Climate Change Impacts on Mental Health with Child Psychiatrist & Pediatrician Elizabeth Pinsky, MD

Elizabeth Pinsky, MD: [00:00:00] Anger is a really positive and positive emotion when what you want is action. Fear, grief, all of those things less so. But anger actually is a good way to get people to not be numb and to still take action. And it is very clear who we should be angry at. It's the fossil fuel industry.

Margaret: Welcome back you guys to How to Be Patient, the podcast about psychiatry. Would you say that's still accurate, Preston? 

Preston: it's like eight- you know the 80/20 rule? It's 80% about psychiatry and 20% about all the other fun stuff that comes from psychiatry or influences psychiatry- Exactly ... which I think is privy to the environment that we'll be talking about today.

The 

Margaret: environment? 

Preston: Yeah. Was that a 

Margaret: metaphor? 

Preston: Or, I guess, I guess the climate that we're in. that's probably what I meant. The climate that 

Margaret: we're in. I-- we didn't prepare the transition. we have Dr. Elizabeth Pinsky on with us today, who I have gotten [00:01:00] the opportunity, the lesson- Honor? ... to learn from, honor to learn from, Dr.

Pinsky. Y- do you want your full bio? 

Elizabeth Pinsky, MD: No. God, no. I j- I didn't 

Margaret: know what you guys wanted- So

let's see your whole bio ... so I sent that thing. Attended Harvard Medical School and completed residency in pediatric medicine psychiatry and child psychiatry. She works as a pediatric consult-liaison psychiatrist at the Massachusetts General Hospital and at Shriners Hospital for Children. Her clinicals interests lie at the intersection of child mental health and physical health, including childhood trauma associated with medical care, fostering resilience in medically ill children, and climate change.

I won't make you s- sit through your entire description 'cause there is, is more we could say. how would you describe the work you do clinically and then related to s- the overlap of psychiatry, children's mental health, and climate change? 

Elizabeth Pinsky, MD: So I trained both as a pediatrician and as a child psychiatrist.

and perhaps to the [00:02:00] consternation of some people in our program or in the audience, I really do see myself as a pediatrician who specializes in child psychiatry. always knew I wanted to work with kids. realized that I actually found conversations with them and their families, more interesting than, like, going inside their cells when I was in medical school.

and so ended up entering pedes residency knowing that I then planned to do child psychiatry sort of as a sub-specialization. There was no obvious pathway to do that at the time, so I ended up triple boarding, and I would say that I did that with an intention to be taking care of kids at the intersection of physical health and mental health, knowing that I had that area of interest.

It wasn't until I was sort of probably still an early career psychiatrist, but you know, certainly an attending, that I realized that having that training positioned me really well to [00:03:00] learn and educate and sort of expand what was known and talked about in terms of climate and child mental health specifically.

so I ended up working at that intersection, but not, necessarily in the way I expected. I thought I'd be working with kids, you know, exclusively with chronic disease and life-limiting illnesses and things like that, and still do those things as a consult psychiatrist here at MGH, but also have this interest in climate psychiatry.

Margaret: I've never heard you frame it that way of, like, viewing yourself as a pediatrician who is specialized in child mental health, which we could talk about that, but we'll come back to it. one of the things we always do is have kind of an icebreaker, like, opening question, For our audience to think about with us before we get into the topic for the episode.

And so one question I had that Preston and I were talking about before the episode is how each of us, have seen climate change and the conversation around it impact the patients that we see with [00:04:00] Preston and I obviously, at different points, and with Preston working with adults and going into neuropsych after he finishes residency, and then obviously with your work, Dr.

Pinsky. 

Elizabeth Pinsky, MD: That, that face was just for Preston having to work with adults. 

Preston: Oh, yeah. Yeah. 

Elizabeth Pinsky, MD: I don't know if that's what made you pause, but- I mean, 

Preston: we're-- I think we're all kids at heart ... 

Elizabeth Pinsky, MD: have you seen their feet, Preston? 

Preston: You know, so here's the thing- We 

Margaret: have a lot of adult psychiatrists who listen to the podcast.

Preston: I see myself as a psychiatrist first and a psychiatrist second, so actually it's not very often that I look at their feet. 

Elizabeth Pinsky, MD: All right. Fair enough. 

Margaret: Well, you should maybe look at their feet depending on what you are prescribing them. 

Preston: Yeah. So it's like I'm, glad their, that their feet are there. They- they-- the socks stay on.

Margaret: Okay, climate change and how it's impacted our patients. I feel like with even just starting in child, the anxiety around it is present in some of, like, more my teen patients, but I think I actually saw [00:05:00] it more working in perinatal and infertility where people were kind of trying to make decisions of how to pursue fertility and sometimes even before that if they wanted to have kids.

And one of the things that would come up was kind of how will the world look when my child is an adult, and like what kind of world am I giving them to inherit? And that was part of, well, we'll get to this, but like part of anxiety, but I think also pa- part of a like reality-based thinking about what their kid's future might look like.

So that's the one way I've seen it brought up clinically. 

Preston: And for me, it's, like it was interesting that you're sharing that like, people are thinking really far ahead. I think with, a lot of the San Antonio patients, they're lower on their Maslow's hierarchy of needs, I think just in general, than some of the other like, w- like wealthier cities that people can practice in.

And for them, it's usually just like it's hot out, and it's hotter this summer than it was last summer. So like I'm coming up on a stretch the next two [00:06:00] weeks where I think the lowest high we have is 99, and it's like 99 feels like 106, and it's just like that consistently. And what, what sucks about w- our infrastructure is that we're a really heavy AC-run city, which means we're pumping a ton of hot air out into the streets.

We have low shade, like we have limited amounts of shade. We don't plant a ton of trees, so it's just a lot of asphalt emanating heat off with your buildings shooting heat out at people. And then we have a lot of unhoused patients that are just basically extra vulnerable to the heat each year that it gets a little bit hotter.

