Hello, it's such a privilege to be moderating this panel, which is titled climate change as a socio political determinant of mental health. This panel will discuss how to understand the links between climate change and mental health, and how you can address it as a clinician and advocate. You will be hearing from three national leaders on the topic of climate change and mental health. As you listen to the presentations, feel free to enter any questions or comments into the chat function. We'll have time for q amp a at the end of the session. Dr. Elizabeth Haas is the medical director of psychiatry at Carson Tahoe Regional Medical Center and associate clinical professor of psychiatry at the University of Nevada School of Medicine in Reno, Nevada. She serves in several leadership roles on climate mental health including chair of the APA committee on climate and mental health and gap committee on climate and mental health and steering committee for the nonprofit climate psychiatry Alliance. Dr. David Pollack is professor emeritus for public policy in the Department of psychiatry at Oregon Health and Science University. His activities include teaching, writing and consulting on policy systems and healthcare leadership issues. Since retiring, he is exclusively focused on addressing the mental health and public health impacts of the climate crisis. He is a founding member of the climate psychiatry Alliance, and has been pivotal in many of the climate related policy and educational initiatives conducted through the APA, OHSU and other health related organizations. Dr. Robin Cooper is a San Francisco psychiatrist, who has had a private practice for nearly 40 years, and as an associate clinical professor of medicine Department of psychiatry and behavioral sciences at the University of California San Francisco, where she has worn many different hats over her career, both as educator and supervisor with psychiatric residents and medical students. She is a co founder and president of climate psychiatry Alliance, a group dedicated to understanding education and advocacy about the specific impact of climate change on mental health. In addition, she is an active member in a number of organizations, addressing the interface of climate change and health, both at the University of California San Francisco Medical Center locally in our community and nationally. Hi, my name is Dr. Beth has my talk today is called all roads lead to Rome socio political pathways to poor climate mental health on a planet in decline. And what I'm really going to do is take a climate informant look climate informed look at some case examples for both the climate and socio political determinants of mental health in the cases. I'm the chair of the APA committee on climate and mental health and work with the climate psychiatry Alliance and the gap community on climate as well. I have no disclosures. So we're going to start with a clinical informed. Sorry, let me start that over. So, we're going to start by doing a climate informed clinical assessment of a number of cases. And for each of these cases we will ask, what are the emotional attitudes, both those internalized from our culture and our American values, as well as the emotional attitudes due to personal psychology around change, loss, growth, loneliness connection and achievement that have contributed to the decisions and the life outcomes that are in the cases. What are the social factors and the public policies that have shaped the opportunities and decisions that were available to each of the people that we're going to talk about how did climate change magnify the mental health risks for each person biologically environmentally and socially, turning a winding life trajectory towards a worse mental health outcome. This is a 38 Mexican American 38 year old Mexican American woman from Texas who presents with depression, related to the suicide of her eldest son, a promising football player who hung himself at the peak of the training season. When you begin to think about this case, how will the larger community view the suicide of Christie son, the white community, the other football players, the religious community, the Hispanic community. How will suicide reverberate through the life of the community of Christie in her marriage, and in the life of her son's brothers in the coming years. Do you know about the relationship between heat, air pollution and suicide. Do you know the data on suicidal ideation and young people concerned about climate change. Christie was raised in the San Joaquin Valley with several siblings, losing her mother to leukemia at an early age. What's the most likely environmental influence on her mother's early cancer and death. What are Christie's own environmental risks from growing up in this area. What climate change environmental risks might come to your mind a little bit less quickly than pesticides. And what does it mean to say that Christie has a toxic legacy. How do such legacies create an ecological debt in the climate justice work that we all must do to take care of Christie, her family, and others who carry this epigenetic burden. Christie dropped out of college after her mother's death and had several sons moving to Nevada. Consider this simple sentence from a socio political standpoint. And from an emotional standpoint. How might early maternal loss of shaped Christie's decisions. How might early maternal loss shape Christie's response now to her son's suicide. From a climate perspective for all of us. How will our early losses help or harm our ability to respond to climate related changes and our grief about them in the natural environment. How does the college dropout rate for women like Christie, or worsen our climate outcomes as a global and local community. How can American values are reflected in Christie's decisions that work against our climate adaptation, and her long term health and mental health. How can we move from a counter phobic triumph oriented culture to one that finds meaning without this psychology of overcoming. Christie's boys did well in school in Nevada, but mounting anti immigrants and led them to be increasingly bullied. Do you know how climate change will influence the numbers of immigrants exactly like the real numbers. Do you know how climate change will affect interpersonal and social violence. Given this, how is climate change likely to impact the psychological development of immigrant children like Christie's in this country. How can we work with patients to make them better able to imagine themselves as global citizens with shared goals and resources in order to prevent these violent outcomes and improve the mental health of children. How can psychiatrists address real patient fears of communities overrun with climate refugees, while also working to decrease anti immigrant violence. What would you say to patients to make this happen. Christie's father then lost his job because he was underskilled for the technological demands of servicing electric cars at his automotive workplace. Consider this from a socio political