Since the early 1990s, ecopsychologists have been a marginal but persistent voice in the field, warning that separating ourselves from the natural environment creates a wide range of mental disorders, including anxiety, depression, and addiction. Now as evidence mounts about the growing impact of climate change, recognition of the link between the environment and mental health issues is increasing within the field.

As evidence of this trend, the May/June 2011 issue of the American Psychological Association’s (APA) flagship journal, American Psychologist, includes recommendations from the APA’s Task Force on the Interface between Psychology and Global Climate Change. Psychologists, says the Task Force, have a responsibility to motivate individuals, communities, organizations, corporations, and governments to address climate change and “help humanity effectively mitigate and adapt to it.”

The Task Force’s call is a sobering acknowledgment that the question has shifted from whether we can stop climate change to whether we can eventually slow it down and learn to live with its serious consequences. A stark statement of that later position was Bill McKibben’s much-discussed recent book, Eaarth: Making a Life on a Tough New Planet, a look at what our lives will be like in the next half-century. He purposely changed the spelling of Earth to emphasize that, in the future, we’ll be living on a different planet. According to McKibben and many other environmentalists, the dire effects of climate change—species extinction, ocean acidification, droughts, severe storms, rising temperatures, and dwindling water supplies and arable land—are already evident. Even if the major countries took unprecedented steps tomorrow to reduce greenhouse gases, those already released would likely continue to cause a rise in the world’s average temperature for several decades—well above the 2-degree centigrade increase that marks the tipping point of runaway environmental change.

Climate change triggers and is partly fueled by psychological processes that therapists are presumably experts at addressing—denial, dissociation, apathy, and despair. In her article, “The Myth of Apathy,” on Sustainable Life Media, psychosocial researcher Renee Lertzman, who consults with organizations and individuals about taking action on environmental issues and teaches courses on psychology and sustainability, says that what appears to be apathy is really a “‘tangle’ of confusion, emotions and desires.” This results in a gap between our values and behaviors.

While the overwhelming majority of people are in favor of saving the environment, she says, many of the habits of consumption they consider integral to their well-being and comfort contribute daily to climate change. A common technique that people use to solve dilemmas like this is to dissociate from them. Furthermore, she says, some people have a difficult time even contemplating the long-term consequences of a problem so vast and of such catastrophic consequence.

What, if anything, should psychotherapists do to deal with climate change? Justifiably, therapists are wary of injecting their own social agenda into therapy. A therapist whose depressed client says she feels so hopeless about climate change that she’s no longer doing well at work is likely to turn the focus toward the client’s cognitive processes and personal history, rather than focusing on the issue of climate change. But while that may be standard clinical procedure, has the time come to question whether the broader issue also needs consideration?

Only when we get in touch with our own fears, ecotherapists say, will we be able to help our clients explore what climate change means to them. But therapists first need to do their own work and make sure that their apathy, fear, confusion, and denial don’t deafen them, however subtly, to what their clients tell them. Discussing climate change, says British therapist Ro Randall, can open up exploration of “existential questions about the purpose of life, re-evaluations of basic beliefs about human nature . . . and assumptions about solutions.”

Psychologist Mary Pipher’s upcoming book, The Green Boat, calls upon therapists to acknowledge the new reality and take action. “Therapists are experts at navigating complex changes, problem solving, listening deeply, and purveying hope,” she says. Allowing—not forcing—discussion of climate change names the elephant in the living room, Pipher notes, and turning toward things we’re reluctant to face is a bedrock principle of therapy. Openly discussing fears won’t stop climate change, but it may allow for that human connection that opens the door to hope and action, which, Pipher says, is “often the antidote to despair.” Just as therapists know about making referrals to support groups and social services, in these days of climate change, she says, therapists ought to make themselves aware of, and explore with clients, opportunities for doing something to address the problem.

Pipher, who grew up in a rural county immersed in nature, has dealt with her own despair and grief about the environment by founding a local chapter of 350.org, a grassroots organization that mobilizes people around local environmental actions. Now she’s vowed to speak about climate change at every public opportunity. “I once had a gay client in a homophobic community,” she says, “who ended up killing himself,” and as a result, she vowed to talk about and try to normalize homosexuality whenever she could in her public and personal life. “We shouldn’t be running from our despair and anxiety about global climate change,” she says. “We should be exploring and processing it and, ultimately, turning it into something useful for us and the planet.”

New Perspectives on Termination

Studies indicate that the average course of therapy lasts only five sessions and that as many as 60 percent of clients drop out of therapy before their goals are met. These numbers suggest a lot of treatment failures and the need for practitioners to reevaluate their basic assumptions about anticipating drop-outs and tracking clients’ session-by-session satisfaction with the therapy process. That’s especially important early in therapy. Outcome research by Michael Lambert and others finds that clients who don’t experience progress in the first few sessions are the likeliest to drop out and the least likely to ever make progress.

So why don’t more therapists identify therapy that isn’t working and take steps to address it? The cynical view attributes their reluctance to potential income loss. But the reluctance to admit that therapy isn’t on track, especially in the early stages, may reflect the very quality that accounts for effectiveness: the therapist’s refusal to give up hope for successful treatment. There may be some ego involved, too—clinicians who buy into the notion of therapist as a Master Fixer may find it difficult to admit when therapy isn’t gaining traction.

Finding out from clients early on how they feel therapy is going can alert overly sanguine therapists that something is amiss and help them understand more about what specifically isn’t working for the client and why. Out of that collaborative discussion, decisions can come more organically about how to alter therapy or, when appropriate, make a referral. Directly soliciting feedback and discussing it may require a different mindset for many therapists, however. Studies have shown that therapists often assume clients are primarily responsible for treatment failures, and therapists operating from a blaming mindset are less likely to handle a dissatisfied client’s negative feedback well.