So when I'm like thinking about climate change with my patients, a lot of it is just how do I connect you with resources so that you can like have access to water? And anything that I know is gonna like mess with your fluid status, I'm not gonna touch as often, especially if I know you don't have that option.

Like you-- maybe we could have, you know, 30 years ago when I'm not worried about someone like dying of heatstroke the second they leave the clinic. 

Margaret: Yeah. It's much more like right and [00:07:00] present, I guess, with you and your clinical decision-making, especially 

Preston: some of the population you're seeing. It's like look outside.

Oh crap, it's 

Margaret: really 

Preston: hot today. I 

Elizabeth Pinsky, MD: would say that once I started thinking like a climate psychiatrist and sort of putting that lens on, I see climate everywhere. So I see it in Preston's patients who we have to worry about, staying healthy, and not getting really sick when they're out in, you know, incredible heat.

see it in certainly in adolescents, and even sort of older tweeny kids who have a lot of worry and anxiety about climate. see it in kids who end up in the emergency department with trauma-related symptoms who have, you know, maybe came up, through the southern border during the migrant crisis and experienced trauma and ended up in the emergency department.

Those are at heart, climate cases. They're all climate cases. And so I think what, you know, one of the things that I would like to communicate, I think oftentimes [00:08:00] when we talk about climate change and psychiatry People do leap, I think, Margaret, to thinking about cli- climate anxiety, which I'm sure we'll get to today.

Climate touches everything and every system of the human body. And so once you start thinking about climate change and sort of putting the climate lens on, I think you s- you start to see it touching almost, you know, a, a huge number of your patients in one way or another. 

Margaret: Yeah. No, definitely. I think that was in some of the materials, like, you sent before, just which we will kind of get into the more concrete ways that it impacts people.

Something you mentioned, it wasn't till you were, like, an attending that you started to see this. is there any particular story or, like, particular arc of, like, your early career that was, like, really in- made you wanna be like, look into this more? 

Elizabeth Pinsky, MD: Yeah. So for me, I had always been climate anxious and climate aware.

[00:09:00] I had been worried about it for a long time. I voted, I gave money, I went to marches, I did things, but saw those as something that I did in my sort of personal or extracurricular life. and for me, and this is actually common experience for a lot of people who sort of have become climate people, I think, it was when the 2018 IPCC report, so the 2018 United Nation report came out.

I read, I think, initially just sort of like the coverage in The Times or whatever, and it hit me when I read that report that climate change was not sort of something I could think about in the future, or something my kids' kids had to worry about, or that may be something my kids had to worry about in adulthood.

It took that long, as worried as I was about climate, for me to realize that it was in fact coming for me and for my children, and this isn't that long ago. This is maybe eight years ago. Things have changed so much in the past eight years. But I really panicked and spiraled [00:10:00] out at that point, and was sort of desperate to try to find a way to protect myself and my family, and particularly my children, as if that's, like, a thing one could do.

And was like, "My God, we have to hoard food, we have to move to Canada, we have to, like, get-- We're gonna have water in our basements," like, all this crazy stuff, and I was really panicked about 

Margaret: it. Like- Joining us for 

Elizabeth Pinsky, MD: a bunker right now. ... doom scrolling and just, like, going down rabbit holes on the internet and, like, really kinda spiraling out in a way that I thought, like a sort of good parent and child psychiatrist, I was containing and, you know, shielding my children from.

And then there was sort of, I don't know, maybe a week or two into that, one night at dinner, out of the blue, my son, who was five at the time, said... I swear to God he said this , "Mama, the Earth can never die, right?" It's like Santa Claus and it can never die." And I was like... [00:11:00] And s- so first of all, I, obviously I had not contained my anxiety.

not a good parent, not a good psychiatrist. Yeah. I had not contained my anxiety. but second of all, I d- truly realized in that moment that I didn't know what to say to him. And, like, I knew in the moment what to say to him and sort of how to find out what he was wor- You know, I knew, like, sort of all of the things one learns about, how to talk to a kid in a moment like that.

But big picture, I realized that I really didn't understand how to talk to him about, how to help him think about it, what, how to equip him best to sort of manage in this really uncertain future. And I am a literal expert in talking to children about really scary and potentially life-changing things that are happening.

Like, literally, if anyone in the world knows how to do that, it's a consult liaison pediatrician and psychiatrist. and I didn't know how to do it. And so that was the moment where I sort of said, "You know, I can [00:12:00] bring my sort of personal life and my professional work into alignment around this." and as it turned out, there really was a gap in terms of climate change and mental health in general, but child mental health in particular, and there was plenty of room to sort of build a, a niche for myself doing that, because so few people were thinking about it and talking about it at the time.

Margaret: Yeah. I want us to get into kind of, like, the concrete parts that then flowed out from that, but first we'll take a really quick break, and we will be right back.

Okay, we're back. Preston was just saying how he is a flat-- No, just kidding. so- I recently 

Preston: converted. 

Margaret: Yeah ... you are famously a flat Earther. Exactly. Mm-hmm. Not-- But you believe in climate change, you just believe it's- 

Preston: Yeah ... not really a serious situation. it's more density and buoyancy. Like, you can have climate change withou-without gravity, right?

You know? separate fields. 

Margaret: separate episodes. Separate, something else for us to think on. But to get [00:13:00] kind of concretely, especially for our-- the people who are listening who are parents, but also who are pediatricians or social workers or med students, I wanted to get in kind of concretely how we explain to people this impact of climate in multiple dimensions that you go into in your work.

And so one part is just the sentence, "Climate change harms mental health." You had a bunch of things on your slide that I really wish we could get to, and so I'm gonna actually ask it to you this way. What are the most common beats you feel like you tell people when you're explaining this to them? You ment-mentioned, like, climate, like, trauma from migration from- 

Elizabeth Pinsky, MD: Mm-hmm

Margaret: patients you saw, but, like, other examples like that or ones that you feel like- Yeah ... come up often in the field. 