standpoint and climate standpoint. What does it mean to make a just transition to a clean economy. What are the implications of failure to do this for the psychology of fathers and sons, and long term how might this job loss of contributed emotionally to Christie's son suicide. Psychiatrists ensure that address transition is built into our vocational rehabilitation programs. How can we work on the psychological traits and experiences that will help people change careers and try something new. What values and emotional traumas make us more resistant to change. And how specifically would you work with Christie's husband on his capacity to adapt to a new clean energy economy. When he saw it to move to a new school district, they were priced out by families fleeing the fires in California tax policy and job growth favorite Texas so they move there. How does the way we think about lifestyle leave us vulnerable to climate change. For example, how did common ideas of the good life, lead people to entrapment by California fires, like the couple on the left. She died in his arms in the swimming pool of their dream retirement home in the California foothills. How does Christie's move to Texas, increase her mental health vulnerability from both the social and the climate perspective. What is your duty to warn when you see a patient making uninformed or risky decisions about their social determinants of health. Where will Americans be likely to move as climate changes. And what policies will ensure that all Americans have equal access to housing and land as increasing number of people become climate refugees. Should psychiatrists be out advocating for policies that equalize land based social determinants of health. In Texas Christie's husband became increasingly allied with a new church with autocratic style in terms of male dominance, and eventually he became so abusive and bizarre that his doctor did a medical workup, which surprisingly revealed B1 and B6 deficiency. While her husband was beating her Christie needed him for insurance so she had lymphoma in her 20s, linked to her environmental exposures as a child, and a pre existing condition. How is climate vulnerability predicted to lead to a rise in autocratic leadership, seen in this church and seen in our country. How will this grow more because of climate. Should her husband possibly have developed diamond and niacin deficiency, because of climate change in a nation with plentiful food stores. And what climate changes are likely to lead to an increase in domestic violence, which will worsen the situation for Christian Texas. Christie's emotional resources are now strained and her family is few and far away. She envies her peers whose mothers are there in support. Working hard to overcome anti Mexican sentiment to lift his mother out of her low mood and escape the bullying and problems at home. Christie's son throws himself into football, scoring one of the first touchdowns of the season. Christie's son is petite with little hope of a football career after high school. How is his style of resilience, clinging to something that idealizes a single dominant culture, as we do in our failure to confront climate realities, different than the kind of resilience, we need to make sustainable societal change and different from the kind he needed for long term success success as a short Hispanic male. Models for transformational processing of loss and grief, as well as communal and family healing would better help Christie's son with his father's failures and his social exclusion and better transform our society as we confront our climate and social realities. What role should psychiatrists play in this transformational work. After his touchdown, Christie's son collapsed on the field in the heat, a humiliating moment that led to more bullying at school, and led him to refuse to return to practice. A week later in the midst of a devastating heatwave, Christie could not respond to a concerning text from him due to a power grid failure. She returned early from work and found her son hanging from the rafters of their new garage. What's the relationship between heat and depression. How is an intact power grid necessary to support communication during mental health emergencies. So, if that's the case, how should psychiatrists be involved in power grid development and policy. This case speaks to the despair young people feel when they cannot influence the world around them successfully. And this is also true with climate change. What are we going to do. So that's our first case. Christie a mom with a toxic legacy and early maternal loss who loses one of her three sons to suicide in a heatwave, displaced by climate refugees from California to Texas, and suffering the consequences of extreme heat poor infrastructure and social policies that do not adequately support sustainable habitation and job retraining. As a client climate informed therapist we now turn to Elena. Elena, a 30 year old postdoctoral geologist brought in on a legal hold from her former lab. After blacking out with rage and expressing homicidal ideation to her principal investigator aimed at local authorities who are supporting a new oil pipeline, unable to find a tenured faculty position or any industry job that aligned with her values. Elena has been on leave for the summer. What is terror fury. states. Why might Elena have experienced this rage in a dissociated and overwhelming way. And how can her boss or you as her therapist respond in such a way as to direct her rage and validate her concerns. What therapeutic approaches and assumptions are likely to worsen her clinical outcome. At a policy and social determinative health level. How have funding priorities and denialism shaped our national energy security and our lack of clean new technologies such as geothermal power, which might have led to ethical employment for Elena. She rails against the duplicity of the oil company who have ignored an environmental assessment that there's no oil in the area of exploration, although she has sent it to them 17 times. How are young people like Elena responding to older generations and companies who have stymied action on climate change. How is Elena's experience harmful to the development of mature emotional capabilities, and a young adult stuck in an oppositional position. What do oil companies, or why do oil companies, invest in stranded assets in the first place. Elena's psychopathology is determined by oil exec is demonstrated by oil executives who act against the health interests of others, including their own families and stockholders. Elena has been protesting with local tribe members reporting stories of excess force by police tear gas use against small children and elders, and the death of several pets she's become attached to trampled during the protests. Attachment paradigms, what attachment paradigm is embodied in Elena's concern for native people, children and animals. How might you embed an assessment of this kind of attachment into a routine psychiatric interview and psychological assessment. What