Integrative Community Therapy in Brazil: An Interview with Adalberto de Paula Barreto, MD, PhD – Community Psychiatry Part II

Juan Manuel Pichardo/AdobeStock

SECOND THOUGHTS

Belo Horizonte, Minas Gerais, Brazil

In my first column on community psychiatry, “The Revolving Door”: From the Asylum to the Community and Back,” I discussed my interview 50 years ago as a young man with Marcel Lemieux, MD, a Canadian psychiatrist who was a pioneer in deinstitutionalization. What that interview made clear even then was that at best, Dr Lemieux’s efforts were very limited. Like the 1980s psychiatric reformer Franco Basaglia, MD, in Italy, deinstitutionalization could close or transform the asylum but treating the mental, relational, and social suffering in society was a much more complex and difficult task.¹ That complexity triggered a mental health crisis in Italy and elsewhere. In Italy, part of the solution came from systemic family therapy, an import from the US that was adopted, adapted, and radically transformed in Italy.²

Adalberto de Paula Barreto, MD, PhD, is a Brazilian social psychiatrist from Fortaleza, the capital of the northeastern state of Ceará, who trained in medicine in his native Brazil and did postgraduate training in Paris, France with Georges Devereux in ethnopsychiatry as well as in systemic family therapy. His early training in theology shines through his values, his principles, and his compassion for and solidarity with the poor and disadvantaged people of Brazil and Latin America.³

Dr Barreto has created another solution, made in Brazil, a therapeutic resource that he calls integrative community therapy (ICT).^4-6 ICT is representative of the Brazilian genius to take things from many sources and synthesize them into something new, like the syncretic Afro-Brazilian religions and the Bossa Nova which adapted Jazz to a Brazilian beat to create something totally new and original. All of this is evident in my interview with Dr Barreto. Key words that stand out from his interview include: community, integrative, pluralism, spirituality, and kairos.

With this approach, Dr Barreto reaches out more broadly into the community beyond the usual medical psychiatric institutions to work directly with the social determinants of health and mental health. He works with large groups, entire neighborhoods and communities, and has trained tens of thousands community workers, creating healing resources by training community workers who then become local resources in their own communities.

Dr Barreto’s work has been presented, taught and adopted in Latin America,⁷ in Europe,³ and now with the translation of his book into English, also accessible in the US through the support of American leader in community psychiatry Ken Thompson, MD, and the Visible Hands Collaborative based in Pittsburgh, PA.⁴

Adalberto Barreto, MD, PhD and ICT in Brazil

Our interview was conducted in Portuguese on August 16, 2024, at the 15th Congress of the Brazilian Association of Family Therapy (ABRATEF in the Portuguese acronym) in Belo Horizonte, the capital of the inland state of Minas Gerais after his workshop. Dr Barreto’s workshop entitled, “Trabalhando as Ressonâncias na Relação Terapêutica” (“Working with Resonances in the Therapeutic Relationship”), was a lively and engaging encounter with him and his way of working with communities.⁸

Vincenzo Di Nicola, MPhil, MD, PhD, FCAHS, DLFAPA, DFCPA: Thank you very much for your workshop. I want to start by asking how you see the future of social psychiatry in this country and around the world?

Adalberto de Paula Barreto, MD, PhD: I believe that the future for psychiatry and mental health is to invest in affective bonds rather than in spaces. For a long time, psychiatry preoccupied itself in building asylums, hospitals, and even community clinics where medications and biological treatments were much stronger. The great challenge facing our society today is to find ways to invest in the bonds that bring differences closer together, generating respect. We know almost all of the pathologies of the intracellular sphere; the same applies to the intrapsychic sphere. Now it is the pathology of interactions, of coexistence with plurality. Wars and migrations force people to be together without having made a choice. This brings suffering, which forces each person, in their relationship with the other, to find, let's say, their new space. I think we should understand that mental illness is not just linked to a problem with the mental synapses and biochemistry of our brain. It has to do with social synapses. In other words, it is about intervening in social determinants, which today are increasingly linked to intolerance and violence due to ethnic and religious issues. This seems to me to be becoming increasingly clear. I believe that social psychiatry—its future—should have a perspective that goes beyond the clinical or individual-clinical perspective to the collective perspective. Because the clinical model we have is the problem of an individual and a community, and the response to it is up to the specialist and the institutions. The sociocultural resources that exist in the group are not taken into account. And yet, the community that has problems also has solutions. So, we increasingly need to create spaces to work collectively. The individual model, if you look at it, like the people who come to see me individually, is not possible because it is very expensive, it requires many specialists. I can perhaps see 10 people a day, if I give each one about 45 minutes, but there are millions in need.

Di Nicola: In your vision of humanity, do you imagine, first of all, the individual, or do you imagine the collective?

