Psychiatry’s Climate Reckoning: Time Is Now

Climate change is happening now, and it is overwhelming. Wildfires, floods, and destructive storms are now chronic and pervasive. They have predictable impacts of markedly elevated population-level trauma, depression, suicide, and substance misuse. Emerging research on the distress caused by anticipatory dread and awareness of this unfolding planetary-sized threat to the future indicates these harms are increasing and disabling.

The climate future is not far off or far away. It is here and now, in the COVID-19 pandemic, rooted in unsustainable food and wildlife management practices that will yield more, and perhaps worse, pandemics. COVID-19 is a dress rehearsal for what planetary-sized, ongoing, disruptive system failures and loss resemble and how quickly they erode the foundational socio-emotional fabric upon which societies rise or fall in the face of such challenges. In the early months of the pandemic, epidemiological surveys revealed elevation of depression and anxiety three to four times over baseline. These numbers have since worsened.

Even now, enough environmental changes are literally baked into the atmosphere that our social climate—our social ties, emotional capacity and strength, our collective efficacy—are inexorably compromised and, at the same time, more sorely needed. Climate change demands all sectors of society to step up now to behave differently, including our profession. We face a long-avoided reckoning with the vanishing connection between what psychiatrists do and what society needs.

The questions for psychiatry are: What are we doing to augment and heal the social climate? Why and how should we build community and civic resilience? How can we stem escalating levels of collective trauma, the results of the relentless psychological terrorism of structural racism, violence, and extractive and predatory inequality? How do we address the psychic tidal wave to come from being woefully unprepared to face and endure the accelerating and literal loss of earth as our home?

Our prevailing paradigms of knowledge and practice are not adequate to these necessary tasks. We are more focused inward than outward through a narrowing circle of interest in genome, neuroscience, marginally distinguishable medications, and the nuance of diagnostic labels. These foci revolve around a basic pattern of waiting for people battered by the world to come to us for brief visits when their resources, insurance, and wait times allow. Our system of care is perfectly designed to avoid seriously taking on these challenges through what we do: study and prioritize. It is time to update the paradigm, to move from “ego” to “eco.”

What does that look like? Let us go to them and connect what psychiatrists know and do with the contexts of people’s lives. This can happen through social innovation: Becoming change agents who put more of the work and skills for care, prevention, and promotion (noncompeting aims) in the hands of others, such as grassroots groups, teachers, community health workers, peers, and clergy.

This approach—what the World Health Organization calls “task-sharing”—provides a high-value role for mental health professionals to be coaches and capacity builders for others in their uptake and use of an array of well-studied, layperson–provided counseling, recovery, prevention, and promotion skills and interventions and to provide backup when more formal care is needed.

Let’s start within the fabric and spaces–the ecology–of the community. Then, as necessary, we can use more specialized clinical toolkits. Let’s partner in participatory, community co-created and driven “upstream” forms of help and resilience by enabling and collaborating with the credible and familiar people and places in those communities. When I was deputy health commissioner in New York City, we deeply pursued this approach. We joined clinicians with nonclinical grassroots and social service organizations, such as job training programs, day care centers, community centers, justice-equity groups, and houses of worship, in this effort. Psychiatrists and mental health professionals who joined in these partnerships and worked to enhance the skills of others and follow their lead on what people needed and how they could best be reached were struck with how rewarding and liberating it was to forge closer connections regarding the social determinants and structural contexts that shape risks and outcomes.

The psychosocial demands of the climate crisis also call for an examination of how our clinical formulations and treatments can reinforce counterproductive extracting, hyperindividuating, monetizing, producing, consuming, and commodifying self-identities and values. Instead, we can collectively assert and individually apply policies and methods that prioritize and build nurturing, regenerating, reciprocating, preserving, caring, critical consciousness raising, and prosocial modes of psychological growth across the lifespan.

We are all psychologically unprepared to face the accelerating existential crisis of climate and ecological change that will further deepen other destructive fault lines in our society. The future will extract enormous social and emotional costs and suffering and require enormous social and emotional strengths to combat. We must sound that alarm and put our own house in order.

Professional culture, knowledge, skills, partnerships, and payment need to adapt. I have been facilitating a collaboration of national mental health professional, health, and climate organizations (including APA), called the Social Climate Leadership Group. This group has recommended steps toward that change. The House Select Committee on the Climate Crisis endorsed a task-sharing approach and referred further consideration of its translation into policy to the Energy and Commerce Committee.

The Biden administration will pursue a broad, intersectional approach to climate change. A robust and sustainable social “software” is as crucial to success on climate and the human future as is transformed “hardware” of energy, transportation, or food systems. APA should seize the opportunity to make that case and prepare its members to be part of putting it to work. It is time to consistently include mental health in climate policymaking, as reflected in the recent decision to create the APA Committee on Climate Change and Mental Health. APA must help transition the profession toward that end.

This is very daunting. But new paths are possible if we decide to forge them and urgently and unapologetically lead on the overdue revitalization of what our professional community can bring to this critical phase of life on earth. ■