are parallel values in less climate oriented, more conservative communities around family, children and pets, and how can we leverage these to build community. Is this a question that psychiatrists should be addressing as they try to improve social determinants of health. Elena begins to cry, talking in a dissociated way about her own wish to have children and her decision to be childless to protect the planet. After assessing her risk of violence you release her with a chart diagnosis of depression unspecified. Do we have diagnoses for people like Elena. Is she even sick. How would you write a formulation of this patient that commented on her relationship to the natural environment or environmental exposures, the social and policy determinants of her mental health, the psychological relationship of the patient to the larger society and global community as a part of her core well being. What is the birthstrike movement. How are her biological reality, her social reality and the climate reality and conflict, as she enters the final years of reproductive possibility, and also career development. So this is Elena, a 30 year old postdoc in geology, enraged by the denialism of the oil industry witnessing environmental destruction and injustice and struggling with her own reproductive desires and career. We turn next to Mr. Craig. Mr. Craig is a successful entrepreneur, a 60 year old self made man who retired early to a lakefront property in Maine, and whose bipolar disorder has been easily and well controlled with lithium and propranolol for tremor. Mr. Craig comes in for his annual assessment, reporting paresthesias brain fog and diarrhea that have persisted since an episode of heat stroke on a business trip to Florida. Lithium side effects would be an obvious consideration. But how does climate change broaden this differential. What causes of cognitive dysfunction are associated with the places he lives in the places he travels to. Mr. Craig went to Florida to buy a beachfront restaurant with some minor water damage that had gone into foreclosure because of the COVID-19 pandemic. He reports he's been shaky and barely eating because of the diarrhea. He has continued energy and business smarts, snapping up several properties at bargain prices. How is the current pandemic shifted economic determinants of mental health for people who are less fortunate than Mr. Craig. How does this inform our preparation for future new infectious epidemics due to climate change. How my COVID and other infectious diseases be influencing his manic symptoms. What are the climate risks of Mr. Craig's business decisions. How does social media and capitalism for that matter, blind him to them. Would you directly advise such a patient on his climate risks to improve his long term social determinant mental health outcomes. Several months later, Mr. Craig returns severely depressed. The hurricane has completely wiped out his investments, which he had not yet insured. Several trials of antidepressants failed to remit his symptoms, and you become significantly concerned about his future well being, as he seems to be showing some really cognitive decline. As we step back from this and think as a climate informed therapist. What are the societal and emotional assumptions of well being that underlie his depression. As a result, infectious diseases are more likely with a prolonged depression in the era of climate change. If you see this treatment refractory picture. What my older generations feel and think as they witness the value system in society. They helped to create, leading to a decline in the America they built, and the suffering of future generations. What strategies would be most effective for communicating with older Americans like this about climate risks and issues. And how might you leverage Mr. Craig's depression to mobilize change in his behavior. The case of Mr. Craig, a 60 year old bipolar investor with cognitive decline after travel in Florida and Maine, who is grappling with climate change losses. Finally we turn to Dana. Dana is a 34 year old African American woman who requests a sample of Xanax for anxiety, which he has taken since her home was destroyed in a back to back Louisiana hurricanes. How might implicit racial bias influence your perception of this request. IE what if Dana were a white woman. What is the role of short term benzodiazepines in the treatment of post term disaster post disaster insomnia. What are the differences in psychological responses to single versus repeated natural disasters. Do you know the criteria for pre traumatic stress disorder. Do you know the qualities of compound disaster effects on mental health. What did you assume Dana was anxious about. What might you forget to assess for in this context, in terms of longer term mental health problems, longer terms personal issues. What aspects of Dana's identity might be part of what she's lost. And how would your work differ if you were to focus on post traumatic growth, rather than resilience in psychotherapy work with Dana. Dana has been drinking to get to sleep in a motel where the air conditioning is out, and she's not been able to find a pharmacy to refill the old prescription. She's in the second trimester of a wanted pregnancy and has her four year old son with her. How is Dana's plight absolutely paradigmatic of a disaster scenario that disaster preparation and mitigation strategies would seek to prevent. When you think about Dana's mental health. What are the health and mental health risks of drinking in an overheated motel. What are the mental health risks of benzodiazepine prescription shortages after hurricanes of heat exposure for pregnant women and their babies of alcohol or benzodiazepine withdrawal seizures on fetuses. Identity preparation strategies would prevent these risks to Dana. And what role should you play as a psychiatrist living in such a community. Dana says she lives in constant fear of what will happen next ruminating on an apocalyptic future for her son and unborn child. She lost a grandmother in the first hurricane where she was unable to be evacuated from a nursing home inadequate time. From a traditional psychiatric perspective does Dana have a psychotic depression. How would your management change if data supported that you were correct about this apocalyptic future. What countertransference attitudes towards her dire future vision. Should you watch out for what literature would you research to deepen your knowledge about the impact on mothers have an inability to protect their children from this kind of future. Do you know where that literature is. How do we move between disasters, when we know that another one will come. And what are the particular impacts of climate change on women and children in general, and women's reproductive health. So that's the case of data, a 38 year old who lost her home in consecutive hurricanes, and is struggling to fill her prescriptions and process the loss of her history as compound disasters accrue. So those are the cases. Thank you for listening to them. Now turn this