Barreto: I think first of the collective, because the individual belongs to it. Because in the model we now have [in psychiatry], we do not take into consideration the horizontal resources that these groups bring. For example, immigrants, when they come, initially experience difficulties in their integration, but they bring ancient knowledge such as medicine, ways of healing, a vision of a world that enriches us. If we segregate them, we prevent people from entering. Because the word “exclusion,” a word that comes from the Latin, excludere, does not mean to throw away—it means to not let in. So, I think we have to open our concepts and our minds so that in practice we can find other integrative forms of knowledge and know-how that are different and do not compete with the previous model. In this sense, community therapy is a collective space for welcoming people and their suffering, which takes into account the resources they have, without denying the fundamental value that psychiatry has.

Di Nicola: I saw that today you integrated Lacan’s thought with the Real, the Symbolic, and the Imaginary and you also talked about Jung. So, you take a little bit of everything, right?

Barreto: Exactly.

Di Nicola: Which do you think is most fundamental?

Barreto: I think everyone is. I had a diverse background. I mean, I studied medicine, then psychiatry, philosophy, theology, and then I specialized in systemic family therapy. In each of these universes, we take things and there comes a time when we have a synthesis that we do not know where it comes from! However, I understand that it is part of my training, I think it is a bit like this. In community therapy, I use cultural anthropology [Barreto trained with the Franco-American anthropologist Georges Devereux in Paris, France]. That is why I use proverbs a lot, which are expressions of knowledge produced over centuries, of traditions. Because we need to take into account and understand that it is not about one model against another—they are complementary. In this sense, we have to collect and integrate other forms, and through that, one of the fundamental issues for us as university professors, is to provide good training. It is human minds that create these models, these asylums. So we must change our minds, our conception. This was one of the discoveries I made working in a context of precariousness. By the way, precariousness is also within us, whether in me, as a psychiatrist, in the institution I represent, in the models I have, which are important, but not unique, since there are several. The way out is to start from the singular, move to the plural.

Di Nicola: You also studied theology. How do you see religion and spirituality today, here, because you know that in the Global North it is losing out, right? Where I live, in Quebec (which was once a large Catholic province), almost no one believes in religion anymore. They are no longer believers. How do you see this here in Brazil and around the world?⁹

Barreto: I think religion is decreasing, but spirituality is growing. Today, if someone asks me, “What is your religion?” I would say that I am more “spiritualized,” that is, more of a spiritual than a religious person. For me, spirituality is a universal energy whose expression is love, which unites, brings together, produces life, produces creativity.

Di Nicola: And it does not divide.

Barreto: And it does not divide. So, I think that religion that divides, prohibits, condemns, and judges is becoming extinct. Its tendency is to become the opposite [of what we want], to become just a sect. I think we are moving towards an openness, an understanding that if I believe in universal love I must be consistent in my practice, that is, not excluding, destroying, eliminating, and judging others. Today, some religions are in a position of reaction to everything that is modern, to everything that comes from the new, clinging to things of the past.

Di Nicola: In a reactionary way.

Barreto: In a reactionary way, and I would say, in the most destructive sense possible, because it loses the possibility of “airing out” [a Portuguese expression meaning “letting it breathe” or “a breath of fresh air”]. In our Afro-Brazilian culture, we have the notion of an open body and a closed body: if your body is closed you protect yourself ...

Di Nicola: But it does not help.

Barreto: It does not help because people die of asphyxiation, they lack oxygen.

Di Nicola: That’s what I call trauma! But the problem is that I see 2 trends in the North: one is that people have lost their faith, the ability to believe not only in religion but in spirituality as well, and we are lost. And on the other side, there are people who are a bit reactionary. I do not like to say that, so let’s say they really believe in recapturing the past, as you said, which is not a present past, it is not a living past, it is closed.

Barreto: It is a stagnant past.

Di Nicola: It is stagnant in life. I hope that Brazil has another trend that can go beyond that, but in Canada it is almost lost.

Barreto: I would say the following, I like to work with the notion of 2 Greek times, chronos and kairos. Chronos is the horizontal time where traumas and events happen, this chronological time. When people come to see us, in their suffering, they talk about a chronological time of accidents, of life's traumas. In a therapeutic relationship, I welcome chronos, the chronological time, but I position myself with questions that arise from the perspective of kairos, meaning that which is eternal and immutable... that is what it is for me [see the work of Italian philosopher Giorgio Agamben on the theme of chronos versus kairos or messianic time¹⁰].

