The importance of teaching climate-health literacy in psychotherapeutic training and continuing education

Introduction

We live in a time of crises that affect our health in many ways. One of these is the climate crisis. Climate change affects health either directly through heat waves and other extreme weather conditions or indirectly through changes in natural systems, such as the increased release of allergens or more favorable conditions for disease-transmitting organisms. The extent to which climate change affects health can be assessed in conjunction with population dynamics, as well as in economic development and health care. According to a report on climate change and health by the Austrian Panel for Climate Change (APCC, 2018), a higher proportion of older or chronically ill people, poorer health care, and an increasing number of people with lower incomes lead to an increased societal susceptibility to climate change.

In February 2023, the research team of the “Kompetenzzentrum Klima und Gesundheit” (Competence Center for Climate and Health) wrote a research letter about health-related climate competence among health professions. The research team is part of the Gesundheit Österreich GmbH, which is the national research-and-planning institute for the health-care system, as well as the central agency for health promotion. The Republic of Austria represented by the Minister of Health is the sole shareholder of Gesundheit Österreich. In a letter about climate literacy among health-care professionals, they stated that physicians and nurses should have more literacy in dealing with climate-related health issues in their training programs (Brugger, 2023; Brugger and Horváth, 2023).

Austrian research agencies have mentioned the psychological effects of climate change. The research letter is based on detailed reports by the APCC in 2018 and a long report and the study by Brugger in 2023. The psychological consequences are mentioned only once briefly or not at all in the report for politicians in the short forms of the APCC summary in 2018 and the research letter from Brugger and Horváth in 2023. This applies not only for Austria; the psychological consequences of climate change have a lower priority than physical ones worldwide. There are numerous studies on the effects of climate change on physical health, but few studies on its effects on mental health (Cianconi, Betrò, and Janiri, 2020).

The purpose of this paper is to make a scientifically based plea for greater consideration of the psychological impacts related to climate change in the education and training of health professionals. For reasons of limited publication space, only one health profession will be in the focus of this paper, namely psychotherapists. They work primarily with mental-health disorders and benefit most from climate-health literacy through learning about the effects of climate change on the human psyche and vice versa in education and training. The impact of climate change on mental health and the impact of mental health on physical health should also be included in the training and education of other health-care professionals.

Climate-health literacy

Climate-health literacy is a term recently used in scientific papers. It is more than a combination of climate literacy and health literacy. These two concepts are briefly defined below.

Some authors use both climate literacy and climate-change literacy interchangeably, while others distinguish between them. Dupigny-Giroux (2017) suggests that climate literacy refers to knowledge about the climate and acting accordingly to this knowledge. Climate-change literacy is more specific and refers to the knowledge and actions evolving from knowledge about the anthropogenic climate change and its impacts. This paper uses the two terms synonymously and refers to knowledge about climate change, its impacts on the planet and humans, human impacts on the environment, and complex reciprocal influences. “In other words, a climate literate individual is an expert in the principles of climate science and can assess information and communicate about climate change clearly and take responsible action towards decreasing unsustainable practices that negatively affect the environment.” (Suhaimi and Mahmud, 2022, p. 2).

A systematic review of health-literacy literature was published in 2012. The authors created a combined model based on 17 different definitions of health literacy. This model contains three health domains and four dimensions. In short, health literacy is the ability 1) to access information on clinical issues, risk factors for health, and health-promoting factors, 2) to understand medical information and information on factors risking and promoting health, 3) to interpret and evaluate this information, and 4) to make informed decisions based on the interpreted and evaluated information (Sørensen et al., 2012).

Both the fields of health and climate are very complex, as is the concept of literacy. One reason is the difficulty of drawing a line between literacy and illiteracy. According to Suhaimi and Mahmud (2022), a climate literate is an expert on climate science. The question is, when is someone considered to be a climate-change expert, and what does this mean? The US Global Change Research Program wrote a guide on the essential principles of climate science to help individuals and communities gain climate literacy. They defined a climate-literate person as someone who “… understands the essential principles of Earth’s climate system, knows how to assess scientifically credible information about climate, communicates about climate and climate change in a meaningful way, and is able to make informed and responsible decisions with regard to actions that may affect climate.” (US Global Change Research Program, 2009, p. 4). The difference between the former and the latter definition may simply be wording, but the question is whether a climate-literate person must understand the principles of climate science or has to be an expert in the principles of climate science. Based on the (etymologic) original meaning of the term literacy, the ability to read and write, it is obvious that a literate person does not have to be a language expert but must have knowledge of the principles of reading and writing. Therefore, the definition of the US Global Change Research Program is briefly summarized below.

Health literacy is the ability to find, access, understand, interpret, evaluate, and communicate information about health, including clinical issues and both risky and protective health factors, and to make decisions and act accordingly on that information. Climate literacy is the ability to find, access, understand, interpret, evaluate, and communicate information about climate science, including the impacts of climate change on living and non-living environments and vice versa (especially our impact on climate change), and to make decisions and act based on that information. Climate-health literacy is, therefore, the ability to find, access, understand, interpret, evaluate, and communicate information about the impact of climate change on human health and to make decisions and act accordingly on that information. The following definition of climate-health literacy based on a review of numerous studies and papers was published in 2020.