over to David and Robin to elucidate more formally the social determinants of mental health in these cases. Please join us at the Climate Psychiatry Alliance and become a climate-aware therapist yourself. Thank you. So my name is David Pollack. I'm a professor emeritus for public policy at Oregon Health and Science University, and I'm going to be following Dr. Haas's brilliant presentation of cases with more of a theoretical and policy-focused discussion of social determinants and their relationship with the climate crisis. I don't have any conflicts to disclose, and I should say, though, that I'm very involved in the climate and mental health issues and climate and health issues more broadly in being a co-founder of the Climate Psychiatry Alliance, and I represent the APA and the American Association for Community Psychiatry on the steering committee of the Medical Society Consortium on Climate and Health, and I've been involved in a number of the APA's and the AACP's initiatives that relate to climate and mental health. So what are these things we're calling social determinants of health and mental health? These are the factors that impact upon health and well-being, the circumstances into which we are all born, where we grow up, where we live, where we work, how we work, how we age, and these include, among other things, the health system in which we all work and many of us have experiences in terms of getting care. This quote from Rudolf Ehrkau is very important. He's a famous cell biologist from the 19th century in Germany who said, among other things, do we not always find that the diseases of the populace are traceable to defects in society? He had a long history of identifying social factors that were relevant and how political leaders and health experts, physicians, had a lot in common in terms of the work that they did. Causative factors. These circumstances, the social determinants and the foundational factors that we're talking about, they're shaped by the distribution, generally the maldistribution, of money, power, and resources at all levels, global, national, and local levels, which are themselves influenced by policy choices and the prevailing social norms. Then we think about the causes of the causes. Well, if we think that these risk factors are the precursors of disease, then the environmental and the contextual factors that precede or shape these risk factors are the causes of the causes and therefore amplify or diminish the prevalence and the incidence of various health conditions. As you can see, I've taken a lot of this material from the work of my colleagues, Michael Compton and Ruth Shim, whose brilliant book, The Social Determinants of Mental Health, published by Abbey, came out in 2015. This is a very important slide. It really distills a lot of what we're talking about. It can give you some way to categorize some of the issues that were embedded in the cases that Dr. Haas presented. If you look at the bottom, public policies and social norms are the foundation upon which all of the rest of this rests. The public policies that have to do with laws and ordinances, et cetera, and social policies that are based on popular opinion and biases and the prevailing ethos in a community, both have tremendous impact on whether or not fair or unfair or just or unjust opportunities are distributed, how power, empowerment, voice, access to resources, et cetera, is distributed in a community, which leads to the emergence of a number of factors, all of which I'm going to describe here very briefly, that we call the social determinants of health and mental health. The adverse features of the built environment, homelessness and poor housing, access to housing and housing instability, low education, poor education quality and educational inequality and access to educational resources, adverse early child experiences, childhood maltreatment, and I think we can add to that the kind of trauma that Dr. Haas is describing that adults and youth are also experiencing beyond childhood in relation to the disasters that we're being exposed to, neighborhood disorders, disarray, disconnection, food insecurity, poor dietary quality and access to food, unemployment, underemployment, job insecurity, discrimination and social exclusion and social isolation, racism in particular, exposure to air, water and soil pollution and exposure to the impacts of global climate change. These are two factors that Drs. Compton and Shim have added to the list that they had in their original publication, but are quite relevant. Poor or unequal access to transportation, poverty, income inequality and wealth inequality, exposure to conflict, violent shootings, war, migration, et cetera, including domestic violence, exposure, as I said, to the impacts of global climate change, which we'll talk about more, poor or unequal access to insurance or health care, poverty at the community level and concentrated neighborhood poverty, the disparities that are seen in different communities that manifest, for example, in greater or lesser tree cover in a community that might lead to more urban heat islands, interaction and involvement with the criminal justice system. So all of these factors by themselves, each one of them will have an impact on someone's health, but it should not be a surprise to most of you that if someone has one of these, they probably have many of the others operating in their lives. With the one exception of adverse early life experiences, there may be some people who have upper middle class families without many of the other social determinants affecting them who do have adverse childhood experiences. But in the case of the other 15, if you have one, you may have many of the others. What then happens is that these factors lead to reduced options, poor choices that people may make, behavioral risk factors, physiological stress responses and psychological stress. The outcome and endpoint is poor outcomes, poor mental health, mental illnesses, substance use disorders, morbidity, disability, physical illness and early mortality. How do you approach a patient? Many of the questions that Dr. Haas listed in her very insightful and comprehensive description of those cases could be facilitated in terms of how one approaches a patient that they're seeing. How do you deal with the people that are in your practice in the clinical settings and in the other settings that you come into contact with as a practicing or active psychiatrist or clinical specialist? The first in this acronym that I say, TAKE AIM, is to ask, then inform and then motivate. By asking, I mean use various methods, whether it's direct inquiry, intake forms, surveys, et cetera, to determine if and what the social and structural determinants are that your person that you're seeing is experiencing, what's relevant to their life and the conditions that they're experiencing, the physical and mental health conditions that they're experiencing. You inform them, educate patients individually or collectively about the risks that they are being exposed to and the