|Year : 2023 | Volume
| Issue : 1 | Page : 29-35
From Individual Psychiatry to Planetary Health Care: A Personal Account of a Brazilian Social Psychiatrist
Olga Garcia Falceto1, Enrique Falceto de Barros2
1 Department of Psychiatry and Legal Medicine, Universidade Federal do Rio Grande do Sul, Instituto da Família de Porto Alegre, Porto Alegre, Brazil
2 Post-Graduation Program on Science Education, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
|Date of Submission||11-Mar-2023|
|Date of Acceptance||12-Mar-2023|
|Date of Web Publication||26-Apr-2023|
Prof. Enrique Falceto de Barros
Post-Graduation Program on Science Education, Universidade Federal do Rio Grande do Sul, Porto Alegre
Source of Support: None, Conflict of Interest: None
This article describes the personal journey of an experienced Brazilian child psychiatrist who also trained as a systems-oriented family therapist who realized that she was not systems oriented enough. Her son, a family doctor, has been influencing the inclusion of planetary health care in her work. Personal, intergenerational, and professional development go hand in hand in this account, along with scientific developments. The account aims at inspiring other social psychiatrists and mental health workers to include 1 min for the planet in consultations, preventive, and rehabilitative work and to spread the word to our countries and international mental health institutions.
Keywords: Family therapy, planetary health, psychiatry, social psychiatry, third-order thinking
|How to cite this article:|
Falceto OG, de Barros EF. From Individual Psychiatry to Planetary Health Care: A Personal Account of a Brazilian Social Psychiatrist. World Soc Psychiatry 2023;5:29-35
| Where Do I Speak From?|| |
I wrote this provocative article following a personal account lecture for the WASP World Conference in 2023, which I developed in partnership with my son Enrique. I am happy to be a Brazilian psychiatrist that can speak to you with hope in the future. After 6 years of suffering with authoritarian governments, Brazil has recently had a democratic, well-organized election using the safe electronic voting machines. A democratic coalition won over the incumbent president that used all his power to influence the election.
There is now a large political democratic alliance in power led by President Lula, who previously served two terms in Brazil. This alliance promises to transform Brazil: eliminating hunger again (previously achieved by Lula's past governments) and overcoming the post of the second-most unequal country in the world, and safeguarding our civilization's survival by stopping the destruction of the Amazon forest Alves de Oliveira et al.
There have already been difficulties along the way, but Brazilian democratic institutions have proved resilient. We remain alert!
| From Adult to Child Psychiatry, to Family, Community, and Planetary Health: A Summary of My Journey|| |
Each person we receive in the psychiatric clinic brings with him/her the complexity and the resources of his/her family and community organization. We psychiatrists and other health professionals also bring resources and difficulties in all situations.
I will tell you about my personal history. Like many of us participants of WASP, I am a migrant, the daughter of a migrant family, a refugee from the Spanish civil war of 1936–1939, when a democratically elected republican government was overthrown by Fascism. My family went first to France, where I was born, and later, when I turned 3, to Brazil.
My family history is central to my way of being in the world. I have had from day one a political “homeschooling” that taught me to be sensitive to suffering and inequities, especially with children, and to be proactive.
Although my family had to leave everything behind when it got a place on the last ship for Second World War refugees chartered by the United Nation (UN) Refugees Organization in 1952, we felt and continued to be lucky. My family worked hard, received community support, and built a strong social network in South Brazil. As a result of that, I was able to study and become a psychiatrist! However, what kind of psychiatrist could I become with such a history? Certainly, I had to be very creative in trying to integrate many different experiences brought about by this personal history.
I developed the belief that life diversity, in all its forms, and freedom are basic to life and that psychopathologies as well as social conflicts, are linked to the process of domination X submission. In medical training, these beliefs were reinforced. As I loved both Sciences and Humanist Studies, I decided on Psychiatry and later Child Psychiatry, already looking for ways to prevent problems that seemed so hard to change in grownups. I chose to train in Psychiatry in the US, flying a dictatorship that ran Brazil from 1964 to 1984. After the basic training in adult Psychiatry, I choose to train in Child Psychiatry at University of Pennsylvania in a family therapy systems-oriented school.
I was fortunate to work with different cultures and all social classes, starting during my training. Back in Brazil, which I realized was my home country while living abroad, I became a University Professor. Consequently, I was able to develop a flourishing private office too. At the University Hospital and its outpatient clinic, I worked at the public Unified Health System of Brazil (SUS) with poor people. In Child and Adolescent Psychiatry, which is my subspecialty, it is obligatory, from my point of view, to work with intergenerational families, schools, community services, and programs, and with the justice system. My academic research, mostly on family development, was done inside one underprivileged community, interviewing families at home longitudinally, in close alliance with the local public health service. My approach was always that of a social psychiatrist systemically oriented. Not by mere chance, my son Enrique went on to train as a family doctor in this same community.
