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First‑Person Account/Narrative/Reflections

From Individual Psychiatry to Planetary Health Care: A Personal Account

of a Brazilian Social Psychiatrist

Abstract Olga Garcia

This article describes the personal journey of an experienced Brazilian child psychiatrist who also Falceto1,
trained as a systems‑oriented family therapist who realized that she was not systems oriented enough. Enrique Falceto de
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 Barros2
with scientific developments. The account aims at inspiring other social psychiatrists and mental
1
Department of Psychiatry and
health workers to include 1  min for the planet in consultations, preventive, and rehabilitative work Legal Medicine, Universidade
Federal do Rio Grande do
and to spread the word to our countries and international mental health institutions. Sul, Instituto da Família de
Porto Alegre, 2Post-Graduation
Keywords: Family therapy, planetary health, psychiatry, social psychiatry, third‑order thinking Program on Science Education,
Universidade Federal do Rio
Grande do Sul, Porto Alegre,
Where Do I Speak From? From Adult to Child Psychiatry, Brazil
I wrote this provocative article following to Family, Community, and
a personal account lecture for the WASP Planetary Health: A  Summary of
World Conference in 2023, which I My Journey
developed in partnership with my son Each person we receive in the psychiatric
Enrique. I  am happy to be a Brazilian clinic brings with him/her the complexity
psychiatrist that can speak to you with hope and the resources of his/her family and
in the future. After 6  years of suffering community organization. We psychiatrists
with authoritarian governments, Brazil has and other health professionals also bring
recently had a democratic, well‑organized resources and difficulties in all situations.
election using the safe electronic voting
machines. A democratic coalition won over I will tell you about my personal history.
the incumbent president that used all his Like many of us participants of WASP, I am
power to influence the election. a migrant, the daughter of a migrant family,
a refugee from the Spanish civil war of
There is now a large political democratic 1936–1939, when a democratically elected
alliance in power led by President Lula, republican government was overthrown by
who previously served two terms in Brazil. Fascism. My family went first to France,
This alliance promises to transform Brazil: where I was born, and later, when I turned
eliminating hunger again (previously 3, to Brazil.
achieved by Lula’s past governments) and Address for correspondence:
overcoming the post of the second‑most My family history is central to my way Prof. Enrique Falceto de
unequal country in the world, and of being in the world. I have had from Barros,
day one a political “homeschooling” that Post-Graduation Program on
safeguarding our civilization’s survival by Science Education, Universidade
stopping the destruction of the Amazon taught me to be sensitive to suffering and Federal do Rio Grande do Sul,
forest Alves de Oliveira et al.[1] inequities, especially with children, and to Porto Alegre, Brazil.
be proactive. E‑mail: enriquefbarros@gmail.
There have already been difficulties com
along the way, but Brazilian democratic Although my family had to leave
institutions have proved resilient. We everything behind when it got a place on
remain alert! the last ship for Second World War refugees
Access this article online
chartered by the United Nation (UN)
Website:
Refugees Organization in 1952, we felt www.worldsocpsychiatry.org
Submission: 11‑03‑23 Web Publication: 26-04-23
Acceptance: 12‑03‑23
and continued to be lucky. My family DOI: 10.4103/wsp.wsp_11_23
worked hard, received community support, Quick Response Code:
This is an open access journal, and articles are
distributed under the terms of the Creative Commons
and built a strong social network in South
Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially,
as long as appropriate credit is given and the new creations are How to cite this article: Falceto OG, de Barros EF.
licensed under the identical terms. From Individual Psychiatry to Planetary Health Care:
A Personal Account of a Brazilian Social Psychiatrist.
For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com World Soc Psychiatry 2023;5:29-35.

© 2023 World Social Psychiatry | Published by Wolters Kluwer - Medknow 29

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Falceto and Barros: From individual psychiatry to planetary health care
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.[2] The
30
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,[3] 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.[4] 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.[5]
The São Paulo Declaration on Planetary Health[6] from
October 2021 launched during one of the Planetary Health
Alliance[7] 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
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Falceto and Barros: From individual psychiatry to planetary health care
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.[8] 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.[9]
In Brazil, there is a scarcity of research, but it indicates
that around 12% of the young population needs psychiatric
treatment.[10] The prevalence is higher in adults: 20%–
56%.[11] 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?[12] 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,
World Social Psychiatry | Volume 5 | Issue 1 | January-April 2023
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.[13]
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.[14]
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.[13]
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.[13]
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?[15]
Breastmilk nursing is at the center of mother‑father‑baby
relationship building. A diagram [Figure 1] from my
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Falceto and Barros: From individual psychiatry to planetary health care
doctorate thesis studying the duration of breastfeeding
and mental health 20 years ago illustrates it.[16] 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.
Figure 1: Breastfeeding network diagram
32
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.[17] 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
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Falceto and Barros: From individual psychiatry to planetary health care
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,[18] 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.,[17] 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].[19]
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.[20] 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
Figure 2: From individual care to planetary health care
World Social Psychiatry | Volume 5 | Issue 1 | January-April 2023
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.[21]
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.[22]
In clinical work with our patients, we can stimulate specific
actions. Perhaps, 1  min for the planet in the office would
be sufficient.[19] 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 [Figures 3 and 4].[23]
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
Figure  3: Brazilian Lacent Countdown Policy Brief 2021: the need to
overcome a vicious cycle
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Falceto and Barros: From individual psychiatry to planetary health care
Figure 4: Brazilian Lacent Countdown Policy Brief 2021: cooperation for a
synergistic and virtuous cycle
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
Nil.
Conflicts of interest
There are no conflicts of interest.
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Falceto and Barros: From individual psychiatry to planetary health care

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.”[24]

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