“With Art We Build What Poverty Destroys”: Adalberto de Paula Barreto, MD, PhD, on Integrative Community Therapy in Brazil

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SECOND THOUGHTS

Belo Horizonte, Minas Gerais, Brazil

In last week’s column on integrative community therapy (ICT) in Brazil, I shared my interview with the founder of that approach, Adalberto de Paula Barreto, MD, PhD. This is part 2 of our interview. Key words in part 2 are: inclusion, transmitting hope, autonomy, and integration.

In my column on community psychiatry, “The Revolving Door”: From the Asylum to the Community and Back,” I discussed my interview 50 years ago with Marcel Lemieux, MD, a Canadian psychiatrist who was a pioneer in deinstitutionalization. What that interview made clear was that as he acknowledged, their 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 And 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, 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 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 stood out from part 1 of 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

“With Art We Build What Poverty Destroys”: Part II of the Interview with Adalberto de Paula Barreto, MD, PhD

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” in English), 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: All over the world, the Global Health and Mental Health Movement, talks about the “treatment gap,” which is the difference between known levels of disease, illness, and social suffering and the limited resources available to treat them, so that people do not have access to them.⁹ But the problem with that approach is that it is very materialistic, they do not talk about the soul. Another thing that is shocking to me as a child psychiatrist is that it is not only that the soul is affected, but that the soul does not unfold—I prefer the word “unfolding” rather than “developing.”¹⁰ (See my column, “Unfolding”: Rethinking Development, A Report from the Global South). So, children are practically unsocialized because they do not have the resources to unfold, that is, to grow, expand, and change.

Adalberto de Paula Barreto, MD, PhD: Exactly. When the United States left (I think it was from Iraq), the Americans brought with them those who had helped them, their friends. Many went to the United States, and others went to France. Of those who arrived in Paris, at that time, there was a meeting to find out what to do with these people. It seems that there were 100 families, 30 of one ethnicity, the rest of another, and they did not even speak the same language. We proposed a community therapy circle. How would we work with them? Because they were not sick, individually there was no way. In the therapy circle, we started with a metaphor: “When the bird lands on a branch, it’s not afraid that the branch will break, because it can fly. So you flew from your tree, it wasn’t an option.”

Di Nicola: You know what my grandmother used to say in Italy? She said, “It’s possible to go on foot if you have a horse in the stable.” It is the same thing, no?

Barreto: Yes. To continue, the question from the circle was, “You were forced to, you did not choose to leave. You lost a branch and now you are going to create a new nest, a new home. In building this new home in another country, another culture, what values ​​from my ancestry, from my culture do I need to include in this construction of a new identity?” So, it was very interesting, because one said, “My belief is this: never forget that we are heroes, and that we were warriors, that our ancestors were too. Let’s continue to fight for what we have.”

Di Nicola: That sounds very much like Tobie Nathan’s work in Paris, on ethnopsychiatry.¹¹

Barreto: Yes, from the perspective of ethnopsychiatry, but he did a more clinical ethnopsychiatry, because he treated patients individually.

Di Nicola: Yes, very clinical. I am not sure if he worked directly with communities.

Barreto: And we were colleagues, we studied together with Georges Devereux.¹²

Di Nicola: Yes. Tobie Nathan also spoke of, interestingly, a type of positive segregation, “positive ghettos,” let’s say, positive favelas in the sense that they can bring together people who belong to the same tribe, tradition, and religion, and so on.

Barreto: Yes, they start to create positive ghettos because they support each other, they find each other. In fact, there was a time when I accompanied a group of teenagers and preteens who “worked” in gangs—that is, they lived by stealing and assaulting people. For a year, I accompanied them once a week, doing group dynamics, and I realized that the gang was a positive social intermediary. Because once you join the gang, you have guaranteed fun and money every weekend, no one hits you anymore, and you think, “I am protected.” At the time, I wrote an article about it, that it was a positive social internet that they had there. That is why I think that for the future of social psychiatry, we must include other resources in our treatment. Obviously, for pathologies and illnesses, only doctors, health professionals, and us psychiatrists can intervene, because we were trained to diagnose and prescribe. But, on the other hand, there is the human dimension, which is suffering, pain of the soul, grief, like that of a mother who loses a child to drugs. This is not a pathology, there is no chemical medicine for this, it has to be treated with resources other than chemicals, although it may be necessary at times. What I see today in psychiatry, and here (in Brazil) in the CAPS, which apparently was an interesting step, is that they are medicalizing, doing the same thing.

Di Nicola: Please tell my North American readers what is CAPS?

Barreto: It is the Portuguese acronym for Centro de Atenção Psicossocial (Psychosocial Support Center).

Di Nicola: We have the same thing in Montreal where we call it a Centre local des services communautaires (CLSC) – a Local Center for Community Services.

Barreto: Yes, it went from the big hospital to the small one, when it should be like the project we have there in Ceará [Dr Barreto’s state in northeastern Brazil], which is the Quatro Varas Project: an integrated community mental health movement, where we hired local healers and trained them and today they work earning a public salary. [This is significant in an area marked by high levels of unemployment and poverty, although this is improving rapidly.]