Elizabeth Pinsky, MD: So climate change touches everything. Super, super complex systems. It touches social determinants, it touches emotions, it touches physical health, it touches a million things. I think that the easiest way to think about how climate change impacts [00:14:00] mental health is to break it down into three big buckets or categories So the first one is the direct effects of heat.

The second one is the direct effects of air pollution, which really is sort of a twin hazard along with heat, and then the effects that are mediated through trauma. So, and then if we run through those just super briefly, heat is terrible for mental health, as Preston has sort of already talked about.

And we sort of say it's terrible for mental wellness. For even for people who don't have mental illness, heat, it affects your sleep, it affects your mood, it makes you irritable, it makes you cranky. it impacts your both your cognition in the moment and your learning. So heat is bad for performance on a given test, and it's bad for learning over the course of an academic year.

Heat is, you know, increases hate speech online, it increases assault deaths. Heat is just bad for sort of human wellness and human behavior, whether you have mental illness or not. Heat- 

Preston: In San Antonio, we see it with road rage incidents. 

Elizabeth Pinsky, MD: Yeah. 

Preston: Yeah. [00:15:00] Yeah. 

Elizabeth Pinsky, MD: Yeah, I believe it. So, there's a very big study from Korea looking at assault deaths that go up when it's hot out, and then there's a giant study looking at Twitter and, like, billions of geo-located tweets, and hate speech online also goes up when it's hot out.

So it's just like it, it's bad for behavior. For people who have mental illness, it's also really increases symptom severity, and it's bad for outcomes. So anxiety, PTSD, depression, suicide rates go up when it's hot out, and specifically violent suicide, completed suicide, so lots of different ways that heat is bad for people who have mental illness.

Separate from that is the fact that people who have certain mental illnesses, and particularly, like, severe mental illness, schizophrenia, things like that, are extraordinarily vulnerable to heat So that's sort of one big category, heat. And we can talk about that. That data's super interesting, and scary.

Margaret: What do you mean by the people who have, like, s- or severe mental illness, are particularly vulnerable? Do you mean, like, in terms of their actual [00:16:00] physiology, or, like, being... having less access to resources and being vulnerable to the impacts of heat? What do you mean by that? 

Elizabeth Pinsky, MD: Both. Both. Both. So people who have schizophrenia in particular are massively vulnerable to heat illness, and then to also having sort of underlying illnesses that are worsened by heat, things like cardiovascular disease or kidney disease that heat makes worse.

So, like, if you look at the, heat dome in the Pacific Northwest in 2021 or '22, they looked at a whole bunch of different chronic illnesses, kidney disease, heart disease, and schizophrenia, and looked at excess deaths. And people with heart disease and kidney disease, the odds ratio of death when it was really hot out was, like, 1.2, 1.3.

For people with schizophrenia, it was a threefold increase, so three times increase. 

Margaret: Wow. 

Elizabeth Pinsky, MD: vastly higher than any other group. And some of that is due to basic underlying physiologic changes that people with schizophrenia have that p- probably have to do with [00:17:00] sort of common pathways of the neurotransmitters that modulate heat.

So people who have schizophrenia are just at baseline not as good at thermoregulation. And then their situational awareness, environmental hazards, sort of decision-making, and all of the meds we give them that impair their ability to regulate their heat, that puts them at even further increased risk. So there's a range of reasons that people with schizophrenia in particular are super, super vulnerable to heat.

This has been known forever. So Shakespeare, in King Lear, there's a character, Mad Tom, who he's a- actually, like, the other dude who's dressed up as a crazy person, and he's not actually... Whatever. There's a whole backstory. But there's a character, Mad Tom, who's supposed to be, like, the- you know, deranged beggar, crazy person in the story.

And one of the things about him is that he wears too much clothing. So Shakespeare says that Mad Tom, who ha- hath had [00:18:00] three suits to his back and six shirts to his body. And if you think about it, when you see, you see sometimes people who have chronic mental illness who wear too much clothing, and there's this super interesting and elegant study, from 1993, the author's Valerie Arnold, where they did a study where they just looked at people coming into the psych ER, and it's like this super simple two-by-two positive predictive value square, where it's just w- are they wearing redundant clothing, yes or no?

And do they end up having a diagnosis of schizophrenia, yes or no? And redundant clothing was 99.5% specific for a diagnosis of schizophrenia for people presenting to the psych emergency department. And then you think about all of the people around the turn of the century who were like Putting people in saunas and in ice baths and- Yeah

wrapping them in wet sheets and- I mean, even that was- ... hydrotherapy and all this nonsense, right? So, like, we don't, we d- this stuff is not well-researched and not well understood, [00:19:00] and there's clearly something about the way that we regulate heat. But he- heat and mental illness have a, a lot to do with each other, both just in terms of if you don't have a home or access to water, you're at increased risk, and sort of on a molecular level.

And we haven't even touched on substance use disorders, which is another sort of whole group of patients who are extraordinarily vulnerable, to heat. 

Preston: Did y'all ever watch MASH? Remember that show with Alan Alda? A 

Elizabeth Pinsky, MD: million years ago, yeah. 

Preston: Yeah. Do you remember Klinger? Who, he was always trying to get out of the military by claiming that he was insane.

Yep, he 

Elizabeth Pinsky, MD: would, like, dress up in women's clothing and things like 

Preston: that. And he would... but he would have layers on layers. Like, I remember there was one episode where it's, like, a super big heat wave, and Klinger's like, "What? I can't tell. I'm just, I'm way too cold, guys." And they're like, "Okay, man, jig's up.

Like, we know you're sweating through all this stuff." But, just, I just thought it was a funny connection that, you know, even in pop culture in the '60s and '70s, like, we're already, like, pinpointing this, this correlation between redundant [00:20:00] clothing and extra heat or, Yeah ... mental instability.