Di Nicola: Always present…

Barreto: Always present in the religious dimension. So, these are questions that glimpse hope. When someone tells me that they lost their father or mother and that their life lost its meaning, I listen to them; but there are times when I ask the question, “What did death not destroy about your father who is gone?” Then the person glimpses a different perspective, such as, “the sense of justice that my father had…” And I remind them, “That didn’t die, it’s in you!” In other words, they killed Christ but they did not kill love; they killed Martin Luther King, Jr. but the desire of Black Americans for equality continues. There is something that is eternal, and that is what I call spirituality. It is not a belief in a superior spirit; it is a belief in man, a belief in this dynamic that we are experiencing, and I cannot understand a therapist who is not someone who asks a question that makes me glimpse the eternal. Because if I stay in the logic of material chronos, there is no end, there is no meaning, the tendency is towards depression or dying before one’s time.

Di Nicola: There is no goal.

Barreto: The question is not for people to join a church or a religion, but for them to glimpse hope, and there is a very interesting image in the Gospel. When Christ was killed, at the time, it was common for women to come the next day to embalm the body. And when they arrived the next day, they went to the tomb and he was not there. So, they said, “Where is the man?” And they say that an angel who was there said, “Why are you looking at the ground when something is already up above?” I think that the perspective from the therapist is to make the other person realize that in that death there is something that died, there within the material, the chronological; but there is also something of the kairotic – of that which is eternal and which did not die.

Di Nicola: What always struck me about this story is that, before understanding, the 3 women who arrived there suffered a lot. Because, for a moment, on a chronological level, there was suffering, until they understood that there is another time, a timeless time.

Barreto: Which is kairos.

Di Nicola: But at that moment, they suffered. And that is very moving for me.

Barreto: Because that is when the patients come to see us! They have lost hope, they have fallen into a hole. And when you are in a hole, you no longer have a horizon, and someone tells you something that awakens. That is why I say, being a therapist is being an awakener of memories—what we have forgotten from the past—is making connections and integrating them so that I feel like I belong to something, greater than temporality, of a temporal power, of a dictatorship that kills, to understand that this is part of a broader process.

Di Nicola: Wonderful! And you used a word that I love: horizon. We are in Belo Horizonte, after all [which means “beautiful horizon” in Portuguese]. I work—and no Brazilian believes it, but it is true—in what you call a favela, a disadvantaged neighborhood or slum, in Montreal. And the reason Brazilians will not believe me is that it can be materially beautiful, but inside, there is poverty. There is free education in public schools and free health care, there are many advantages, but there is human and emotional poverty, they do not know their own history. If I ask children, “Today is December, what’s special about December?” they do not know. “There’s a feast this month, what are we going to celebrate?” They do not know anything! They do not know about Jesus Christ, religion. And it matters even if they are atheists since they do not know their own history, religion, or country, so they do not have what I call a “social horizon.” This is an idea I use a lot. They do not have what Jerome Bruner calls narrative resources to imagine a different life, I think that is what a social horizon is.¹¹ This is what is missing in the poverty we have in Canada. I do not know Brazil as well, but I imagine that people who are on the streets, the sem terras or “landless,” and those in the favelas are often very religious and have resources and strengths, but I also see people on the streets who do not have a social horizon.

Barreto: Exactly. Here in Brazil, violence and material poverty, which affect the body and mutilate these people (you see toothless people, for example, people mutilated in some way), this violence and lack of care ends up affecting the soul, which is the animus, that which animates. In this sense, religions, Catholic, Evangelical, Umbanda, Afro churches, whatever, have become “existential ICUs,” spiritual intensive care centers. There, people go to revive the anima, the soul, discouraged by the hardships of life. That is why people do not go there to fix a broken foot. The excess of these cults, that is, the increase in religiosity, in Latin America and in Brazil, reflects a lack of faith in social institutions, because people turn to God and the saints for what they do not receive from social institutions. Churches that play this game, turning to God, therefore create yet another need, yet another way of life, yet another beginning.

(Part II of the interview continues in my next column.)

Provisional Closing Comments

ICT deals with communities and takes us beyond the usual institutions. Adalberto Barreto, MD, PhD, is deeply engaged, highly respected in Brazil and abroad, and ICT appears to be a very successful community intervention, accessible to large groups, even online.^4-6

The questions I am left with are these: Is ICT social psychiatry (or community mental health)? Is it therapy? These basic questions provoke deeper reflections on what we mean by social psychiatry and mental health (both academically and clinically) and what we mean by therapy.

It is a credit to Dr Barreto and his team that ICT is sufficiently well-framed and successful that it stimulates such questions. Success always brings deeper scrutiny. I am enthusiastic about this work as a partner for social psychiatry. And I remain open-minded as to whether ICT resolves these deeper questions and whether it could be a resource for what is perceived as a crisis in mental health. I will address this more deeply in the second part of our interview in my next column.

As to the public and professional perceptions of a contemporary public mental health crisis, we will deal with that in a later column. Let me say for now that I do not easily take these declarations at their word and I am concerned that it represents a moral panic and a moral crusade. I am deeply worried about both.

