10 May 2021
Our lead author on the College’s sustainability position statement, Dr Katherine Kennet, joins us to discuss the importance of integrating the natural world with more traditional therapy and how she would encourage other mental health professionals to use ecotherapy.
Find out more about how the College is taking action on environmental issues by viewing our new position statement on Sustainability.
Ella Marchant: Hello and welcome to the Royal College Psychiatrists Podcast with me Ella Marchant. You're listening to the Climate Change Podcast Miniseries which we are bringing to you alongside the College's position statement on sustainability. Our mental health is deeply connected to the health of our natural world. We'll be exploring this connection across three short podcast episodes. On Episode 2, we'll be talking to Dr. Katherine Kennett, who is a Child & Adolescent Psychiatrist working in North London and is a social prescribing lead for the Royal College of Psychiatrists.
She is an active member of the College's sustainability committee and has spoken widely on social prescribing and the links between mental health and sustainability. Katherine was the lead author on the College's position statement on social prescribing and she believes passionately that climate change and access to green spaces are social determinants of mental health and should be treated as such.
Katherine, could you please tell us a little bit about your work and how sustainability fits into mental health care?
Katherine Kennet: Yes, thank you for having me. As you said, I'm Dr. Katherine Kennet, and I'm the Royal College of Psychiatrist's lead on social prescribing. I'm involved in the sustainability committee, and my day job is as an ST6 trainee psychiatrist in North London. In terms of sustainability, I've been involved in sustainability in the College for about six years, and it's a really exciting aspect of mental health care, and it's something that links so closely with what you do. In terms of how it fits in, sustainability is so closely linked to psychiatry and mental health care.
As I say, that's something that I don't think that many people are aware of. Sustainability, the environment, the natural world, the places where we live, our interaction with the environment are all parts of the social determinants of health that we think about all the time, more classically, in medicine, but particularly in mental health care, and the climate change aspect, how nature affects us, it's all part of that. In terms of my role, in my day job, I use sustainable principles pretty much every day as I think most psychiatrists do, probably without knowing it.
In terms of my work at the College, I've been involved in various aspects of policy development around sustainability and around social prescribing. Specifically. I'm not sure if your listeners are aware of what social prescribing is, it's essentially supporting service users and anyone in the community to interact with their local community, and often their natural environment near them in a way that's helpful to them, build connections. It can have the effect of feeling really empowered, really part of a community.
We've all seen particularly in lockdown, how connecting with other people and connecting with nature can play such a massively beneficial role in our mental well being, whether that's somebody who is just feeling a bit lonely, feeling a bit low maybe, or at the other end of the scale, someone with a severe and enduring mental illness can get huge benefits to support other aspects of their mental health care by being in nature and being with other people.
Ella: How beneficial do you think the natural world is in a time where we've had three lockdowns in a year?
Katherine: We all know the advantages and how important it is of being in the natural world, and how hugely beneficial it can be. From a personal point of view, I got into gardening and that sounds unusual, but I was not somebody who was into gardening before. I had a tiny balcony, and I really found during particularly the first lockdown being around things growing, hugely beneficial. In terms of the wider population, we've all seen how important it is just to be in the natural world.
We know from numerous studies, actually, it can be so beneficial, whether you are, as I say feeling a bit low, or whether actually, you have a severe and enduring mental illness actually being in the natural world can have huge benefits, and being with other people as well. I think outside spaces can have a wonderful effect on our mental health. It certainly is often not the only cure, it needs to be around other more traditional ways of managing mental health. This isn't about saying that somebody with a severe and enduring mental illness just needs to get outside more, for example, or go for a walk.
We have seen that, in supporting other traditional methods of mental healthcare, so alongside medication where that's needed, talking therapies where that's appropriate, other OT support, for example, that adding in nature-based care can be really helpful. It also has the effect of being quite empowering. So much of what we do in psychiatry is not truly patient led. If somebody is very unwell, then actually often it’s not the case that it's truly patient led because it can’t be sometimes.