I was satisfied with the way I was able to integrate my interests and how I developed as a shrink, but with time and more scientific knowledge, in recent years, I found that I was not systemic enough. I was not considering the influence of climate change and did not pay enough attention to how air and water pollution and other environmental factors might be related to my patient's presenting symptoms. I did not consider how I, my patients, and our health system influenced the development of the Anthropocene epoch [Appendix 1] and vice versa. However, the dangerous actions to the environment by the macrosystem economy already had a lot of my attention.
I have become curious, I am studying how to include climate change in clinical work and I am becoming an activist working toward mitigating the causes and adaptation to consequences. Yes, adaptation is already here. Bruno Latour, the French philosopher recently deceased, suggested that we call it climate mutation because the temperatures have already increased significantly. The average increase in the planet is around 1.1°C, which has already increased the frequency and intensity of forest fires and floods, pushed biodiversity loss, increased heat waves, and caused loss of agriculture output. Beyond direct harms, unchecked climate change may cause tens of millions of migrants. Unfortunately, greenhouse gas emissions and climate change are accelerating. Hence, it is widely regarded as the greatest health threat to human health in the 21st century.
| Networking for Action|| |
I am inspired by Fridays for future, the youth movement led by Greta Thunberg, to become more of an activist.
I am trying to find where I can be more efficient. I am part of a local movement of physicians called Medicine in Alert, which has been feeding information about human health problems related to global warming to a large social movement in our home state. It has been a part of the effort to stop the building of an open pit coal mine at a distance of only 16 km from our city. It would be the largest in South America. Luckily, the social movement won, and it was stopped by the Justice system. A victory unheard of previously in our state.
More recently, I have been close to the Brazilian group, led by my son, that works with the Lancet Countdown, a British-led international effort to improve the awareness of human health consequences of climate change and to propose solutions. It was in the last few years that I fully understood the breadth of Planetary Health [Appendix 2] care, which is basically “the insight that we need to care for our environment so that the planet cares for us” – as my son says. Hence, I embarked as a mentor on the Brazilian Program of Ambassadors for Planetary Health, in which we mentor university students from all over Brazil to learn and act on planetary health issues.
The São Paulo Declaration on Planetary Health from October 2021 launched during one of the Planetary Health Alliance annual meetings is a product of this large group along with other similar groups globally. It reads:
”This great transition demands a rapid shift in how we produce and consume food, energy, and manufactured goods; requires rethinking the way we design and live in the world's cities; and insists we heal our relationship with nature and to each other. Such a paradigm shift requires the participation of every sector, every community, and every individual.”
I associate these ideas with our clinical work with families: we do systemic diagnosis and plan necessary systemic involvement to facilitate change, bringing in as many family members as possible. As our planet is our big house, we all become “family.” Although some “parents” have delusional ideas about moving to other planets, it seems certain that as human civilization, we do not have where to move to. Sometimes, we can diagnose psychosis in a home visit to our patient. What can we say about our civilization when the world is so messy?
| Building Actions|| |
We all know the terrible news about climate change! But what can we do? How do we include this knowledge in our lives and our work?
Working in Psychiatry, we need to consider the findings published in December 2021 in an article about the prevalence of eco-anxiety in young people worldwide. The authors used the Kantar Platform to send a questionnaire to thousands of youngsters, financed by AVAAZ. Ten thousand people aged 16–25 (including a Brazilian sample) responded. The results are worrisome but introduce the hope that youngsters may become more creative and resolutive than my generation: 59% were very or extremely worried and 84% were at least moderately worried. More than 50% reported each of the following emotions: Sadness, anxiety, anger, powerlessness, helplessness, and guilt. Forty-five percent say that the worries affect their daily functioning, and there is a generalized feeling of betrayal by their governments. Betrayal by the authorities, their grown-ups.
The question arises: If the prevalence of eco-anxiety is so high, should we consider it a disorder?
This intergenerational crisis is often something we work on with our psychiatric patients, isn't it? Can we make this association? There seems to be a larger intergenerational crisis: Greta Thunberg put it into words in her UN speech “How dare you!” in 2019.
In Brazil, there is a scarcity of research, but it indicates that around 12% of the young population needs psychiatric treatment. The prevalence is higher in adults: 20%–56%. These numbers are from a few years ago. They have probably increased now with the COVID pandemic and all the associated personal and social traumas of the last few years. COVID-19 is, unfortunately, one of the many pandemics we will have to face as the world temperatures increase and the natural environments are affected.