Elizabeth Pinsky, MD: And you guys will, no doubt, throughout this hour be asking me for areas to point out where there's clinical relevance to this stuff, 'cause some of this stuff is kinda like theoretical or, like, mushy sometimes. Climate anxiety, how do we help people? But making sure that we're thinking really carefully about our patients with chronic mental illness, and particularly when we're prescribing anticholinergic medications and lithium and things that are messing with their ability to sweat, making sure that our patients have a plan to keep cool, know how to keep themselves safe, and all of that.

Same thing for patients with substance use disorders. That's a really relevant clinical intervention where you can be saving people's lives just by helping them think about what they're gonna do to keep themselves safe and cool, which I actually think in some ways is a bigger issue in places like Boston, where we're really not adapted and don't think about, keeping ourselves cool quite as much.

I mean, it's an issue everywhere, but, it's not just in Texas. Yeah, 

Margaret: it's like here when, like, it snows in Texas, they're like, "What do we [00:21:00] do?" And, like, here- Yeah 

Preston: Mm-hmm ... 

Margaret: we're like, "Why is it 100 degrees? What's going on?" 

Preston: Yeah. 

Elizabeth Pinsky, MD: Yeah. You know, and our patient, you know, it's, energy costs, it's w- gets into all kinds of social determinant stuff.

Margaret: Yeah For those who want it, I did find the paper you just referenced, and I-- it will be in the show notes today for those who would like to see this paper. It's 

Elizabeth Pinsky, MD: a 

Margaret: very 

Elizabeth Pinsky, MD: elegant paper. 

Margaret: There's probably other ones I could put in there, but I feel like this is the kind of random paper that, like, our listeners will find the other kind of in the field m-more popular ones.

But this is the kind of one that I feel like they like to nerd out on. Okay. Heat. Again, there's a million things we could talk about with that, but I want to go to your next kind of bucket, which is air pollution. 

Elizabeth Pinsky, MD: Yes. The next bucket is air pollution. So, air pollution, is also really terrible for mental health, and that is true both chronically over time.

So like children, for example, who grow up in cities with really poor air quality- are both at increased risk of preterm birth, which then increases their risk of negative neurodevelopmental outcomes, ADHD, [00:22:00] all of those things, and at increased risk over their lifespan of anxiety. And then, you know, looking sort of further into, Preston's populations.

dementia is more common in people, who live in cities with dirty air. That's over time, but even acutely, crisis presentations are higher on days with poor air quality. So both sort of over time in terms of your risk of developing mental illness, air pollution is bad, and then acutely, on days when air quality is bad, it's worse for crisis presentations.

So that's bucket one. So we have the heat bucket, we have the air quality bucket, and then we have this somewhat mushier trauma bucket, and that I think is actually in some ways the most relevant way that climate change impacts mental health. Climate change is increasing the frequency, severity, and unpredictability of severe weather events.

Mm-hmm. And severe weather events, [00:23:00] unsurprisingly, are you snapping for the severe weather question? I'm snapping in agreement, yeah. He's being Gen Z. They're terrible. He's being Gen 

Margaret: Z. Bucket. 

Preston: Yeah. 

Elizabeth Pinsky, MD: Oosh. Oosh. 

Preston: Hurricane Preston coming 

Margaret: soon. This is when I was around- Got it ... with Dr. Pincy, I'm like the, like Gen Z, like med students would always say, "I feel like something..."

We would say something, and then our psychologist and you would be like, "Is that something people say?" 

Preston: Yeah, I think this was- I'm trying 

Margaret: to adjust 

Preston: that one ... this was Millennial. I think Gen Z would, I'd be going like this, like T. 

Elizabeth Pinsky, MD: I am pretty confident- I- Millennials don't do that ... that Margaret just called me old, and I- I did not.

Oh, how'd it feel? Oh, you fully did. You absolutely did. All right. okay. So- ... hurricanes, typhoons, flooding, wildfires, all things that can expose you to life-threatening experiences. Unsurprisingly, in the wake of extreme weather events, rates of PTSD go up, but also anxiety, depression, substance use disorders, community violence, including child abuse, would then like cascades down to sort of tertiary mental illness.

So extreme weather is [00:24:00] terrible for m- mental health in terms of acute traumatic exposures. There then is this other sort of category of secondary trauma from climate change that's what I would describe as slower-moving catastrophes. So we have lots of data from the disaster literature on how things like hurricanes or floods, cause PTSD, lead to increased rates of PTSD.

it's much harder to study things like droughts Famines, loss of land to rising seas and encroaching deserts, sort of slower moving catastrophes. But we know that those are also connected to sort of complex traumatic, you know, complex PTSD and negative outcomes including, like, suicide, particularly in farmers and droughts or lots of negative health outcomes, negative mental health outcomes associated with those chronic traumatic exposures, which are also migration.

You know, thinking about the kids who we see in the ED who, have been forced off their lands or, you know, where their families may [00:25:00] have been for generations, and that certainly can be a traumatic exposure. And then I sort of, in order to have this neat three-bucket category, defined this third type of trauma that I call vicarious trauma, which is, kind of messy, right?

Like, this is definitely trauma with a lowercase T. We're talking about- vicarious trauma. But knowing about climate change and knowing what's coming, and this is where we talk about that experience of eco-anxiety, is, as I'm sure we'll talk about, I would argue not a form of mental illness, but it is a stressor.

It is absolutely sort of a, I would argue, really pretty new human experience that people are having that's causing stress and distress, and sometimes impairment in function. And so that's where this whole nomenclature has sprung up over the last several years to sort of try to help us have these conversations about what it means to be living in the era of the climate crisis.

and so that's where, you know, eco-anxiety, climate anxiety, climate grief... [00:26:00] Do you guys know what solastalgia is? 