ways to reduce the harms associated with those risks. Dr. Cooper will give a good example in her presentation relating to heat. Motivate people. You encourage patients to actively engage in ways to manage the key issues that may underlie those risks, but also motivating people to become more directly involved in collective and corrective actions at their community level may help people to manage some of the hopelessness and the anxiety that they may be experiencing. Environmental, climate, and social justice are all linked. These demographic, geographic, and social factors that I've described increase the vulnerability that people experience to having health and mental health effects, in particular effects of climate change. The demographic factors such as location, age, gender, socioeconomic status, health status, and disability, existing systems of oppression that operate in their communities or in their nation. The disadvantaged and vulnerable populations that we see often experience these impacts first and worst. You'll hear this term first and worst a lot when we talk about climate change and its impacts and disasters. Any efforts that we extend towards improving equity in various ways have an impact on environmental justice, whether it's human and civil rights issues, income and housing equity, food security, transportation accessibility, police accountability, healthcare access, just transitions, et cetera. These things all are relevant. The intersectionality of these issues mean that anything that one does towards improving equity in one way can contribute indeed to environmental justice. So we conclude that climate change is both affected by social determinants and is in itself a social determinant that is probably the ultimate social determinant of health and mental health. So climate change is real, it's immediate, and it threatens health in many ways. The health risks are derived primarily from the consumption of fossil fuels and large-scale animal production. These lead to increased atmospheric CO2, increased global temperatures, extreme weather events that we're seeing more and more, rising sea levels, air pollution, and other factors. And these risks lead to extreme and acute events with longer-term physical, psychological, economic, social, and political impacts. This results in a wide range of physiological and psychosocial conditions that are substantial, they're long-lasting, they're persistent. They affect those who are more vulnerable, as I've described earlier, and mainly related to the social inequities that we've mentioned, the first and worst phenomenon. This requires immediate, ongoing planning and implementation of efforts to combat acute and chronic impacts. What I'm talking about is how do we address these issues at the community and national and regional levels. It depends upon broad participation of health, public health, and mental health professionals, as we'll describe momentarily. But now there's another social determinant that is emerging, I see, and it's hopelessness. The impacts of climate change are worsened when climate denial and disavowal drives the social norms or public policies. Look what happened during the Trump administration, when he pulled out of the Paris Accords and said that climate change was a hoax. The biopsychological and psychosocial-spiritual impacts are interdependent, they're mutually reinforcing, and thus they increase the degree of suffering and disability that many people experience. These recurrent, more frequent, compounded, and cumulative harms that Dr. Haas was describing in the recurrent hurricane case may contribute to hopelessness and amotivation. This state, in and of itself, is antithetical and counterproductive to the collective and corrective actions that we must engage in at the individual or community levels to mitigate, reverse, and prevent further impacts of the climate crisis. So here comes something we're calling transformational resilience. This is derived from the work of a colleague and friend of mine, Robert Doppelt, who has done a lot of writing on transformational resilience and is the leader of a number of groups that are working on incorporating transformational resilience into public policy. We have essential responses to disasters, generally, but to climate change we're looking at the important efforts to eliminate the fossil fuels, to reduce the impacts of carbon emissions, and to prepare the human-built environment and infrastructures and natural resources to be able to withstand and adapt to climate impacts. But as Bob Doppelt points out, it's equally important, but it's unacknowledged and unaddressed generally, is the urgent need to proactively prepare individuals, families, organizations, and communities to cope with climate adversities without harming themselves or other people or the natural, social, economic, and political environments in which we exist. These adaptive efforts, also known as transformational resilience, can be catalysts to increase social, psychological, and ecological well-being. So traditional disaster recovery methods, although important, are insufficient to address this. They're usually short-term. The most harmful biopsychosocial, spiritual impacts of climate disruption and many other disasters are due to the persistent, overwhelming, toxic stresses, not just acute disasters. So when the Red Cross comes in or FEMA comes in, they help to stabilize the situation. They're gone after a few weeks or months, but the problems remain. Even if we reverse the environmental impacts of climate change, the psychological and psychosocial, spiritual impacts will persist, and data has shown that they will likely be the slowest to recover. So comprehensive, preventive, transformational resilience initiatives must be launched at the community level worldwide, not just in areas that are directly affected by these extreme, acute events. We can create and sustain what I call a good enough Mother Earth. Transformational resilience initiatives must prevent maladaptive responses by empowering all adults and youth with knowledge, skills, and attitudes to do the following, to think and act in healthy ways, even in ongoing, unhealthy circumstances, to use these adversities as transformational catalysts to both find meaning, direction, and hope in life, and to remain actively involved in constructive, pro-social, and climate solution initiatives. These skills that we're talking about that adults and youth must learn are simplified by saying they're presencing skills and purposing skills. Presencing is understanding and paying attention to the neurobiology of trauma and toxic stress, and figuring out ways to regulate one's mind and body to adapt to these stresses. Purposing is in the midst of those adversities to turn towards them rather than denying or ignoring them, and to develop post-traumatic growth and resilience skills that will build upon themselves. This requires the broad participation of community-based experts, providers of mental health and substance abuse services, trauma-informed services, and