Is the climate crisis creating a mental health crisis?

A growing network of psychiatrists is tackling a mental health crisis spurred by climate change.

Psychiatrist Dr Lise Van Susteren did not expect to be allowed into a public hearing of the Federal Energy Regulatory Commission (FERC), the agency responsible for regulating interstate energy transmission across the United States.

She had interrupted a FERC meeting before, which typically results in being barred from entering again. But to her surprise, she was allowed into the late February hearing, along with activists from Beyond Extreme Energy, a collective fighting fossil fuel extraction and calling for an overhaul of FERC to enable the quick transition to renewable energy sources.

Van Susteren had nothing prepared, but she knew the drill: she found a seat in the middle of a packed row so it would take longer for security to get to her. "Like a crowded aeroplane, the more people that are on either side of you, the more time you have," she explained.

The commission was in the middle of considering a proposal for a liquefied natural gas (LNG) terminal and 230-mile (370-km) pipeline in southwest Oregon - until it was interrupted. Following six other activists, Van Susteren stood up to speak about climate change's far-ranging harm to mental health, including the patients who turn up at her office in Washington, DC, struggling to cope with a quickly warming world.

Van Susteren warned the commissioners that by approving the construction of the sprawling pipeline, they were fuelling this mental health crisis.

It is an issue that she has been studying for more than a decade now. In 2012, she co-authored one of the earliest major reports (PDF) on climate change and mental health, published by the National Wildlife Federation.

"We may not currently be thinking about how heavy the toll on our psyche will be, but, before long, we will know only too well," she wrote in the report.

Yet this evidence-backed warning has gone largely unheeded, especially by those controlling the world's energy future, which is why Van Susteren is still fighting for it to be heard.

It did not take too long - about a minute, Van Susteren estimated - for the security guards to press through the crowded row and escort her from the room. "Talk about surreal," Van Susteren said, recalling the experience. "You can hardly believe that you are there, right at the confrontation between good and evil. And I don't mean 'good' in a self-serving sense. I mean, in the sense of life versus our demise."

The commissioners did not listen to the warnings of Van Susteren and other activists: in March, FERC approved the pipeline and LNG facility, a decision that will allow more greenhouse gases to be emitted into a world overwhelmed by enormous wildfires, prolonged stretches of drought, relentless hurricanes, thinning permafrost and the current global pandemic - a world unprepared for even more unscalable loss of life.

Mobilising psychiatrists

Van Susteren is far from the only psychiatrist warning of the anxiety and suffering resulting from living on an Earth that is being destroyed. She is a founding member of a nonprofit and all-volunteer network of psychiatrists, known as the Climate Psychiatry Alliance (CPA), which share a common goal, Van Susteren explained, of "pointing out the mental health tragedy that awaits as a result of climate disruption and how to build resilience".

In 2014, Van Susteren was searching for other mental health professionals who were strategising around the climate crisis, but could not find any groups dedicated to this in the US. So, she went to England and met with members of the Climate Psychology Alliance in the United Kingdom, which left her determined to try to form a similar group back in the US.

"I came back and was continuing to look for allies here and they started popping up kind of randomly," she explained.

A web of climate-focused psychiatrists was beginning to come together, many having already met through professional affiliations. So, in early 2017, they decided to have an initial phone call to work out how they could organise for broader change, particularly within their own field.

In just a few years, the handful of psychiatrists ballooned to more than 400 across the US. Every two weeks, they conduct a meeting by phone, which begins with a meditation, prayer, or thought to establish a sense of community and trust.

The network is premised on the idea that psychiatrists can play a unique role in helping people emotionally navigate the climate crisis, while also communicating its health risks, Van Susteren explained. "We're good at talking people off the ledge who are very anxious. We're also good at finding a silver lining. Even when things are dark, we understand science and urgency."

Along with mobilising psychiatrists to address climate change, the CPA has been pushing the American Psychiatric Association (APA), the largest professional body of psychiatrists, to take a stronger stance on the climate crisis.

'A race against time'

But there is still a long way to go. Many psychiatrists remain untrained in how to talk about climate change, recognise its far-reaching, ongoing devastation, and prepare for a growing surge of people in need of their services.

"It's really a race against time to get psychiatry where it needs to be," said Dr Elizabeth Haase, a founding member of the CPA and a Nevada-based psychiatrist. "No one is really prepared for the magnitude that is predicted to occur, and with things going much faster than we thought they were going to go, that impact is coming much sooner than we thought."

It can be hard to recognise the scope of this tragedy, explained Haase, because the mental health effects of climate change show up in so many different layers of a person's life. Rising temperatures and heatwaves can be devastating, including being linked to increased rates of suicide and violence. The social and economic upheaval of climate change can also cause a range of psychological harm, from acute stress to more chronic responses to trauma.