Actually having this aspect to healthcare, something that individuals are choosing to do, whether that's being outside in a nature-based walking group, whether that's just spending time amongst flowers, amongst birds, whatever it might be, or something a little bit more intense things like sporting activities outside, can be hugely helpful, particularly if that's something that someone is choosing to do.
Ella: So you're very keen to join the two elements of not only being outside engaging with the natural world, but also being part of a community as well?
Katherine: Yes, I think in terms of social prescribing, they go hand in hand, both are hugely beneficial. Often if we're in a difficult place, and we're having a difficult time, making the decision to get outside on your own can be quite hard but being part of a group that can support you and encourage you in that can be massively beneficial. It takes away the decision-making bit of it sometimes if you know that there are people waiting for you in a group, in a community, who can be with you in a space and enjoy it or feel part of the natural world together. It can just be so beneficial.
It can be a connection, not just to something bigger than your experience, the planet, nature, the environment, but also your community, and knowing that there are other people there enjoying it, too, can be incredibly powerful.
Ella: Yes, I absolutely agree. I think having mental health needs can make you feel very introspective and very insular, and engaging with the outside world makes you remember that you're bigger than just this one thing. How is the climate crisis and ecological crisis going to affect us?
Katherine: Well, that's a big question. I think humans' mental health and well-being, and the planet's health and well-being are totally linked, and we're going to see them be more and more linked in the coming, I think months and years. We're already seeing the impacts of climate change on our mental health, we don't have to go very far at all. If we look at flooding, for example, that's been something that's becoming more and more frequent in the UK over the last few years. The impacts of that on individuals' mental health are huge.
For example, recent studies have shown that almost a third of people who have had severe flooding in their homes in the UK have most likely got anxieties. They meet the criteria for anxiety, over a third have PTSD, this is at one year, and just under a third have likely depression. That's a big impact if we're thinking of the number of people who've been flooded and that's just one natural disaster that can happen due to climate change. That's massive, that's a huge number of people.
If we look at the wildfires in Australia, in California over the last two years again, it's not difficult to see how that massive social trauma, losing your home, being displaced, potentially having injuries or personal tragedies in other ways directly due to these natural disasters that are becoming more frequent due to climate change has a huge impact on individuals’ mental health. It's not that different from what we learn as trainees and what we see every day as psychiatrists, trauma contributes to mental ill-health, not for everybody but for a lot of people.
You need to be incredibly resilient and quite lucky, I think, to get by these massive traumas in your life, without an impact on your mental well-being. There are other aspects too, so climate warming in itself is linked to all aspects of mental health. Rising temperatures has been linked to higher mortality in those with mental ill-health. It also can be linked to those completing suicide. Things like pollution have been linked quite strongly to dementia, and to completing suicide. There are all sorts of aspects on the immediate impacts of climate change, particularly.
We also spoke in your previous question about the environment and the benefits of being in the natural world, and also losing the natural biodiversity that the planet has, as a direct impact of human action, has a big impact. That resource, that wonderful natural world that we can see outside our windows and we can go for a walk in even in lockdown, that we all feel the benefit of and certainly have felt in the last year - that's being lost and it's been lost at an alarming rate because of climate change and because of human action.
The other aspect of it is that large social changes that happen - wars, drought, or things like famines due to droughts that lead to huge migration. Internal and international migration also have an effect on mental health. We know again from our daily work that somebody who has had to move from their home to another part of a country or to a different country is at higher risk of some severe mental illnesses like psychosis. That's only going to increase if more people have forced migration.
The link between climate change, and the environment's health, and our own mental health as a population of the planet, and also even within the UK are massive. The sooner we realise that the sooner we incorporate that in our practice, the better.
Ella: Going back to mental health more, how can a psychiatrist or any mental health professional incorporate the use of the environment into their everyday practice?