public health services, but also environmental and social justice activists, educators, faith communities, and others. And it doesn't mean that mental health and health providers need to be the leaders in these initiatives. It can really vary in community-based approaches. Another colleague of ours, Gary Belkin, has written about this, and Bob Dobbelk and others have worked on this. In particular, we now have a bill that's been written, the Resilience for All Act of 2021, that's being shopped around to a number of congressional and senate offices to be incorporated in some of the infrastructure legislation that's being worked on in the Biden administration. So I'm about to close, but I want to, in the theme of today's presentation, leave you with one last case. And then we will go on to Dr. Cooper, who will describe her responses and recommendations for the kinds of cases that Dr. Haas has presented. This patient that we're seeing in this last case shows up in the emergency room presenting with life-threatening symptoms. She's a four-and-a-half-billion-year-old female who goes by the name of Gaia, although some call her Mother Earth. She's experienced relatively good health, although she sustained and survived a few serious infections, the last of which was about 66 million years ago, so-called dinosaur extinctitis. Then about 150 years ago, she developed the onset of a fever of unknown origin. This was followed by a number of accumulating symptoms over the next hundred years, including sweating, palpitations, respiratory difficulties, and abdominal discomfort. In the last 40 years, her symptoms have progressed steadily, and she's now having much greater respiratory difficulty, worsening fever, edema, intermittent episodes of urticaria, and excessive flatulence. These progressive symptoms have coincided with the onset of self-destructive, cruel, and short-sighted behavior of some of her children, who have severely damaged their own home and livelihood in their reckless pursuit of immediate gratification and accumulation of wealth and power. In other words, social determinants of their mother's health. Her vital signs and lab findings on admission are very troubling, with markedly elevated temperature, fluid overload, electrolyte imbalance, dramatic alteration of her gut and skin microbiome, onset of septicemia, lower pH, and markedly elevated CO2. Her mental status examination reveals a mature, pleasant, and loving woman who's quite distressed, with extremely depressed mood, and some suicidal ideation alternating with denial of illness and manic-like symptoms. She's being admitted to the ICU for further evaluation. Our patient, Mother Earth, reflects the situation we all face. Human-caused climate change is threatening the health of the planet and all its inhabitants. Continued dependence upon fossil fuels and large-scale animal agriculture create increased greenhouse gases, resulting in global warming. These health threats are urgent and extensive. They aggravate existing medical conditions and create new problems. The health impacts range from mild and transient to severe, chronic, and life-threatening. And as I hope we've demonstrated, the social determinants are very important factors in the development and this level of severity of this and the other cases that Dr. Haas described. So we see ourselves as in a position to take care of this patient and the other patients that have been described, whether we do it through our physical medicine approaches or psychotherapeutic skills. Now I'll stop and turn things over to Dr. Cooper. Hello, my name is Robin Cooper, and I have a associate clinical professor position at the Department of Psychiatry and Behavioral Health Sciences at the University of California, San Francisco. And I'm a co-founder and on the steering committee of Climate Psychiatry Alliance with David Pollack and Beth Haas here and many others. And just as a personal aside, I am, I'm probably inclined temperamentally to think about action in what we do. So that will be what I'm addressing today. I have no financial conflicts of interest to report. So we've heard these grueling stories that Beth Haas has talked about, an incredible richness as she's described these cases. And David Pollack has set the stage as he's addressed the social determinants. Now, I want to turn our attention to what we do. The urgent need to respond to act now to make a difference in the world that we are going to exist in for ourselves and our grandchildren about climate chaos. My picture here, the jigsaw puzzle indicates that there is no single solution, that there are many solutions and that these all fit together in a way that joined together in a complex picture, but not all of what we do has an equal impact. And I'm going to particularly say that the role of psychiatrists in engaging in political and policy advocacy is essential since we must address the underlying causes, those social determinants that have created this situation and that this may be a new and slightly uncomfortable position for psychiatrists or mental health professionals who see their roles primarily within the consulting room, but that is not enough. I suggest this is the part of a physician's role. Now, I want us, people, the cases that Beth has talked about show that people are face the problems in their lives with great attempts to manage the stresses, but that these people have been caught in a web which climate change has only aggravated and exaggerated. And that climate change must be considered a risk and inequity multiplier with the wealthy doing better, those going up and people with less resources having the greatest impact. Now, if we're going to understand some of the ways that we intervene, it's important to have a conceptual framework about the issues that are particularly vulnerable. Exposure represents the degree to which someone is exposed to a particular climate event. Sensitivity represents the degree to which a community or individual is affected by that exposure. And adaptive capability is the degree to which a community or individual can prepare or recover from that event. These are all social determinants. So as I think about what we do and ways we can intervene, I created this hierarchy of intervention strategies going from the individual to the community or systems of care, which is a public health model. And again, to political advocacy, influencing the policies that are so essential. The upward arrows indicate that these are all interconnected and influence each other. The individual interventions are essential, but they are not enough. Staying in the consulting room with patients does not have the heft, enough power to address the big changes that we must address now. I'm gonna switch now to some of those specific solutions. And this will be a very limited conversation about the cases that Dr. House has richly described. But because we're limited in time, those are going to be just specifically limited to these particular domains that influence, that are influenced by climate change. And I'm gonna try to use