"Because we're having more extreme weather, more people are living in areas with food scarcity, more people are homeless, more people are financially struggling," said Haase.

Climate disasters, like intensified hurricanes and wildfires, can lead to mental health consequences that linger for years. As parts of the world become nearly uninhabitable, more people will become climate refugees, forced to migrate and experience the pain of leaving one's home.

Communities 'on edge'

An emotional response to the climate crisis can permeate whole communities.

Dr Robin Cooper, another founding member of the CPA and an assistant professor of clinical psychiatry at the University of California San Francisco, described the emotional distress felt in her community from the wildfires of recent years.

"The community was just on edge," said Cooper, recalling the screen of smoke that fell over the Bay Area during the wildfires in 2018. "Those are the moments where the absolute anxiety of what we are doing to the world just emerges."

Cooper recalls one patient who came into her office in an extreme state of anxiety.

"[She was] breathing heavily, hyperventilating, agitated, her thought patterns were scattered and talking about how we had destroyed the Earth," said Cooper. In a matter of minutes, she began asking "Where can I go?" until it dawned on her that there was no place she could move that would fully solve the continuing, worsening threat of climate change. "In a moment of extraordinary grief and powerlessness, she wept and said, 'I should never have had my son,'" said Cooper.

Such an emotional response to the climate crisis should not be pathologised, Cooper explained, given that it is a normal reaction to a profoundly disturbed planet - and one that is becoming more common.

As more disruptive weather patterns intensify, this grieving, anxiety and suffering is expected to worsen. The immediate future is already looking grim: the oceans, which are now at the warmest temperature on record, are predicted to spur a year of colossal hurricanes and wildfires.

Not only does the CPA aim to help people face this complex reality, but also to have the courage to build a new, better long-term reality.

"We can positively frame this crisis," reads a statement from the CPA. "The antidote to hopelessness, cynicism and magical thinking is awareness of our responsibility and active engagement in this crucial work with others at this crucial time."

'First do no harm'

Early on, the CPA decided to take on a goal that could create a ripple effect through its field: encouraging the American Psychiatric Association (APA), which has 38,800 members, to divest its investment portfolio from fossil fuels. By cutting off the APA's most direct contributions to the climate crisis, it would send a strong message to many psychiatrists.

"The APA has a wide membership" said Cooper. "So, it is the most powerful way we can influence and educate psychiatrists."

Fossil fuel divestment was a tall demand, especially considering it took the APA until 2017 to publicly acknowledge the threat the climate crisis poses to mental health. Yet there was precedent for it: the British Medical Association, the Canadian Medical Association, the World Health Organization and the American Medical Association had all adopted policies to divest.

So, the CPA reached out to Dr Todd Sack, who drafted the American Medical Association's resolution to divest from fossil fuels, and asked him for advice on how they could follow suit. This effort soon resulted in an action paper that clearly laid out why the APA has a responsibility to divest. The paper points to the fact that the "health and mental health impacts of climate change fall disproportionately upon the mentally ill". Citing the Hippocratic oath to "first do no harm," the paper argues that psychiatrists have a responsibility to "minimise fossil fuel consumption and strive to influence the healthcare institutions in which we practise," to curb this worsening mental health crisis.

In early November 2018, Dr James Fleming, a Missouri-based psychiatrist, representative to the APA, and founding member of the CPA, stood before the assembly of the APA and urged it to divest. He read a plea written by Van Susteren. "Folks, we cannot mess this up. We do not have time. Be under no illusions, the climate-aware generation of kids are beside themselves - scared, angry, grief-stricken," said Fleming. "They are experiencing inaction as assault."

Just a month before, the Intergovernmental Panel on Climate Change released a groundbreaking report, warning of ecosystems collapsing, the disruption of food systems, population displacement and a rising death toll from extreme weather that can only be averted through "rapid and unprecedented action". This timing may have made the assembly particularly receptive to divestment, but in any case, the action paper passed with a 61 percent majority, which Cooper described in the Psychiatric Times as "a result stunning for both the margin of victory and speed with which it moved through the Assembly's usually slow process".

In October 2019, the APA's Board of Trustees took the first step of enacting the paper's goal by blocking all future direct investments in fossil fuels. The APA's Investment Oversight Committee decided to regularly review the APA's investment portfolio to screen for ways to completely divest from fossil fuels. Currently, less than five percent of its investment portfolio is in companies that derive most of their incomes from fossil fuels, according to Fleming.

Shifting attitudes

The divestment effort also helps spread awareness to all of the APA's members on the mental health effects of climate change, connecting to a broader CPA aim of communicating this ever-present connection.

"By articulating the connection between health and climate, it gets more people motivated to recognise that they individually and, more importantly, collectively need to do something," said Dr David Pollack, a community-focused psychiatrist based in Oregon and another founding member of the CPA.