Margaret: No. It sounds like a nice word. I'm gonna guess it's 

Elizabeth Pinsky, MD: not Preston? Preston- No ... 

Preston: do you 

Elizabeth Pinsky, MD: know what solastalgia is? 

Preston: I, can take a stab, but- Oh, don't bother ... do not know. 

Elizabeth Pinsky, MD: So solastalgia is a term that, this Aus- I think it was Australian environmental philosopher came up with, maybe 20 years ago, solastalgia.

It is the experience of homesickness, feeling homesick, when you are at home, but home- has changed around you. 

Preston: Oh. 

Elizabeth Pinsky, MD: So this would be the person who grew up in Upstate New York, and there were always ice rinks in the backyards in the winter, and nobody's been able to have those for the last several years.

It is the experience, I grew up in Northern California. We did not have a wildfire season. So it's the experience of going home to Northern California and seeing the skies choked with smoke every summer, solastalgia. And so that's an example of something I ... You know, I'm, I don't think solastalgia or that feeling [00:27:00] is pathological in any way, but when I defined it, both of you guys went, "Oh," like, 

Margaret: Yeah. 

Elizabeth Pinsky, MD: Mm-hmm. It's, it, like, has resonance, and it almost always means something to people. So it's clearly describing a real human experience, which doesn't mean that it's a clinical human experience or that it's pathological. 

Margaret: There's almost something about if you name it as pathological, that does this, the thing it always does in psych that locates the problem within the individual and kind of implies that it's an irrational response, to the situation, which it sound, you know, is not, so 

Elizabeth Pinsky, MD: Well, you're jumping ahead, but yeah, exactly.

Exactly. That's the, my fundamental problem with the concept of climate anxiety. 

Margaret: You did include one of your slides. I don't know if we'll be able to put it up, but it's that cartoon that's, like, a bunch of chopped down trees, and there's someone, two, like, people writing notes looking at a koala, and it's this young koala has a mental health problem holding onto, like, a stump of a cut-down tree.

This is that concept of, like, yes, you're in [00:28:00] a really similar to capital T trauma that we talk about with, like, other settings and abuse and things like that. It's like, is this a problem within, in the individual, and how do we make them think of themselves and make them feel more or less capable if the problem is them, quote, unquote, versus around them?

Elizabeth Pinsky, MD: Well, and so there's two ... I mean, you've, hit on this, Margaret, but just to make it a little bit more explicit. That is ... I do love that cartoon that I put up every time I give a talk. But that is the fundamental problem with this notion of climate anxiety, and, like, the lay press, and, you know, people have really latched onto this idea of, like, the kids have climate anxiety.

And like, what are we gonna do about the kids being so climate anxious? Gen Z is climate anxious. What does this 

Preston: mean? They're 

Margaret: climate anxious. What do we, how do we help? What should we do? Well, I used to like- And it's- ... fire. We had s'mores when I was a kid. Now this Now fire's a problem. 

Elizabeth Pinsky, MD: And so you look at the cartoon of the koala clinging to the eucalyptus, right?

And I don't ... Like, does the koala have a mental illness? Maybe he does, right? 'Cause, like, he's surely traumatized. Maybe he has [00:29:00] p- you know, I don't know But it gets at sort of like the obvious problem with it as a concept, is that it's pathologizing what is actually super healthy response. So it's not just that it's a normal response.

Anxiety in the faith of, face of a true threat is not just normal, it's actually healthy. It is what allows... It's, like, adaptive. It's what allows us to, like, know the saber-toothed tiger is coming, and, like, run or grab our spear or whatever we're gonna do. So I would actually argue that being climate anxious is not pathological, not normal, but actually a sign of health, and of, like, attachment to the world and to people and to animals.

And so obviously, there's the problem of just we're pathologizing it. But I actually think the bigger problem is what you're getting at, Margaret, which is that it is individualizing what is really a collective problem. Like, we don't... W- i- individuals have diagnoses. And so when we talk about climate anxiety, we're making it about the koala and about what is his problem.[00:30:00] 

And what we are failing to talk about is who cut down all of the eucalyptus. 

Margaret: Certainly in American healthcare, we'd never do an individualized solution to a systemic problem, right? Right. That would, that has never happened. Never. Would never 

Elizabeth Pinsky, MD: happen. But so for every article that we're writing where we're talking about, "Gen Z's climate anxious, and they don't wanna have kids, and they're freaking out, and what should we do?"

We are failing- And no one wants to work anymore. Ahh. Exactly. They're all quiet quitting 'cause they're so anxious about climate change. All starting podcasts. What we are f- failing to do is talk about the fossil fuel industry. And so every time that we talk about, it, like, for every 10 articles that are written about climate anxiety, one of them will talk about our ongoing reliance on fossil fuels and how that's the fundamental problem.

and it... I actually would argue that it is a way to allow older generations and people in positions of power and all of that to avoid talking about the actual problem, is to talk about climate anxiety. [00:31:00] 

Preston: Do you... So this is an analogy I guess I'll draw, and I wonder if you see there's any, if there's any legs here.

When it's one thing to say, like, "Hey, you know, individuals who smoke are more likely to have lung cancer." But when we were able to, in the public eye, link that these big tobacco companies are, you know, causing higher rates of cancer, that did get us some traction to suppress the amount of smoking. So, like, granted, climate anxiety pathologizes the individual, but if you say, you know, "Hey, these fossil fuel companies are causing a, you know, global detriment to the mental health of the population," so acknowledging that it's pathology, would that have a benefit?

in your opinion, in, like, moving policy in that way? 

Elizabeth Pinsky, MD: Yeah. So there are good data to show that, talking to people about the fossil fuel industry is a powerful way to get climate action. So anger is a really positive and [00:32:00] positive emotion when what you want is action. Fear, grief, all of those things less so.