Hence, one important question we must answer as mental health professionals is, “how should we classify eco-anxiety”? Is it a disorder or normal and necessary to achieve a less dystopian world? Can we be healthy on a sick planet?
| The Anthropocene|| |
The Anthropocene is a complex Age. No wonder young people are perplexed and enraged. Humans have improved their/our life on the planet in unprecedented ways with increased life span, decreased poverty, and decreased child mortality. In this process, although humans have depleted and poisoned Earth's resources unprecedentedly, our civilization is increasing carbon dioxide emissions, acidifying the oceans, using excessive amounts of energy, polluting the air, destroying forests, misusing water sources, poisoning the soil and water with chemical fertilizers and microplastics, causing the 6th mass extinction and digged a hole in the ozone layer. The biosphere integrity is in severe danger.
Moreover, it is very important to emphasize that the countries that are poorer and have contributed less to the warming process are those that suffer the larger consequences. We need equity in mitigation. Equity is different from equality. Poorer countries need more resources to face their problems.
The question for us social psychiatrists is, “how can we participate in the effort of mitigation, adaptation, and resilience?”
| Mental Health and Global Warming|| |
What are the known effects of global warming on mental health? The International Review of Psychiatry, in a recent issue, includes articles that summarize the effects and bring new hopeful insights into the field.
Around nine million people die every year from direct consequences of air pollution. If we know as mental health workers that one of the major precipitants of psychopathology is unresolved mourning, what do these death numbers imply? Mental illness prevalence certainly is increasing. Pollution is also known to cause dementia, depression, and anxiety. Heat waves are becoming increasingly common and are directly associated with death, anxiety, depression, and violence. It is important to remember that psychiatric medication makes body heat regulation more difficult, so our medicated psychiatric patients are more at risk than others. Draughts and floods cause hunger and are responsible for migrations, which result in family and community disorganization with severe consequences to mental health. The increased temperatures and landscape disruptions increase infectious diseases with a negative influence on mental health.
It is becoming evident that air pollution, heat waves, major climate events, and population dislocation cause important health problems, including mental health problems, which may be a direct, immediate, or delayed consequence. Mental health problems are still underestimated in the literature about climate change health impacts.
There are also many health consequences we do not know about. For example, we do not know what the impact of plastic garbage on human health is. What we already know is that microplastic has been found in maternal breast milk. What consequences may this have?
Breastmilk nursing is at the center of mother-father-baby relationship building. A diagram [Figure 1] from my doctorate thesis studying the duration of breastfeeding and mental health 20 years ago illustrates it. The triad is surrounded by their family and community, including the health-care team. This is a process formative of the human psyche and human relationships. Starting at the beginning of the 20th century, it was interfered with by hyper consumerism when powdered milk was promoted in the occidental world as the “best option for babies.” Now, we know that there are the traces of plastic also interfering. What can the consequences be?
| Mental Illness as Cause of Climate Mutation|| |
It is still not sufficiently recognized that climate change causes psychopathology. Beyond this, I have a question: Isn't psychopathology part of the cause of the global warming crisis? Who is responsible for these events? To a large degree, human greed of the richest people and companies of the world which exploit natural resources beyond capacity. This obviously comes along with the exploitation of submissive human beings. The extraordinary is that nowadays, in light of basic common sense, those are ecocidal and suicidal behaviors because nobody can fly away from Earth's air pollution. Hence, we have omnipotence and submission, two primitive behaviors at the base of how global warming started and continues to increase.
| Third-order Thinking to Guide Mental Health Work to Safeguard from Climate Mutation|| |
How can we frame this scenario? What can we do? It is so overwhelming that the tendency is to deny the facts, not even perceive them, and/or, in acknowledging them, find that a helpful response is so out of our reach that we give up.
Maybe we can be helped to comprehend our difficulties and start a new path with the help of the concept of orders of thinking that comes from cybernetics.
Cybernetics has described the systemic complexity in perceiving and describing the relationship between one agent (A) over an object (B), as seen by an observer (O). In first-order thinking, A acts over B and receives clear feedback from B that O interprets without obvious problems or distortions. Second-order thinking recognizes that A and B interactions are also influenced by the observer O, which affects the field of action with its own energy, making interpretation more complex. Third-order thinking recognizes that the 3 (A, B, and O) interact in an energy field affected by its own socioenvironmental organization that makes the relationships more complex, interdependent, and less easily interpretable. We could say, at first glance, that the usual clinical situation of medicating a patient could be described with first-order thinking. If one looks closer, it is clearly influenced by how the relationship created with the patient by the prescribing psychiatrist and the hospital where he works, makes these phenomena already second-order thinking. Third-order thinking needs to be introduced, although, to explain what happens, especially when there is a scarcity of resources, for example, no medications available, and the doctor and patient (as well as O) are frustrated by the environmental situation, although the person most clearly affected is the patient. Imagine, now, a situation associated with the climate change: at the moment of the consultation, the room starts to flood and doctor, patient and observer experience that they are equally affected. All are in a similar situation of vulnerability. Can the doctor act solely as a prescriber? All three are in danger; hence, all should act, all are responsible. This enlargement of third-order thinking to include planetary factors, beyond human build socioeconomic structures seems necessary and urgent.