According to University of Minnesota professor William Doherty, the ways in which such defensive therapists react may unconsciously push clients toward terminating. They may lapse into a type of consumer-speak: “If this isn’t working for you, you certainly have the right to find someone else.” They may suddenly spring the termination option as the “best” decision for the client before adequately exploring what went awry with therapy, how both therapist and client may have contributed, and whether therapy can be repaired. Or they may slip into a passive voice—“mistakes were made”—that smothers the therapeutic relationship with too much professionalism, killing any meaningful connection.

If the discussion makes it clear that a particular therapist–client match isn’t likely to work, then termination should be conducted with nondefensive clarity, as is the case with other parts of therapy. Therapists can handle uncomfortable discussions about therapy more directly, Doherty says, by thinking of themselves not as the experts at solving every problem that comes their way, but as the experts at therapy: they can’t fix everything, but they can know when they’re not the right therapist for a particular client.

The Age of Digital Therapy

We have no way of knowing how many therapists have at least occasionally used e-mail or video-based platforms, such as Skype, to conduct psychotherapy, but the numbers are growing quickly. As electronic communication has become integral to everyone’s lives, many clients have begun to expect that their therapists will connect with them occasionally via computer. Some have predicted that therapists who restrict themselves to the in-person therapy session may eventually become marginalized and irrelevant.

“Increasingly, our clients are demanding electronic therapy,” says psychologist DeeAnna Nagel, cofounder of the Online Therapy Institute. Medicare and Medicaid already pay for telehealth under certain circumstances, and according to psychologist Marlene Maheu from San Diego, California, founder of the TeleMental Health Institute, 12 states have mandated that insurance companies pay for telehealth. She cautions that therapists currently can expect considerable difficulty collecting insurance payments for such services, but there’s a clear trend. The main question about electronic therapy may soon become not whether today’s therapist should do it, but whether tomorrow’s therapist can afford not to.

It’s become so easy to bring psychotherapy into the Internet Age that a lot of therapists who previously considered sending an e-mail a major accomplishment now have websites and Facebook pages and regularly communicate electronically with clients. However, that’s a long way from providing effective telemental health services. Both Nagel and Maheu recommend that therapists first try it on clients with whom they’ve already done in-person therapy. In fact, Maheu won’t take on a client for telehealth until she’s done an in-person intake. Although numerous studies show that video-based therapy can be as effective as in-person therapy, data indicates that when it comes to intakes, in-person is much more reliable.

Converting an already existing in-person therapy relationship to telehealth therapy leaves less room for subsequent misinterpretations. In e-mail and other text exchanges, says Nagel, therapists can’t see the visual feedback cues from clients that tell whether their feedback has been accurately received. She cautions that when sending messages, therapists should make sure to look at what they’ve written from their clients’ viewpoints as well as their own. “Check and recheck what you write before you send,” she says. It’s important to pay as much attention to the tone as to the content, and check frequently with clients to ensure they’ve understood what you said in the way you meant it. Video brings different complex considerations into the therapy mix, such as eye contact, background, and gestures. For example, if a therapist breaks eye contact while she’s thinking, in-person clients may experience her as thoughtful, while clients watching over a webcam may feel she’s disengaged.

Nagel warns that therapists may have a tendency to lose awareness of the therapy process itself once they go electronic. “It’s not so much about how we use the technology, but how we transfer our skills,” she says. Because e-mail is asynchronous, therapists may lapse into an advice-giving instead of a reflective mode. In synchronous, text-based modes like Instant Messaging chat, there’s a tendency to fall into more of a friend role. Plus, all forms of electronic therapy can have powerfully disinhibiting effects, she cautions. Therapists should remember that, just as in in-person therapy, sometimes it’s important to stop clients from disclosing too much too soon. Clinicians need to maintain the tone they’d use when working in person.

There are legal and ethical issues as well. Many therapists who are using electronic therapy have unwittingly violated confidentiality guidelines and state licensure requirements. Because electronic therapy can cross state lines, Maheu says therapists should know not only their own state licensing requirements, but the licensing rules of the client’s state as well. Some states expressly prohibit their therapists from practicing out of state, so doing therapy with someone who lives in another state can earn a hefty fine in certain situations. For instance, a California therapist who does therapy with someone in Utah can get fined by both states. When doing therapy with a client in another state, says Maheu, therapists should always contact the licensing board in the other state and ask for permission prior to treatment. Failure to do so can technically lead to criminal conviction and subsequent nullification of malpractice insurance, although the licensing boards are only recently mobilizing to take action on such licensing violations.

Many forms of electronic therapy aren’t HIPAA-compliant, including Gmail, which isn’t sufficiently encrypted and passes through junctions where other people could conceivably read or archive the e-mails. Skype, often therapists’ platform of choice, may be free, but it’s not nearly as secure as other services and may not be HIPAA-compliant, warns Maheu. Services such as LifeSize.com will set up more secure connections for a nominal charge, but the field is in such flux that Maheu recommends that therapists make sure that any service they use clearly states that it’s HIPAA-compliant, not simply that it’s “secure.”

Therapists can learn more about how to develop online therapy skills and understand the legalities involved at Nagel’s Online Therapy Institute and Maheu’s TeleMental Health, which feature a range of information and resources.

Resources

Climate: American Psychologist 66, no. 4 (May/June 2011); Ro Randall, “Hope, Despair, and 4° Celsius,” May 30, 2011, http://rorandall.org/2011/05/30/hope-despair-and-4%C2%B0-c/ Termination: Professional Psychology: Research and Practice 42, no. 2 (April 2011): 160-68; William Doherty, Psychotherapy Networker Webcast, “The Ethics of Termination,” http://www.psychotherapynetworker.org/cecourses.

Illustration © Ralph Butler