But anger actually is a good way to get people to not be numb and to still take action, and it is very clear who we should be angry at. It's the fossil fuel industry. I also think that failure to name the systemic problem is actually one of the barriers to individual change. So do you guys know where-- do you guys know, like, the, carbon footprint calculator?

You can go online and, like, put in the, what kind of car you drive and how many flights you take a year and how much meat you eat and all that, and calculate your- Mm-hmm ... carbon footprint. Do you guys know where that came from? 

Preston: I'm s- I'm sure the, the fossil fuel industry would love for us to think about how culpable we are in the climate 

Elizabeth Pinsky, MD: issue.

It was literally British Petroleum literally- ... came up with the notion of a carbon footprint calculator. And so that- Perfect. Which does not abs- it, [00:33:00] it does not absolve us, right, from our... You know, like, climate change is not our fault, but it is our problem. It is very clear that the fossil fuel industry was aware of all of this decades before the rest of it knew.

That it is very clear that there was... So I actually would say that the fossil fuel industry and big tobacco are very analogous in terms of the ways that they have known that they were causing harm, intentionally misled people, and have continued to peddle a product that is killing people. and I actually think reframing it that way, without negating the importance of individual action, right?

'Cause indi- collective action is just lots of individual actions happening together. Individual action's important. But being clear about where we lay the blame, I actually think is powerful and important, and particularly important for health professionals. 

Preston: Th- that really strikes a note with me because I've been on the receiving end of conversations where the blame finger gets [00:34:00] pointed around, right?

and whether it's something as small as like, "Oh, I drive a Tesla, you know, therefore, you know, I'm h- better for the environment. I'm using an all electric vehicle, X, Y, and Z." And then you wanna shame someone who's driving like a 2002, like, Toyota. It's like, well, if you think about the amount of energy that went into producing this, like, brand-new electric car.

Like, first of all, like, th- that isn't, like, helpful for, like, your whole, like, environmental moral superiority, which I think is something that people fall into when they actually should be, like, directing this whole storage change. But the other problem is we shame each other For, you know, "Oh, you're eating bacon.

You're, y- you shouldn't have coffee. Like, think about how far that coffee had to travel there." And I f- I think it's, like, one thing for people to support each other in, making, like, environmentally conscious habits, but if the blame finger is ever to be pointed, it should be, like, acknowledged that, you know, whatever, whatever shipping company's bringing all this stuff over here is, producing way more carbon in one trip than you [00:35:00] probably will in the next several decades with your single car So- 

Elizabeth Pinsky, MD: Yeah

Preston: now it's a hot take for me. I don't know how much I'm adding with this other than just venting. 

Elizabeth Pinsky, MD: that's a luke- lukewarm take at best, Preston. Yeah. Lukewarm. It's-- No, it's-- I mean, all of that math we're doing and all of that whatever is a distraction from the fact that the systems are not set up to allow us to make good choices.

So like I-- I mean, I went to ACAP recently to present on climate stuff, and it was three times as expensive for me to take the train from Boston to New York as it was for me to fly from Boston to New York. Th- that's not a me problem. That is a system problem that is getting in the way of all of us being able to make reasonable and healthy choices.

And so, you know, we can all do our best and we should be conscious of it, but the problem is this system, not whether we're recycling. 

Margaret: I don't know. I think it's part of why we do the pod-- this podcast is to like bring people like you on to talk about the systems and talk about-- and like give a [00:36:00] platform and take Preston's fame and trans- transmit, transmi- kind of give power to this kind of stuff that many people can hear it.

And one of the things we know about our listeners is that a lot of people-- it is a lot of people who work in healthcare and are in positions of giving guidance or being at the s- either at the start of their career or some people more into their career, that we do have some power. I think, I mean, I don't know.

I think everyone who works in healthcare has some power of influence because it's such a vulnerable time and people come to you, whether you're their bedside nurse, you're their physician, you're their like PT, what-whatever. Like they come to you and they want guidance and they're very open to you.

And so I guess one of my kind of last few questions here for you would be, are there examples or are there ways you think about how we use that power for good and to bring this story more to light as people in healthcare who are seeing the impacts and learning how to see the impacts [00:37:00] like from what you're teaching us of climate change and help advocate?

Like how do we use that power to be part of the collective? 

Elizabeth Pinsky, MD: So I would say a couple different things. One thing to be aware of for those of us, particularly those of us who are based in either a, a healthcare system or an academic medical center, healthcare itself is a massive contributor to fossil fuels.

And so here in the US, it's on the order of five percent of our total greenhouse gas emissions are related to healthcare, and globally it's like closer to ten percent. Maybe I have those reversed. It's massive. And so we are, through our operations, we are killing as many people with our emissions as pr- It's like on the same medical-- It's on the same order of magnitude as medical errors, which obviously we put a whole huge amount of effort into preventing And so one thing would be just to start the conversation within your own system with leadership and with colleagues around what is [00:38:00] your healthcare system doing to reduce emissions, which is also a form of raising, awareness.

So things as simple as, like, switching which anesthetic gas is your default within your hospital system can, you know, be a really big, Certain anesthetic gases are really potent greenhouse gases. You know, w- where your energy's coming from, sort of all of those things. There's lots of resources out there for sustainability in healthcare.

So that's one thing I would say. The other thing I would say is, and, you know, Katharine Hayhoe, who's, like, the greatest climate communicator of all time, climate sc- scientist, and evangelical Christian, who manages to, like, bridge those two worlds, often says that the most important thing you can do as a form of climate action is just to talk about it.

And so there's a phenomenon, pluralistic ignorance, where in this country, we all think that many more people are climate deniers or don't believe in anthropogenic climate change than actually do. It's much, much more common for people to understand the basics of climate change, [00:39:00] know that it's being caused by fossil fuels, and to be worried about it, than it is to have people who really are just like, "Oh, it's hogwash," and, you know, "I don't know, someone made it up in Preston's Flat Earth Society," whatever it is.

and so just being able to have these conversations with colleagues and, you know, "The summers are getting hotter as the climate changes. I wanna make sure that because of the medicines that I'm prescribing to you, you know how to keep yourself cool in the summer. You know, what is your plan for the upcoming heatwave?"