Katherine: I'm so glad you asked that because I feel like my previous answer was a little bit bleak. I don't think it is bleak at all, I think there's an awful lot we can do as psychiatrists to incorporate sustainability principles and practices in our daily work. At the sustainability committee at the College, we've come up with five core principles of sustainability and mental health.
The first is prevention - this is something that we all do every day anyway, in our practice, but prevention is so much better than cure in all senses, particularly with sustainability. Keeping someone well is absolutely the best thing you can do. That might mean actually being a little bit creative, it might mean going on that home visit, even if it means spending a bit more time in the car, which might not be the best thing or whatever you might be using to try to get yourself there, to prevent someone from getting on well enough to not require an inpatient stay, for example. Prevention's number one.
Number two is empowerment of patients. I've already spoken about how empowerment with the natural world can feel really powerful. We want our patients to be empowered, we want all service users to be empowered to ask for what they think is helpful. That means that resources will be used. If medications are prescribed, for example, if someone's empowered to use them, and it's what they want, and they're on board with their treatment plan, and then they're much more likely to use what's been described, they're much more likely to get well quicker, or to stay well, and less likely to waste those medications.
We know that nearly a third of medications prescribed in the UK by doctors aren't taken. That's hugely wasteful, so empowerment is really, really important.
The third one empowerment of staff. We know that there's huge amount of burnout in mental health services from staff. Now, being sustainable also means being sustainable with our workforce. We've all been through a huge challenge with COVID. All of us are feeling quite tired, burnouts on the rise, so really making sure our staff are well looked after, not just so they can pass them that good care to their clients that they work with, but also so that they enjoy their work, that they feel refreshed, they're more likely to stay in services is really important as well.
The fourth value that we've come up with - or principle - is high-value care. Again, a lot of this is sounding like gold standard practice, I think that's really key. I'll come back to that in a moment. Actually, we want all the care we give to be of the highest value. Resources that are used, are used in the best possible way to get the best outcome for them.
Then the fifth and final principle we have is reducing waste or thinking about carbon, reducing carbon loss. You'll see that you might think might be the first one is very pointedly the fifth because actually, the other points are so much more important.
Keep people well, keep staff empowered, keep patients empowered, everything we do should have a high value. Hopefully, you can see that sustainable principles of mental healthcare are very much gold standard principles. This isn't about giving less care. This is about giving excellent care, incorporating the natural world incorporating empowerment, working really well as we do to give the best possible outcome to our patients. It's not about taking something away and being stingy with our resources. The natural world and communities are such a valuable resource.
They're ones that don't cost us anything in terms of the climate and in terms of the environment, they're hugely giving. You can spend time outside, you can be in gardening groups, you can go on walking groups, you can be in community spaces in the natural world with others, and it doesn't cost the planet anything. In fact, it gives to the planet. If we're spending time nurturing our natural world, then that gives back to us as a community, but it gives back to the natural world as well.
Ella: That leads me nicely onto the next question, which is what would you say to psychiatrists who felt that practising sustainable mental health care wouldn't work for their patients?
Katherine: I think it's all about thinking holistically. Sustainable mental health care is not about turning off the lights and not printing. Yes, these things can be brilliant. They can be really helpful, but if what you're printing or what you're turning on the lights to see can have a huge beneficial impact on somebody's mental health, then it is sustainable to choose to make those decisions.
Actually, it's all about, as I say, thinking about the big picture, thinking holistically, looking after the environment, looking after our natural world as an investment in a human community and as well as in the natural world itself and thinking about every day the things that we can do to follow those five principles. We've actually come up with the committee with a top 10 highly practical tips for practising sustainable psychiatry. They're things like looking to see if your local area has a social prescribing scheme, if there are any link workers within social prescribing you can refer to, how to make sure your patients are on board with your prescribing plans so that everything that's prescribed is used, thinking about green methods of transport that are healthier - if they're safe to use to get from patient to patient, either by cycling, by walking or using public transport.