Di Nicola: That is interesting. I think that was the weakness of the community psychiatry movement. Many—not all because our American colleague Ken Thompson, MD, is more visionary—did the same thing in the community, in community mental health centers, as in the hospital. Only the place changed, but the thinking did not change. [Canadian historian Matthew Smith, PhD, has documented this in his book on community psychiatry in the US. My interview with Smith will the focus of a future column.¹³]

Barreto: The logic is the same!

Di Nicola: And that is why it was a failure for me, besides the fact that there was no money anymore when the funding sources dried up, but it is the community or collective idea that was not transmitted and incorporated in a real way.

Barreto: It is because [in the traditional medical model], when you look at people, you do not see their resources. In community therapy, we have some values: seeing the other as a resource; returning to simplicity; working on circularity; “I have to grow,” “I have to change,” moving from the vertical to the horizontal; being different does not mean being better or worse, it respects difference, including the value of culture.

Di Nicola: Are you familiar with the thinking of Emmanuel Levinas? A great Jewish theologian, but also a philosopher.¹⁴ He is different than Martin Buber. The latter spoke of the relationship “Ich und Du”—German for “I and thou,” even with God, as equals. [Thou is the archaic English version of “you” in the singular, like tu in Latin languages.]¹⁵ Now, Emmanuel Levinas speaks of what a face-to-face encounter should be like, one in front of the other, and this encounter is also possible—and necessary—even in the face of violence. So, for Buber, the I-Thou encounter is among equals, but for Emmanuel Levinas, it could even be with someone who is going to beat you, someone who is going to rape you, who is going to commit violence, but it is necessarily, he insists, a human encounter, face-to-face, even with violence! It is in the relationship... and this relationship is unavoidable... there is no way to escape…

Barreto: And a relationship that is not vertical, but a relationship that respects differences.

Di Nicola: If possible! Because he was also interned as a prisoner of war during WWII [as a French soldier rather than as a Jew, which protected him from being caught up in the Holocaust]. So he witnessed war and violence. He said, even with the guard who can kill you, you must have this human relationship. Even with the threat of violence! What do you think about that? Because here in Brazil, many people experience great violence, daily, you know, I see it on the streets.

Barreto: I think it is a bit of hopelessness. For a long time, in Christianity, but especially in Catholicism, they said that the true life was in the afterlife, that we would have an encounter with God after we die. There was a prophetic dimension, and from that people began to realize that it was not true, that they would not get there. Then the Evangelical Christians came and said that you do not need to die to meet Jesus, God, and the Holy Spirit, here and now.

Di Nicola: You do not need to do anything.

Barreto: You do not need to do anything, just celebrate and pay your tithe. So, I think what is missing here is hope, because if I want us to become more human in our relationships, and I do what others do to me, criticizing what people do to me, there is something that is not working, that is wrong.

Di Nicola: How can we give more hope to people? Are we the ones who will bring hope or can we release this hope that already exists? How can we work with people who miserable?

Barreto: For me, a person’s greatest asset is self-confidence. When I lose confidence in myself, which I no longer believe in because of violence or [lack of] education, I no longer believe in myself, I no longer believe in others, or in the future. This is what psychiatry calls the syndrome of affective poverty, of internalized poverty. The worst poverty is not material poverty; it is internalized poverty where people do not believe in themselves, in others, or in the future. So, how can we help? In our work, we have helped people value themselves for who they are. For example, the children of alcoholics: they run away from home on the weekend because their father comes home drunk, beats their mother, the son protects his mother, and ends up killing his father. We brought together more than a hundred young people who lived in this context. We created a space, and at the time the program was called, “With art we build what poverty destroys.” They made cards that they designed and sold. Half of the proceeds went to them, the other half to the project. So, we recovered that. The research we did at the time showed that people would do anything to avoid going home, so they would turn to drugs, prostitution, and religious sects; and we created an alternative space where they would come to do this work. We started to value them, “Your work, your drawing is beautiful,” but they did not believe it. “No, it’s not,” they said. It was very interesting because after a few years, someone who was the son of a drunkard, we told them, “You are the father of an artist.” They started to believe in their potential. So much so that today, the people who run the Quatro Varas Project in the favela are the ones who started welcoming them, “It’s Cláudio!” one of the boys from back then.

Di Nicola: This hope is transmitted.

Barreto: But it cannot be an alienated experience, of later, in the future. No, it is the here-and-now—and that is why it also involves economic and educational inclusion. I think it is a much broader process of inclusion; it is insertion. I think it is from this perspective that I think [Brazilian] President Lula has this vision, of integration, of thinking about the poorest, of opening schools. Since we have federally-funded schools [which are very competitive and selective], where only the upper class goes, [Lula] created a law that guarantees half of the places for people from the favelas, that is, for people who did not come from private schools, which are the most expensive.

Di Nicola: There was a time, before the military dictatorship, the coup [in 1964], when there were those schools in Rio Grande do Sul called brizoletas—Governor Leonel Brizola’s schools [with the slogan, “No child without school in Rio Grande do Sul”], but that is from another time, right?

