Richard Smith: Emotional distress (not mental health) and climate change

The main thing I learnt from a webinar on mental health and climate change organized by Climate Cares is that we should stop talking about mental health and use instead words like “emotional wellbeing” or “emotional distress.” Indeed, the phrase “mental health” is more broadly out of control when it puts in the same bracket princes of the realm who have mental health problems and people living with schizophrenia.

The obvious objection to the phrase “mental health” is that it pathologises or medicalises. It is entirely rational to feel emotional distress about the climate crisis or about the gross injustices in the world, structural racism, or the covid-19 pandemic. Indeed, it might be more pathological not to feel distress. “Hanging on in quiet desperation is the English way,” sang Pink Floyd.

Unfortunately framing a problem as a health problem leads to responses of services, specialists, counselling, and drugs. But are they the right response to “the stress associated with homeschooling children while sustaining work, indebtedness, loneliness…relationships that fatally cracked, and grief,” as an article in the Financial Times, entitled “Experts fear mental illness crisis in covid’s wake,” describes? Are they the right response to floods, heatwaves, and climate breakdown?

“The government has vowed an extra £500m spending on mental health services this year to address waiting times for specialists,” reports the Financial Times. But what can specialists do for loneliness, indebtedness, broken relationships, grief, or the distress that follows your house being flooded and the fear that it will be flooded again? How can specialists help young people who feel that their future has been taken away from them by a climate catastrophe that comes closer every day? They can call it “eco-anxiety” or “solastalgia” and debate inserting it into the next volume of the Diagnostic and Statistical Manual of Mental Disorders, but how will that help anybody?

A young woman at the workshop described the relief she felt when a psychologist described the distress she was feeling about climate change as a normal response. She didn’t have a “mental health problem,” she was distressed by the state of the world.

Drugs and counselling are the two main tools of mental health services, and neither can help with the emotional distress that follows from being repeatedly flooded. Doctors wrote 71 million prescriptions for antidepressants in 2018, almost a doubling from 36 million in 2008. Almost a fifth of the population of England (17% of the adult population) was taking an antidepressant in 2018, while 3% were taking benzodiazepines, 3% gabapentinoids, and 13% opioid pain medicines. Many people have become dependent on these drugs. They may be receiving little benefit from the drugs, but suffer greatly if they try to stop them.

After every disaster there is a loud call for counselling. It is understandable that people should want to help and do something, but systematic reviews have shown that most people don’t need professional counselling. Indeed, professional counselling might suck them into sickness services and prolong their distress.

I’ve come belatedly to understand that two of the most powerful influences on health are “agency” and “relationships.” Agency is the capacity to respond to the challenges in your environment, and those who have wealth and education often have more agency than those who have little of either. But agency is not just a capacity of individuals, but of communities and groups. A better response to the distress caused by flooding and the climate crisis than engaging with mental health services is to take action, campaign for better flood protection, or for vigorous action to mitigate climate change; or join Extinction Rebellion.

“Relationships—the simple human bonds between us—are the foundation of good lives,” writes Hilary Cottam in Radical Help. “They bring us joy, happiness, and a sense of possibility….Building on relationships enables the growth of further capability: supporting us to learn, contributing to good health and vibrant communities. Without strong bonds with others, or with unhealthy relationships, very few of us can feel fulfilled—or even function.” Agency and relationships are mutually reinforcing: more agency means more relationships.

The state, the NHS, can create neither agency nor relationships. Indeed, they may have greater capacity for destroying than creating them. Something much subtler is needed, and Cottam describes such experiments in Radical Help. But when it comes to the distress caused by the climate crisis the state must take the lead. Increasingly politicians are managing the rhetoric, but the necessary actions are not following. “Broken promises and inaction coupled with the enormity of the climate crisis are all beginning to take their toll on children’s mental health,” writes psychologist Caroline Hickman

I can see that it isn’t going to be possible to avoid the term “mental health,” and I applaud the lessening of stigma and the aspiration to level up mental health services to the standard of physical health services. But mental health services should concentrate on caring for those who can benefit, not become a substitute for the urgent action that is needed on the climate emergency.

Richard Smith was the editor of The BMJ until 2004.

Competing interest: RS is the unpaid chair of the UK Health Alliance on Climate Change.