Just it's-- it is fact, it is true, and incorporating it into the conversations that we have. and then certainly for those of us who treat kids, normalizing being worried about climate anxiety, that the koala has some reason to be worried. 

Margaret: Yeah. I mean, I think it's interesting even from A sort of therapeutic approach.

I, well, I think that there's a big tie between screens and, like, the, quote, un- like, the loneliness epidemic and the disconnection feeling and disconnect in the modern, like, American Western mind from, like, [00:40:00] land and nature. And I-- There's-- I don't know. There's something kind of consistent to me about both, like, thinking more about this, even though it's maybe scary to confront it head-on, and having actions align with it because I feel like often it looks like being more connected to your community.

Like, not that everything is individual action, but, like, knowing your neighbors, knowing what bothers them, knowing what your patients are going through, like, not just when they come to your clinic. Knowing how your hospital runs and then even for, like, the kids we see. There, there's something when it's available that, like, connecting with nature in your local parks and rec system is also really good for your mind and body and a positive thing.

So I don't know. I don't know if that makes sense, but I feel like there's a coherence between addressing the problems is also a solution for some of the current problems that feel unrelated. 

Elizabeth Pinsky, MD: Yeah. No, you're talking about multi solutions. So we think about climate change as being a, a poly crisis. Like, it's not just an atmospheric crisis or an even [00:41:00] an ecological crisis.

It's a geopolitical crisis. It's an economic crisis. It's a, you know, spiritual crisis. It's a crisis in all these different ways. And that feels hard, but it's also really hopeful because the things that are solutions for climate change are also solutions for loss of social infrastructure, for disconnectedness, for, you know, inequity.

Like, we cannot fix the climate crisis without also becoming as like a civ- not just a society or a community, but a civilization, becoming more just, more fair, healthier, more connected, all of those things. And that's what you're talk-- Who is the most-- What is the most important factor for survival in a disaster?

Margaret: Connectedness, relationship 

Elizabeth Pinsky, MD: It's your neighbors. It's your neighbors. It's not FEMA, it's not first responders, it's not anything, it's your neighbors. And so as we think about this future that in some ways is scarier, right? Because there's gonna be cascading climate disasters, traumatized communities are sort of more brittle and less able [00:42:00] to come together.

In some ways that can be scary, and in some ways we have to adapt and adjust to what's happening. And once we have done that, we will, by definition, be in a better spot as human beings. and as, you know, sort of immediate and however many concentric circles out you wanna go, communities, we will be better off once we have done what we need to do.

We have everything we need to solve the climate crisis. We have the technological know-how. We know what to do, we just need to do it. 

Preston: So I guess extending on that, like what we need to do, a lot of this will probably have to come from policy change. So hypothetically, if you had a magic wand or, you know, supreme power for, you know, an afternoon on a random Thursday, I think for this hypothetical, let's make Dr.

Pinsky a dictator. 

Margaret: Okay, perfect. Oh, 

Preston: glory. Just curious what would your decree be, or like what's a policy that you would wanna pass like tomorrow that you think could make a difference? [00:43:00] 

Elizabeth Pinsky, MD: I'd like, I would, I wish that it were that simple. I mean, the fact of the matter is that the answer is kind of like the Inflation Reduction Act, but more so.

Like that, that we had many of the solu- we had much more funding for many more of the solutions, than we have now. it is both incredibly complex, right? 'Cause we can't actually just stop burning fossil fuels tomorrow because we do continue to have energy needs that are not currently met with renewables.

But we need to stop, or like in some ways it is so simple. We just need to stop burning stuff We just need to stop burning stuff. We need to electrify everything. We need to stop burning stuff. And that is incredibly complex and, you know, a, a very large set of sort of cascading large and small policies.

and I'm not the right person to name all of those. But as a dumb doctor, I [00:44:00] also get, to say what is really true and really simple, which is stop burning fossil fuels. We ha- we have to stop. We had to stop 20 years ago. We didn't, and some of the harm is baked in. But every incremental degree of warming represents suffering and lost lives.

Mm-hmm. And every degree of warming that's averted i- is the opposite, represents more health and healthy children and healthier communities and all of those things. so it is a scary moment. It is also a hopeful moment. And the solution isn't complicated. It's just incredibly complicated.

we have to stop burning stuff. 

Preston: Mm-hmm. it's the most simple and most complicated at the same time. 

Elizabeth Pinsky, MD: Yeah. As, you know-- I mean, it is a crisis that touches every aspect of everything. Fossil fuels are baked into everything we do. So yeah, it's gonna be complicated. Medical schools should-- All medical schools should have a climate curriculum.

All psychiatry residencies should have some climate in their curriculum. [00:45:00] you know, there are smaller things too like that. We need more heat and mental health research. 

Margaret: You started your-- the presentation slides that you usually use and you sent me and-- But we're gonna end probably on the quote you start with, and I wanna ask you why you think it's important to start that presentation with this quote, which is by Dr.

Elizabeth Saw- Sawin: "A system's behavior can get chaotic in advance of transitions or transformations. Don't assume that today is the endpoint of anything. Today is a moment of multifold potential." Why do you start with that when you are lecturing on this? 

Elizabeth Pinsky, MD: I start with that for some of the reasons that we just talked about, because we have a tendency, people like me who talk about climate a lot, have a tendency not to talk about the hopeful and the solutions enough.

and that's a quotation that is about how this poly crisis also has many solutions and things that can allow us to think about a future that really is [00:46:00] healthier, you know, happier, more connected, all of these things, and that the onus for all of those changes can be addressed in the climate crisis.