those cases to address the individual community and policy responses in these domains. So let's go back to those cases with Christy, our Mexican-American mother, who is grieving the suicide of her talented son, who has committed suicide on the verge of his athletic successes. I'm gonna review some of the social determinants that Dr. House has laid out, but review those. Christy experiences discrimination based on race and connected to racism. She's underemployed and has job insecurity, and then therefore experiencing poverty. Now, poverty and race are seen over and over and over as the primary social determinants influencing the outcomes from the climate change disasters. She also has limited educational attainment. She's been exposed in her childhood to pollutants. She has a neighborhood displacement over and over, and therefore is disconnected and experiencing social isolation. She has limited access to healthcare, to her healthcare, because she's dependent on her husband's healthcare insurance, and now is exposed to domestic violence with him. Let's switch to looking at some of the climate-associated determinants. Beth has shown us that her husband has lost his job in that transition from a factory job to one where he's no longer skilled. And she's mentioned how we have to attend to the social trends, the just transition of workers. She has limited housing access due to those refugees, those climate refugees from the California fires making competition for housing in her community very difficult. And so we must attend to the climate refugees themselves, as well as the impact on communities that are absorbing these refugees. She's been exposed to a devastating heat wave, and we know that her son's suicide occurred during one of those heat waves, and that suicide is increased during extreme heat. And Beth has also mentioned the power grid failure, so essential during extreme heat waves. So let's turn to some of the issues that we can look at in terms of solutions around heat specifically, although her case is so much richer. At an individual level, we have to address the education and prepare our patients for making empowered decisions about what to do during extreme heat. Now, I will be sharing a particular handout for surviving heat in a minute. We have to attend to the management that presents ourselves at the individual case level, both with meds and psychotherapy. At the community level, we must develop much more robust outreach and case management for those vulnerable populations during extreme heat. We have to make available cooling environments and shelter and water access for patients and individuals during heat waves. And it is essential that the departments of public health that particularly respond to those periods of extreme heat partner with all of the embedded community-based organizations and leaders in a collaborative way. At a public health level, the policy responses are extraordinarily varied and we must attend to modify our built environment, both creating green spaces, addressing the urban heat island effects. We have to have housing policies that improve substandard housing and address upgrading public housing sector. And we have to address reducing homelessness, a very vulnerable population. And for God's sakes, we have to ban the utility discontinuation during heat waves. That will save lives. And at a national level, we need to develop national occupational health standards for workers, both outdoor workers and indoor workers. And California is the only state now that has regulations for outdoor worker safety and is developing indoor standards. And at a national level, there are national legislation, particularly Senators Markey and Congressman Chris Christie, Chris Chris, excuse me, from Florida, have a bill before Congress now, the heat bill. And that is called the Preventing Heat Illness and Death Act. This is an area where you can contact your members of Congress and advocate for either signing onto this bill as a co-sponsor or supporting it. Now, I told you I would offer you this brochure for surviving heat waves. I collaborated with some colleagues of mine in developing this, and it was funded by the Earth Center at the University of California, San Francisco. And I wanna suggest that we add this prescription for heat health to all our patient encounters before inevitable heat waves. But what is even more important than this downloadable patient infographic is that it is translated into Chinese and Spanish. And that's essential as we address the disparities of available information to those who don't primarily use English. As I say, this is downloadable, and you can find it on the website listed here, and use either as a brochure or as a poster. But I also have printed versions if you'd like to contact me for those and use with your patients. Now, let's go on to Dana, our African-American survivor of multiple hurricanes. The social determinants that she faces, again, are race and racism, poverty. She's been exposed to violence in her youth, in her community, and has adverse childhood experiences. She comes from a situation with very poor housing quality and no air conditioning, but now is displaced and in temporary housing. She experiences food insecurity for herself and her child and lacks the important social supports for childcare as a single mother. The climate associated determinants that Dana experiences are those recurrent repeated traumas related to the multiple hurricanes, and therefore is at risk for post-traumatic stress, ineffective coping behaviors, and complex trauma. She's been displaced and is now a climate refugee. This has created community fragmentation, and she has a loss of major supports, including the loss of supports for her child and children being a particularly vulnerable population. She has had a loss, and her child is particularly vulnerable with loss of those supports from community recreation centers and school. She is at risk for pregnancy-related climate-associated difficulties. She is now experiencing some of those pre-traumatic ruminations that Dr. Haas has spoken about, particularly the hopelessness about the world that she will move into. And she is experiencing extreme heat stress also. So what are the solutions for the disasters? At an individual level, there are the need for acute psychiatric first aid with initial triage and management of acute symptoms. And there are toolkits available from the APA and SAMHSA. We have to have the climate-informed care for individuals and communities in disaster-affected areas. And at a community level, we must mobilize all sorts of those specific community supports for housing, food, health, and mental health resources, and coordinate also those supports for impacted vulnerable children. And Dr. Pollack has also addressed the significant transformational resilience practices that are now being discussed. At a public health policy, we must invest enormously in those vulnerable communities for prevention and response to disasters. And the current bills before Congress, and with President