“Based on our thematic analysis, we define climate and health literacy as the degree to which an individual understands the complex relationship between climate change and human health; a climate health–literate individual can recognize direct and indirect linkages between climate change and health, communicate risks, assess data, comprehend uncertainty, and make informed and responsible personal decisions or advocate for broader policies that protect health.” (Limaye et al., 2020, p. 2185; see also Grabow et al., 2023, p. 2).

The authors of this definition published seven climate-health literacy elements: 1) Root cause (what are the main causes of the anthropogenic climate crisis, which also affects our health), 2) Mechanism (how climate change affects human health), 3) Determinants (the strong bond between our environment and our health), 4) Implications (climate change worsens health disparities), 5) Interventions (How can the impact of climate change on our health be reduced?), 6) Evidence (Which evidence exists for climate-change impacts on our health and how do we get evidence?), and 7) Complexity (the enormous complexity of the connection between human health and climate change, which varies over space and time). The first two elements are so-called functional literacy, the next three elements are intermediate literacy, and the last two elements are advanced literacy (Limaye et al., 2020; Grabow et al., 2023).

The focus here lies on mental health. It can be useful to create a more specific definition of mental-health literacy concerning climate. The impact of psychological issues, like stress on physical health and the impact of a physical illness on our psyche, are evident. Psychosomatics is not just a modern word to describe the impacts of the mental state on physical health and vice versa, but a concept of a body-mind unity (Grassi et al., 2019; Lowen, 2012).¹ A new concept “climate mental-health literacy” is not necessary because of the indivisible nature of physis and psyche. This paper includes mental health in the term climate-health literacy.

The interactions between climate change and mental health

There are numerous scientific publications on the interactions between climate change and mental health. We systematically researched and reviewed articles and books on the topics of climate change and its impact on individuals and society with a special focus on the impacts on health. As a first step, we had to open up the research focus, as many articles addressed, for example, the effects of climate change on pollen and allergies, but not the effects of more severe allergies on mental health. In a second step, we researched and reviewed literature on indirect impacts of climate change on mental health like the impact of severe allergies on mental health. The focal points were formed inductively during the evaluation of the scientific articles and were adapted repeatedly during the review process. The following list was compiled from many different articles and books but does not claim to be complete.

Psychotherapeutic education in German-speaking countries with a focus on climate change

The practice of psychotherapy is not regulated by law in every country in the world. Where it is not, no law prescribes what training must be completed to work as a psychotherapist. In those countries where psychotherapy is regulated by law, there are usually training guidelines. These differ from one country to the next around the world (Pritz, 2002). The author of this paper has mainly studied psychotherapy training in German-speaking countries. The following paragraphs particularly apply to Germany, Austria, and Switzerland. The core statement can also be adopted for other countries.

Since the new Psychotherapists Act in Germany from 2020, the path to psychotherapeutic licensure includes a polyvalent bachelor’s degree in psychology and a postgraduate master’s degree in psychotherapy, which is usually offered in combination with clinical psychology. After completing the master’s degree, one may work as a psychotherapist. Running one’s own practice is only permitted after further specialization over several years in a specific approach. The number of psychotherapeutic approaches that can be chosen is limited. Only cognitive behavioral therapy, psychodynamic psychotherapy, and systemic therapy are legally recognized in Germany. All other psychotherapeutic approaches, like gestalt therapy, can be practiced as an alternative practitioner, but not as a psychotherapist (Bundesrepublik Deutschland, 2020; Bundespsychotherapeutenkammer, 2021).

One must complete a master’s degree in psychology in Switzerland. Following this, several years of postgraduate training as a psychotherapist can be completed in a psychotherapeutic teaching organization. In total, 42 psychotherapeutic educational institutions are accredited in Switzerland covering various psychotherapeutic approaches, such as psychoanalysis, gestalt therapy, psychodrama, person-centered psychotherapy, systemic therapy, and many more (Schweizerische Eidgenossenschaft, 2016). Both Switzerland and Germany consider psychotherapy to be part of psychology and teach students experimental psychology right from the start. This is a view that the author has already opposed in several papers and books (Raile, 2023a, 2023b, 2023c) and will not be discussed further here.

The Psychotherapy Act of 1990 is still valid in Austria. It prescribes a two-part training schedule to become a psychotherapist. This consists of a general propaedeutic course and a specialized course in a specific approach. In Austria, 23 psychotherapeutic approaches are currently legally recognized, including psychosynthesis, individual psychology, gestalt therapy, and cognitive behavioral therapy. Unlike in Germany or Switzerland, it is not necessary to have a degree in psychology to complete psychotherapy training; it is even possible to become a psychotherapist without a degree in Austria (Bundesrepublik Österreich, 1990). This is expected to change in the next few years, as a new psychotherapy law is currently being prepared and is expected to be submitted for parliamentary review in the second half of 2023 (Datler et al., 2023).