To this end, the CPA members also frequently give presentations on the mental health dimensions of climate change at APA meetings and write about the topic in popular trade journals, like The Psychiatric Times. They have been the driving force behind other APA action papers related to the climate crisis, including a resolution to distribute curricula on mental health and climate change in medical schools, universities, and fellowships. This will build on a growing push for medical schools to integrate climate change into the curriculum.

There is already a noticeable shift in psychiatrists' attitudes. "When we first started psychiatrists would say, 'Climate change is a big issue, but it really doesn't affect us. It's not in our domain,'" said Cooper. "Now that has completely changed."

Recently, the CPA has been working on making this knowledge more widely accessible. It has joined forces with the Climate Psychology Alliance in the UK and the Climate Psychology Alliance North America, which Van Susteren also helped establish, to develop training on mental health and climate change. Modelled on Al Gore's The Climate Reality Project training, it will involve a set of slideshows that can be accessed from anywhere and intended for a variety of uses, from how to bring an awareness of climate change into a clinical setting to engaging with lawmakers in pushing for mental health policies.

Climate-aware psychiatry

For mental health professionals already schooled in climate change, the CPA and Climate Psychology Alliance North America have developed a shared referral list so patients can more easily locate a therapist with this background.

So, what makes a climate-aware therapist?

One of the first steps any mental health professional can take is just being aware of the mental health risks of climate change. This way, they can better inform their patients of any interventions to take, such as in the event of a heatwave.

"I think it's incumbent upon us to say before summer season, 'you know we are having more and more periods of extreme heat and there are ways that you need to know how to protect yourself and be aware of early signs of trouble,'" said Cooper.

Therapists should also really grapple with this crisis themselves, explained Dr Janet Lewis, a psychiatrist in New York and another founding member of the CPA. "It really has to be personally digested in order to be able to help others with it," said Lewis. "It's the experience of mental health professionals in general that patients tend to talk about what the therapist is ready to hear."

There are patterns in which "climate anxiety," an umbrella term used to describe a range of psychological responses to the climate crisis, shows up clinically. For instance, Lewis explained, as patients grapple with the climate crisis, they often vacillate between poles of emotions and thought, such as between extreme hope and despair. A therapist can help patients navigate these extremes to find ways to move forward and meaningfully live with the reality of climate change.

Unlike many forms of psychological harm, the threat of climate crisis does not disappear. This can produce in patients "continuous traumatic stress," a term that Van Susteren coined to describe a psychological response that mirrors post-traumatic stress in many ways, but the primary preoccupation is with the future. It is a response that has also been observed in nurses and doctors treating patients infected with COVID-19.

In the longer-term, therapists may be able to help patients experience "post-traumatic growth". This can happen, Haase explained, when "through a profitable, deep reflection and grief about what has been lost, people choose to make some meaningful changes and become typically more connected to other people". She pointed to how reconnecting with the natural world can be a way to facilitate this growth, particularly when the source of trauma comes from nature.

Systemic oppression

Dr Carissa Caban-Aleman, a Miami-based psychiatrist and founding member of the CPA, believes psychiatrists also need to recognise how the consequences of systemic oppression make people more vulnerable to climate change. For example, in Puerto Rico, the effects of Hurricane Maria were compounded by what Caban-Aleman described as "the chronic aggression of colonialism and a lot of economic and political factors," such as laws imposed on Puerto Rico by the US that made the island particularly vulnerable to corporate profiteers swooping in after the storm.

While Puerto Rico's recovery has been rocky and slow, Caban-Aleman also points to ways the community has come together to build long-lasting resilience, such as through solar and agricultural cooperatives. "It's really an option to see in real life how transformational and social resilience can work," she said.

Therapists can support these recovery efforts by first building trust within a community. In her work with the nonprofit mental health organisation CrearConSalud, Caban-Aleman led community-based mental health workshops. At first, this involved "just giving emotional support to people, but more than anything, it was helping them with their basic needs," said Caban-Aleman.

Caban-Aleman also frequently engages in environmental justice activism in Miami, which helps her better understand and provide for the mental health needs of that community. "The best way that I get to thoroughly insert myself in an environmental justice effort is by being part of it," she explained. "If you are trying to help from the point of view of being in the faculty of a university or in a clinic as a medical provider, but you're not really visible in the community that you're trying to impact, it's really hard to get far with that effort."

Long-term resilience to the climate crisis might look like therapists, patients and activists all working together to address the climate crisis. This engagement in collective action, while at times exhausting, can also be profoundly healing. "As we confront climate change, just like with the coronavirus pandemic," said Dr Janet Lewis, "we have to shift to an appreciation of this whole realm of collective action and responsibility."