Resources

Dr Barreto’s work is now available in English:

• Barreto AP. Integrative Community Therapy: Step by Step, Al Jamal, HO, trans. ICR; 2019.
• Barreto AP, Filha MO, Silva MZ, Di Nicola V. Integrative community therapy in the time of the new coronavirus pandemic in Brazil and Latin America. World Soc Psychiatry. 2020;2(2):103-105.
• Barreto, AP, Camarotti H. Integrative community therapy. In: Okpaku SO, ed. Innovations in Global Mental Health. Springer; 2021:1-20.
• For an introduction to ICT, see this page by the Visible Hands Collaborative, an American group that champions ICT: https://www.visiblehandscollaborative.org/about_ict

Dr Di Nicola is a child psychiatrist, family psychotherapist, and philosopher in Montreal, Quebec, Canada, where he is professor of psychiatry & addiction medicine at the University of Montreal and President of the World Association of Social Psychiatry (WASP). He has been recognized with numerous national and international awards, honorary professorships, and fellowships, and was recently elected a Fellow of the Canadian Academy of Health Sciences and given the Distinguished Service Award of the American Psychiatric Association. Dr Di Nicola’s work straddles psychiatry and psychotherapy on one side and philosophy and poetry on the other. Dr Di Nicola’s writing includes: A Stranger in the Family: Culture, Families and Therapy (WW Norton, 1997), Letters to a Young Therapist (Atropos Press, 2011, winner of a prize from the Quebec Psychiatric Association), and Psychiatry in Crisis: At the Crossroads of Social Sciences, the Humanities, and Neuroscience (with D. Stoyanov; Springer Nature, 2021); and, in the arts, his “Slow Thought Manifesto” (Aeon Magazine, 2018) and Two Kinds of People: Poems from Mile End (Delere Press, 2023, nominated for The Pushcart Prize).

Dr Barreto is a professor of community health in the faculty of medicine of the Federal University of Ceará in Fortaleza, Ceará, Brazil. He was trained first in theology at the Pontifical University of St. Thomas Aquinas in Rome, Italy, and the Catholic University in Lyon, France, followed by a doctorate in anthropology at the School for Advanced Studies in the Social Sciences in Paris, France. After his medical training in Brazil, Dr Barreto did a second doctorate in psychiatry at the René Descartes University “Paris V,” in Paris, France. He has trained tens of thousands of workers with his model of integrative community therapy (ICT) in Brazil and around the world. Dr Barreto is president of the Brazilian Association of Social Psychiatry (BASP) and the Brazilian Association of Community Therapy (BACT) and the author or coauthor of many articles, chapters, and books in Portuguese, French, and English. His major work in English is Integrative Community Therapy: Step by Step (2019).

Acknowledgements

I wish to express my gratitude to Adalberto de Paula Barreto, MD, PhD, for granting me time to conduct this interview with him after his workshop and for many stimulating and instructive encounters over the years in Brazil and in Italy, and to my wife, Letícia Castagna Lovato, for her meticulous transcription of the interview in Portuguese. The English translation is my own.

References

1. Basaglia F. Psychiatry Inside Out: Selected Writings of Franco Basaglia. Scheper-Hughes N, Lovell AM, eds. Columbia University Press; 1987.
2. Di Nicola V. Luminaries in social psychiatry—a relational dialogue with Maurizio Andolfi: master family therapist and social psychiatrist. World Social Psychiatry. 2024;6(1):6-13.
3. Contini E. Un Psychiatre dans la Favela [A Psychiatrist of the Slums]. Les Empêcheurs de Penser en Rond; 1995.
4. Barreto AP. Integrative Community Therapy: Step by Step, Al Jamal, HO, trans. ICR Printing and Publishing; 2019.
5. Barreto AP, Filha MO, Silva MZ, Di Nicola V. Integrative community therapy in the time of the new coronavirus pandemic in Brazil and Latin America. World Soc Psychiatry. 2020;2(2):103-105.
6. Barreto, AP, Camarotti H. Integrative community therapy. In: Okpaku SO, eds. Innovations in Global Mental Health. Springer; 2021:1-20.
7. Barreto AP. Terapia Comunitária: Passo a Passo [Community Therapy: Step by Step]. ICR Printing and Publishing; 2010.
8. Barreto A,Workshop: “Trabalhando as Ressonâncias na Relação Terapêutica: [Working with Resonances in the Therapeutic Relationship], 15º Congresso Brasileiro de Terapia Familiar, ABRATEF, Belo Horizonte, MG, Brazil, August 16, 2024.
9. Di Nicola V. The Global South: an emergent epistemology for social psychiatry. World Social Psychiatry. 2020;2(1):20-26.
10. Agamben G. The Church and the Kingdom. de la Durantaye L, trans. University of Chicago Press; 2012.
11. Bruner J. Acts of Meaning. Harvard University Press; 1990.