They're very practical steps. I think all of us have a responsibility actually to contribute to planetary health, to prevent our patients from reaping those negative rewards of us not looking after our planet. I think the timescales of this are quite quick.
I think it's within most of our lifetimes that if we are not considering the natural world and climate change, there are actually the large-scale impacts of that are going to come back to bite our patient populations and ourselves. I think I'm always mindful in my clinic of the social aspect of the bio-psycho-social model. I always make sure that I take some time to think with my patients about what they could be doing with their community. Now that's more community environment than necessarily the natural world, but I think it's so important that we link up our patients with their communities, that they don't feel so on their own.
I often think with patients about the natural world actually and just think about-- there's a school of thought that we should be using nature-based histories. Not just our classic mental health histories... we ask our traditional questions; what's your mental health history? Have you been in a hospital before? What medications do you take? But also that we add in a few questions about where are your favourite places? Do you find anything about nature connects with you? That kind of thing. It only takes a few minutes, or a few seconds, but it can be very helpful in thinking about some of these protective factors and bringing another aspect into your formulation about patients.
I also think that particularly in lockdown, the outside world and the natural world comes into conversations with patients every day. People want to connect outside and it's the populations that we work with who don't have access to green spaces that I think it becomes more important, more prevalent. You really see the importance when you're talking to somebody, particularly young people I work with, and how important it is for them to have access to the natural space.
I think also, we haven't touched on this today, but that the aspect of eco-anxiety, the idea, particularly in young people, but in all ages of anxiety that comes knowing that our planet is not being looked after and that we're on a one-way street unless things change to things being very difficult indeed. Then people I work with often bring that as well. Their social responsibility as they see it, their frustration that those around them aren't taking what they see as something seriously. That comes into my everyday practice as well.
Ella: Moving on to the last question, which has quite a big one, the College has produced a position statement about climate change, which you helped to write. What difference do you think it can make and what needs to happen for the position statement to make a real change?
Katherine: Well, that is a big question. I think the most important thing is for psychiatrists to know that this isn't a big issue that happens outside the consulting room. This is something that affects all of us as psychiatrists, but also all of our patients every single day. The decisions that we make today are going to have huge impacts for tomorrow. Also that we're already seeing service users who are feeling the negative results of climate change and of biodiversity loss. What the position statement does is spells out the links, some of which I've touched on here today, between what is happening in the natural world and the climate change and mental health impacts.
It does that in quite a lot of detail using quite a lot of evidence which I think can be really helpful. As psychiatrists, we practice evidence-based medicine and this is where we've pulled together the evidence of where our work impacts mental health and where the interchange is in both directions. What we can be doing to protect the natural world but also what we should be doing to protect our patients from what's already happening. In terms of what needs to happen, I think we need to, as with all these things, it's all about education, isn't it?
We need to let everybody know - training psychiatrists, qualified psychiatrists, those working in all aspects of mental health - about the links, about how intrinsically linked these things are. Climate change, sustainability, and mental health are so closely linked. The climate is a social determinant of health. I think in coming years, we are going to see that in the same way that we now might think of smoking, alcohol misuse, substance misuse, the ACEs, the adverse childhood experiences. All the things that we currently think of as clear links with people's mental health, I think we're going to be seeing that with the environment and with climate.
Spreading the knowledge about the links, I think is one really important aspect, but also letting people know what can be done. Things like our top 10 tips, things like how to practise sustainable psychiatry, things like how to get social prescribing and connections with the environment for your patients embedded in your services. These aren't expensive interventions. These aren't time-consuming interventions, they're things that we can all be doing every day to have a massively beneficial impact on staff, on patients, and ultimately on the planet.
Ella: Thank you for joining us today.
Katherine: Thank you for having me.
Ella: Thank you, Dr Katherine Kennet, for lending her expertise to the climate change podcast mini-series. If you would like to read our full position statement on sustainability, please go to our website.