So partly because I want to be hopeful. I also think that as someone who has thought a lot about how to cope with climate change, and there's sort of some interesting but, not super deep research on like what are the most effective coping strategies that allow you to both not be numb, not be so hypervigilant that like you're freaking out all the time and can't even grocery shop, let alone take climate action, but sort of remain somewhere in the middle, and allow you to sort of continue to do what needs to be done.

and one of those is something that's called, meaning-focused coping. And for me, part of meaning-focused coping is placing climate change and myself in the historical context and try to remain humble about the fact that there have been such dark moments in human history. There have been moments where people who could have been me were in such unimaginable [00:47:00] circumstances that they could not see ahead 10 years or 100 years or 1,000 years, and none of us know what the future holds.

And so, you know, at any time, this is a really, important moment in human history that's never gonna be super comfortable to live through. And we don't know what's on the other end of it. Anybody who tells you that they do is full of baloney. They're trying to sell you something ... and for me... Yeah.

Yeah. And they might be trying to sell you doomerism, which is, I actually think, a bigger problem than, climate- 

Preston: or sell you 

Elizabeth Pinsky, MD: baloney 

Preston: that they're full of. 

Elizabeth Pinsky, MD: Correct. Correct. And I don't, I don't dig baloney. 

Preston: Yeah, 

Elizabeth Pinsky, MD: it's just, ugh And so, so that's the other piece of it, is just that for me, that's a form of meaning-focused coping.

Margaret: Is there anything you'd like to promote or anyone, besides that 1993 paper that I'm gonna put in the show notes, about... Is there any place where people can follow you, learn more from you, or places that you think people who end this episode and are like, "I wanna learn more. I wanna keep [00:48:00] digging into this," you recommend?

Elizabeth Pinsky, MD: I would say that some excellent resources are the Climate Psychiatry Alliance. There's also a Climate Psychology Alliance North America, and both of those are groups that people, psychiatrists can get involved in either group, and that do have a variety of different projects and interesting things going on in this, area.

And then there are committees within the APA, and within ACAP that also are thinking about this, and those are other ways to sort of get involved professionally. Finding an effective local group, whether it's through your hospital, through your church, through your whatever, your neighborhood association, is the best way to get involved in climate action 'cause it's otherwise too big to do on your own.

So finding an effective group is my main advice. 

Margaret: And is there anywhere that people can follow you online, that you post? And I saw you have Blue Sky. I didn't know that. 

Elizabeth Pinsky, MD: I only have Blue Sky I, I only have Blue Sky anymore and I guess LinkedIn. I don't know. 

Margaret: Okay. 

Elizabeth Pinsky, MD: I'm old, Margaret I'll, we'll link you we've been over this.[00:49:00] 

Y- you already established how old I am. 

Preston: Okay. Well, it will be tagged in the show notes. 

Margaret: I haven't posted in years. Okay. We'll put the links to the other stuff and we'll include that. Everyone, let's go flood the comments on Blue Sky and be like, "I thought she was gonna be here." And 

Preston: on Spotify. And on 

Margaret: Spotify Blue Sky, Spotify, please.

Thank you As always.

All right. Preston, do you wanna wrap it up shortly? 

Preston: Yeah. let's, close things out. So how was the show? as always, we wanna know what you hear, what you think, what you saw. If you were watching on video, you may have seen my, screen flash and die for a little bit before resuscitating itself and coming back on.

That's actually because I have to turn the AC off in my apartment so that I can record, and then my camera overheats as a consequence of that. So I was directly- The fourth bucket. You can't film your podcast ... affected by bucket number one of the, climate crisis [00:50:00] today. So it will find you Number one suffering population, men filming 

Margaret: it...

Preston: Climate is everywhere and it still found us today. if you wanna leave your comments on Instagram and TikTok @humancontentpods or @howtobepatient, leave them there. But if you wanna have a priority, you know, A-tier level comment, leave it on Spotify. I have this one- Brandless comments. I have this one from Keely who says, "Proud to be a Spotify-only commenter," and then she did the woof emoji.

So Keely, we see you, and we appreciate that. You can al- you can always find more from me at Espresso where we have our videos and on Spotify. 

Margaret: I just think it's funny. We do 

Elizabeth Pinsky, MD: see comments. The like blowing air 

Margaret: one. 

Preston: yeah, it's like- 

Elizabeth Pinsky, MD: Is that the, like, foof one? 

Preston: Yeah, and the, the eyes are kinda closed a little bit, like foof.

You know, like you sigh. Yeah, that's so 

Elizabeth Pinsky, MD: funny. I just Googled what that one meant earlier in the week, I swear to God. I'm not kidding. I sent it to somebody- It's like, to me, it's like olive d'aboli ... and I was like, "I hope that means oof," and then I was worried maybe it meant something different, so I Googled it.

Margaret: Thank you, Spotify commenter. [00:51:00] 

Preston: and the, and to the woof emoji, if we were all, had glasses in our hands, I would cheers to that right now. So, thanks again for listening. We're your hosts, Preston Roche and Margaret Duncan. Our executive producers are me, Preston Roche, Margaret Duncan, Will Flanary, Kristin Flanary, Aron Korney, Rob Goldman, Shahnti Brooke.

Our editor and engineer is Jason Portizo. Our music is by Omer Ben-Zvi. To learn more about our program disclaimer, ethics policy, submission verification, licensing terms, and our HIPAA release terms, go to howtobepatientpod.com or reach out to us at howtobepatient@human-content.com with any questions or concerns.

How To Be Patient is a Human Content Production.

Thank you for watching. If you wanna [00:52:00] see more of us or if you wanna see... This is Lilac. She's my cat. She's gonna be waving her hand at one of the floating boxes, which will lead to more episodes. Lilac, point to the other episodes. Lilac doesn't know what the internet is, but I swear they're there. They pr- they probably exist for real.

But in the meantime, I'm just gonna pet Lilac, and then I'm gonna go dance in the background