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Many psychiatrists seem to feel that we lack the skill and knowledge to address social issues. What do you think?
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Several touchstones emphasize the importance of social concerns in medicine, and nowhere is that more relevant than in the practice of psychiatry. Among them is the decades-old biopsychosocial (or bio-psycho-social) model of medicine and psychiatry.1 This model emphasizes the importance of social factors in the care of patients, such as socioeconomic status and underserved groups in society. However, as has been pointed out by a past president of the American Psychiatric Association (APA), we seem to have gravitated toward a bio-bio-bio model.2
Another is the emphasis on society in our principles of medical ethics.3 In the Preamble of The American Psychiatric Association Principles of Medical Ethics, society is one of the secondary ethical principles: “As a member of this profession, a physician must recognize responsibility to patients first and foremost, as well as to society, to other health professionals, and to self.” That implies a broader perspective toward social concerns, beyond patient care.
Section 7 states, “A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and betterment of public health.” This principle indicates that we have an ethical responsibility to address social conditions that might worsen the mental health of our patients and fellow citizens. How well have we done as a profession?
A long-standing organization, the American Association for Social Psychiatry (AASP), has focused attention on such adverse social conditions. For self-disclosure, I was president of that organization at the turn of the new millennium. As examples of the social concerns of the AASP, it has been presenting an annual humanitarian award to a deserving psychiatrist, as well as other socially-oriented presentations, at annual APA meetings. Sadly, membership in the AASP has greatly decreased over the four decades of my career.
To illustrate the demise of the social aspects of psychiatry, here are a few examples that might deserve more attention from us.
As I’ve written in many other commentaries for Psychiatric Times over the years, psychiatrists have been relatively late, compared with other mental health disciplines and medical specialties, to convey concern about the health and mental healthcare aspects of climate change. These aspects range from the contributions of human psychology and behavior to global warming to the new repercussions of climate change like Solastalgia, a kind of grief about the ongoing environmental changes surrounding where one lives.
As recent as 2011, environmental issues were dismissed as an important advocacy concern of psychiatry: “APA advocacy needs to focus on health care reform, parity, access to needed psychiatric care, and other topics that immediately impact patient care.”4
A few years back, I organized an informal group of concerned psychiatrists named Psychiatrists for Environmental Action and Knowledge (PEAK). That has evolved into the new Climate Psychiatry Alliance (CPA), which is attempting to educate and rally psychiatrists to the climate cause, including how it is emerging in the care of our patients. For example, there was a great increase in acute and delayed PTSD in Puerto Rico following Hurricane Maria and psychiatrists from the CPA and other psychiatric disaster groups went to help.
Moreover, at presentations that CPA members have been making at annual APA meetings, the presenters and psychiatrists in the audience are sharing examples about how patients are showing climate-related anxiety and how to address that. The CPA has now become a Caucus of the APA, which will increase its opportunities for education, advocacy, and outreach.
The sexual abuse of male children by priests and that of women being reported in many public spheres, including the Supreme Court nomination process, has received much media attention and concern. Although psychiatry had previously made great strides in addressing inappropriate sexual interactions with patients, we have been conspicuously absent in media discussions regarding this challenge. We have much to offer in terms of memory and healing from trauma?
Probably the most prominent current political issue in our time relates to the current Presidency in our country, a topic we addressed in polls and commentary here at Psychiatric Times. The ethically-based Goldwater Rule has been challenged by many esteemed psychiatrists,5 but reaffirmed by the APA. Do we not know enough to address the mental health risks of our country’s leadership, political divisiveness, and the new political policies that threaten mental health?
Now that I have had the opportunity to edit a book on the topic of Islamophobia, it has become clear that we have been ignoring the adverse repercussions of such prejudice.6 Islamophobia may worsen the mental health of Muslim citizens. Research into Muslim mental health and mental health care, however, has been meagre and inadequate. Though Islamophobia does not qualify for a specific DSM-5 diagnostic classification, perhaps it is an example of social pathology.
There are likely many other social issues that could be added to this list. Many psychiatrists seem to feel that we may not be skilled and knowledgeable enough to address social issues. I don’t agree. What do you think?
Dr Moffic is an editorial board member and regular contributor to Psychiatric Times. Before he retired from clinical work for the underserved population, he was a tenured Professor at the Medical College of Wisconsin.
1. Engel G. The application of the biopsychosocial model. Am J Psychiatry. 1980;137:535-544.
2. Sharfstein SS. Presidential address: Advocacy as leadership. Am J Psychiatry. 2006;163:1712-1713.
3. The American Psychiatric Association Principles of Medical Ethics, With Annotations Especially Applicable to Psychiatry. Washington, DC, American Psychiatric Association, 2013 edition.
4. Moran M. Psychiatry needs eyes wide open about environmental issues. Psychiatric News. March 4, 2011. https://psychnews.psychiatryonline.org/doi/10.1176/pn.46.5.psychnews_46_5_17_1. Accessed September 28, 2018.
5. Lee B (ed): The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President. Thomas Dunne Books, 22017.
6. Moffic HS, Peteet J. Hankir A, Awaad R (Eds). Islamophobia and Psychiatry: Prevention, Recognition, and Treatment. Springer Nature; 2019 (in press).