and change over time. Global Environ Change. 2011;21:690-700.
11. McIntosh S. Overcoming Polarization by Evolving Both Right and Left: How Polarity Theory Provides a Path to Political Progress. Boulder: Institute for Cultural Evolution; 2016.
12. 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.