When the author of this paper published the first book on eco-anxiety three years ago (Raile and Rieken, 2021), there were no courses for psychotherapists that explicitly addressed the topic of climate change or the psychological effects of the climate crisis. There is still no dedicated course in the German-speaking world that teaches the complex interrelationships between climate change and (mental) health mentioned in the previous section in the necessary detail (Psychologists for Future, 2023, personal communication). Fortunately, there are at least individual training events:

Organizations like Psychologists for Future offer regular seminars on climate change and psychology/psychotherapy. The Sigmund-Freud University (SFU) in Vienna also offers seminars on climate change and psychotherapy for students and licensed psychotherapists. A Climate Study Group which organizes lectures and discussions on its own initiative has been formed by psychotherapy students at the SFU (SFU, 2023). A separate event was held in October 2022 titled “SFU Goes Climate”, where researchers from all faculties presented their contributions to researching and addressing the climate crisis (SFU, 2022). The Sigmund-Freud University has the first concept for a two-semester course on eco-emotions, which not only teaches the basics of climate change and its complex influences on (mental) health and vice versa, but also focuses on practical psychotherapeutic work (Raile, 2023d). Unfortunately, most German-speaking universities do not offer such training for psychotherapists, although the topic is highly relevant. The possible contents of such a training series are summarized and critically discussed in the next section.

Teaching climate-health literacy in psychotherapeutic education – an example

When we think about creating a course for climate-health literacy, we must define our target audience. Are we talking to psychotherapists about the impact of climate change on mental health, or are we talking to other health professionals, like doctors and nurses, or are we talking to patients, or to the general public? Depending on the target group, the form of communication (use of technical vocabulary) or the content (assumption of prior knowledge) must be adapted. While the general population benefits more from learning about the mechanisms and effects of the climate crisis and individual coping strategies, psychotherapists benefit more from learning about the climate-specific aspects of mental health and how to adequately deal with those in practice. The following paragraphs present a concept of what such a training course could look like. The concept was developed by the author taking into account the theoretical foundations outlined in the previous section and in exchange with students (e.g., the Climate Study Group of Sigmund Freud University), psychotherapy colleagues (e.g., the co-author of the monograph on Eco-Anxiety) and experts (e.g., from Psychologists For Future). A modular and sequential three-level course is being considered with seminars for beginners, advanced professionals, and experts. The explanations below include the contents of the individual courses. The didactic, the way of conveying the contents, is not explicitly described, and can be freely chosen by the lecturers, whereby a mixture of frontal presentations and interactive elements is recommended.

Discussion

The concept presented here does not contain all the points dealt with in the previous section because not all of them are equally relevant for psychotherapists. A separate seminar for the impact of climate change induced infections on mental health may be more relevant for medical doctors but less relevant for psychotherapists due to their primary focus on mental health. However, it is important that mental-health professionals know about these connections and can communicate them. This makes the concept vulnerable to critical review, as other experts may see other contents as more important. Various seminar providers may also select contents according to specific interests to attract as many paying participants as possible. Other education and training providers may delete contents due to a limited budget or (in their view) a lack of relevance for psychotherapists. Regardless of the reasons for the deletions or the choice of contents, it is an important step forward if such topics are taught at all in psychotherapeutic education and training. In this regard, even a small step in this direction is a success in the fight against the advancing climate crisis and for people’s mental health in times of climate crisis.

Especially the teaching of contents like eco-emotions can be criticized by psychotherapists since dealing with emotions is part of psychotherapeutic training, anyway. This criticism can be countered in three ways: First, contents like crisis intervention or trauma therapy are also part of psychotherapeutic training, but not always sufficient to work in depth with severely traumatized people. Further training and specialization are never pointless, but relevant, for example, to get to know the specific characteristics of eco-emotions in depth. Second, pathological emotions, such as generalized anxiety disorder, are different from eco-anxiety, which can also display similar symptoms. The difference is that the threat, i.e., the climate crisis, is real, and the feelings of anxiety are basically adequate. Therefore, in addition to working on the feelings, we also must work on dealing with the causes. Contextual knowledge is of great importance here, which is why further training is important. Third, such training serves to sensitize psychotherapists to the climate crisis and its effects on the human psyche. This is not only important for psychotherapeutic work, but also for their own mental health because psychotherapists can also experience eco-emotions, such as fear or anger (Raile, 2023d).

Conclusions and a plea for teaching climate-health literacy to health-care professionals

Climate change is steadily progressing, and humanity does not presently seem able to stop it effectively. The consequences are severe and affect not only our planet and ecosystems, but also our health. For the sake of our health and because we can only effectively protect the climate if we protect our health, it is important that health-care professionals are informed about the effects of climate change. It is important that health-care professionals, presented here using the example of psychotherapists, have climate-health literacy, i.e., knowledge of the complex mechanisms and interactions between climate change and health.

As most examples for psychotherapy education in this paper are from German-speaking countries, individuals and organizations offering psychotherapy training in other parts of the world may adapt the concept due to very different educational systems or political context. Since climate change is a global threat which affects people’s mental health, all psychotherapists and all institutions offering training and continuing education for psychotherapists and all other health-care professions are recommended to include these contents with any necessary adjustments in their curricula, to offer seminars, and to provide further information on these topics.