When the imminent “existential threat” of climate change is considered, as stated by the UNs Secretary-General Guterres, it becomes evident that health personnel must be trained to work with an enlarged third-order thinking lens. We must embrace third-order thinking, recently proposed by McDowell et al., which focuses on regional interactions of systems and expand to a planetary health lens, recognizing how human complex interactions harm the planet and vice versa. The clinical approach to planetary health care has to be patient and family-centered, developing culturally sensitive community resources, which simultaneously care for our bigger house [Figure 2].
We, mental health workers, must learn to identify early psychiatric signs and symptoms associated with the climate change. For that, we need to become aware of the environmental changes occurring. The goal is to educate our patients and community about risks. We should also pragmatically center on what each one can contribute to mitigating problems as soon as possible. To prepare ourselves to do this, there are the plenty of didactic and accessible resources. It is urgent to introduce these issues in the training of health professionals.
Studies show that our health system provides only 20% of health well-being. Eighty percent of it comes from socioeconomic and environmental determinants. This is why as social psychiatrists, we aim to influence them. Once we realize the urgency of the facts, we need to start working at all levels, from the individual patient to our teaching institutions, the national psychiatric system, and beyond, to the whole socioeconomic system. What a task! Do we have the power for that?
We have some power for sure, some of us have economically and politically influential patients. And all of us are influential in our communities. This seems a tiresome and impossible task. However, it is important to remember that by evaluating risk factors, we simultaneously uncover resources. This happens during clinical work with individuals, families, and communities. Networking and support structures can be built in the process, bringing change. Even happy interactions can be promoted! There are interesting reports of resilience building in the reconstruction work in New Orleans, after the Katrina hurricane, for example.
Another important work is on changing the health system itself to make it greener, knowing that if it were a country, it would be considered the 5th in the carbon emissions. There is much to be done, from changing structures to changing materials and procedures.
In clinical work with our patients, we can stimulate specific actions. Perhaps, 1 min for the planet in the office would be sufficient. Encouraging active transportation is already part of what is done by psychiatrists recommending exercise. Presenting the Planetary Health Diet is central, advising a plant-based diet with reduced red meat consumption, emphasizing choosing the food carefully, buying fresh from nearby producers, and watching for chemical defensives. The Lancet Countdown 2020 policy brief for Brazil concentrated on the study of the Brazilian diet. The study found that 42,000 deaths yearly were associated with red meat overconsumption, which in turn is associated with Amazon forest fires to clean land for cattle while also contributing to air pollution, which is responsible for 19,000 deaths [Figure 3] and [Figure 4].
|Figure 3: Brazilian Lacent Countdown Policy Brief 2021: the need to overcome a vicious cycle|
Click here to view
|Figure 4: Brazilian Lacent Countdown Policy Brief 2021: cooperation for a synergistic and virtuous cycle|
Click here to view
The study group found that by operationalizing plant-based fresh planetary diet food, we can promote local biodiversity, better socioeconomic development, and preserve Brazilian multiple biomes, with special mention to the Amazon forest. This process in itself promotes health and community development and happiness.
Further on, as it is around the table that a family mostly relates, we can, as clinicians, go beyond in our interventions. Working carefully with how food is chosen and prepared, how it is shared at the table, and how the family members interact before, during, and after the meal allows us to deal with family beliefs, relationship patterns, gender, and justice issues. In short, it allows us to influence family life, which has major responsibility for mental health.
| Conclusion|| |
This article describes my personal journey toward planetary health care in my work, in partnership with my son, hoping it will be useful for other social psychiatrists. I believe we need to aim at working clinically, preventively, and in rehabilitation, informed by planetary health. Moreover, we must pass on the word to our countries and international mental health institutions.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| Appendixes|| |
Appendix 1: The Anthropocene epoch is widely accepted as our current geological time. It is marked by the global increase of human life expectancy, reduction of child mortality and reduction of poverty, along with many other human marvels of the last two centuries. On the other hand, the great acceleration of population, exploitation of natural resources, and pollution is overshooting the planetary boundaries to sustain human civilization. Most important is the fact that human impact has overcome any other geological factor in shaping the biosphere.
Appendix 2: The Lancet-Rockefeller Planetary Health Commission defined Planetary Health planetary health as “the achievement of the highest attainable standard of health, wellbeing, and equity worldwide through judicious attention to the human systems – political, economic, and social – that shape the future of humanity and the Earth's natural systems that define the safe environmental limits within which humanity can flourish.”
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]