Biden, on the infrastructure bill and the reconciliation bill have some of those embedded infrastructure preparedness. And we need to also support childcare tax credits and other social and financial supports for those in need. Now let's switch to Elena, our climate activist. She too has job insecurity and income insecurity and poverty, as she is no longer supported by her graduate program income. She's been exposed to those climate-related changes in the activism that she has taken on. And in her civil disobedience and work opposing the pipeline, she's been exposed to conflict and violence and the criminal justice system. For her, those climate-related determinants include climate distress or eco-anxiety, and she's experiencing rage and ecological grief. She is in conflict with her field of study, geology, and her environmentalism, since most of the jobs in the field of geology are within the oil industry. She suffers from the Cassandra syndrome that she's been sounding the alarm over and over, but experiences that as not being heard and her calls are being dismissed. She has involved herself with environmental justice advocacy, particularly supporting indigenous communities that have suffered greatly from the climate crisis. And it's also a reminder that we've had a long history of dismissing the indigenous wisdom that connects us to the land and our vulnerability and interconnectedness with the natural world. And that those principles are beginning to be embedded in the climate justice movement. She takes on that duty to protect, to put herself at own risk as she takes on some of the efforts to stop the degradation that our involvement with fossil fuels have created for this climate emergency. So let's turn to some of the solutions for these eco distress syndromes. We cannot pathologize those who are experiencing the very big feelings about the degradation of our world, but nor can we ignore our professional obligation to assess those symptoms severities when they impair patients functioning. And we have so many tools to offer in our toolkit for emotional regulation, mindfulness, self calming techniques, skills for emotional regulation. And I wanna draw your particular attention to a project that the Climate Psychiatry Alliance and the Climate Psychology Alliance have joined together in creating a national repository of climate aware therapists who are particularly committed to working with individuals around climate distress. At a community level, we must move away from a paradigm that is based in individual interventions and move to a public one. This brings the ability to connect with other people and diffuse the isolation. And there are so many community support groups led both by lay and professional leaders, Good Grief Network, Climate Cafes, Climate Conversations, the work that reconnects are only some of the groups that do this. And we must empower and partner with community leaders and paraprofessionals to do this kind of support work. And then again, Dr. Pollack so carefully outlined that transformational resilience. At a policy level, Elena has shown us the importance of transforming that distress into activation and engagement with community and activist groups for policy changes. One being as David Pollack has shown, the legislative efforts to support funding for the transformational resilience efforts, but also involved as one of those, the divestment from fossil fuels, since it's really important to diminish the profits from the fossil fuel industry. And I wanna suggest that, let you know that the American Psychiatric Association has now a plan for divestment from fossil fuels, fossil fuel investments. These are just some of those tools in our toolkit for those modulating those extreme emotions. But I wanna remind you of resistance and engagement in activism. And then let's move to Mr. Craig. Our last case, that white entrepreneur who has involved with bipolar illness and the social determinants that he brings are that economic insecurity that he now faces, despite his prior wealth, which protected him and gave some degree of privilege. And that he's also been exposed to climate change issues. The psychiatric vulnerabilities that he brings is his bipolar disorder with grandiosity and now depression and his lithium treatment. The climate association determinants for Craig include his climate denial or disavowal. But he's been exposed to multiple climate disasters, the hurricanes, as well as sea level rise, threatening his property and causing great economic loss and impact. He's also been exposed to those heat extremes and it puts him at particular risk for his medication management and possibilities for lithium dehydration. He also experiences the risks for some waterborne illness due to sewage contamination in those sea level rise. So those solutions about climate denial, again, at the individual level, we must manage the medication impacts and the health and medical issues that he faces. Educating him about climate impacts is a complex one. And our motivational interview skills can be within the realm of attempting to help him understand that he has experienced some of the impacts from his climate denial. At the community level, again, that important shift from a community perspective, from an individual one. And we have to engage with that public education showing that climate is a health risk multiplier. At the policy level, we need to expand resources for mental health resources associated with climate change and have resources also for climate refugees, which he now is experiencing. And we need to use our health voice, a trusted voice for public messaging about climate risks and health risks and then as mental health risks. But Mr. Craig also can be, his story can be used at a different level. He faces the consequences of pursuit of wealth while ignoring the risks that it brings. And it's a reminder to us of how that pursuit of wealth at all costs has been a major driver of climate crisis. And I would also suggest environmental injustices. The centuries of an economy driven by perpetual wealth acquisition and profiteering from the extraction in use of fossil fuels while ignoring, denying and actively distorting at sometimes the ravages of such actions on our world have created the threats that we now face. And as we find ways to adapt to this changing world, we must also create new humane ways to organize our economy and social relations. It is a call to action that we must all take haste with that transition from our dependence on a fossil fuel economy and that move to a more economic, social and political system has to be more equitable and is pro-health and pro-mental health. And I wanna just say, this is the enduring issue of our lives. The earth is in our hand and what we do now will affect what the future will be. And I thank you for your attention to this. Thank you.

Climate Change

Socio-Political Determinant

Mental Health

Clinicians

Advocates

Social Factors

Transformational Resilience

Community Interventions

Policy Responses

Vulnerable Populations

Taking Action