Barreto: That was in another time, in a previous government, and it continues like that. For example, I am a professor at the School of Medicine, where there are 30 students. Now, there are 15 white people from the upper class and 15 indigenous and Black people, and the dynamics have changed. They are in a different educational program.

Di Nicola: How do you see the possibility of curing real disorders, having understood that we must heal the soul. People also have bodies, minds, injuries, and traumas. Do you see that this community therapy is also capable of confronting, healing, and caring for people, even those affected by severe trauma?

Barreto: Yes, because Boris Cyrulnik, MD, said that to overcome a trauma, you need 3 things: the biological receptacle to be changed, the resignification of the trauma, and the support of the community.¹⁶ When a person gives visibility to their pain, it generates an identification in which many have the same situation, but they thought they were the only ones. So, a movement of conversation and construction is created among them, resources and the community appear, so there is more autonomy and less dependence on specialists.

Conclusion: ICT is an Opening, Not a Closure

ICT is a major force in Brazilian community psychiatry and mental health and offers us a reliable partner for social psychiatry.^4-6 We must not see ICT in an instrumental way, as just another set of techniques, or even abstract from its practice such techniques. ICT is more than a therapeutic tool in the narrow sense but more like what French philosopher Michel Foucault called an apparatus¹⁷:

a thoroughly heterogeneous ensemble consisting of discourses, institutions, architectural forms, regulatory decisions, laws, administrative measures, scientific statements, philosophical, moral and philanthropic propositions–in short, the said as much as the unsaid…. The apparatus itself is the system of relations that can be established between these elements.

Following Foucault, ICT is located in “the system of relations that can be established” for the greater inclusion and autonomy of individuals to enhance their integration into a community. As Dr Barreto emphasizes here, community therapy articulates and inculcates a series of values:

seeing the other as a resource; returning to simplicity; working on circularity; “I have to grow,” “I have to change,” moving from the vertical to the horizontal; being different doesn’t mean being better or worse, it respects difference, including the value of culture.

In my provisional conclusions to the first part of our interview, I asked: 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.

And I acknowledged that: 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.

Upon further reflection, I see Barreto’s ICT as an apparatus for fundamental change. Unlike many claims for new forms of therapy which directly or indirectly criticize past practices (just as behavior therapy attacked psychoanalysis with the slogan that “Insight does not equal behavior change”), ICT lives up to its name. It integrates other practices. As Dr Barreto said in the first part of our interview, he takes from all aspects of his training, from theology to cultural anthropology, from Lacanian to Jungian psychoanalysis, and from psychiatry to systemic family therapy.

Rather than rejecting elements of other therapeutic approaches, Dr Barreto’s ICT deploys, adapts, and synthesizes them. Participating in his workshop in Belo Horizonte last month, I could tease out the elements of his interactions with the audience of several hundred people—Moreno’s psychodrama, Lacanian psychoanalysis, Devereux’s ethnopsychiatry, Milan systemic family therapy, Michael White’s narrative therapy—all enlivened by the performative elan of Augusto Boal’s theater of the oppressed¹⁸ and sprinkled with a liberal dose of Leonardo Boff’s liberation theology.¹⁹ More importantly, what I experienced was the syncretic mix of elements that come together—Brazilian style—into something new.

• Is it therapy? Well, ICT addresses personal and social suffering and it is change-oriented, as Dr Barreto’s examples show.
• Is it community mental health? More radically than all the approaches mentioned here, ICT situates the problems, encounters, and solutions as well in the community with its mental, relational, and social suffering. It is a new way of looking and seeing—a southern epistemology.²⁰ Or rather, it is a return to a premodern, communal sensibility.
• Can ICT address the serious psychopathology that psychiatry deals with, daily? That is an empirical question that can and must be put to the test, as family therapy has had the courage to do, with very encouraging results. In doing so, however, family therapy also changes the definitions of these issues:

-To what is psychopathology, family therapy answers: relational distress.

-To what is therapy, family therapy answers: working with the self-in-relation and the relational self.

-To the how of therapy, family therapy offers the relational dialogue.²¹

ICT adds another, broader layer here—to each answer, ICT adds the social. Relational and social distress; the relational self is a social self; the relational dialogue need not be a private, intimate affair but can also be held more openly, socially, as Dr Barreto’s work shows—reflecting its roots in Socrates’ social philosophy, walking around the agora, ancient Athens’ public square, and Jesus’ public ministry in ancient Israel.

More importantly, ICT addresses aspects of social suffering that are obscured and occluded by situating clinical work in private practices and hospitals or even in community social and health care centers, whether in Brazil or Canada. And even obscured by family therapy, which started by reaching out to the community but has largely retreated into institutes and private practices. I see both family therapy and community therapy as part of the relational therapies, which are social psychiatry’s third branch. For social psychiatry to realize its mission congruent with our core social values, we must recognize benefits in therapeutic approaches at all levels, as ICT does, and encourage the movement towards the community to broaden its reach.

As I always say about trauma, clinicians of all stripes are never at the site of trauma—at best, the ambulance brings them to our care. ICT places us at the site of potential trauma and rather than being the ambulance that whisks a traumatized population away from the community, brings us as healers, workers, activists, and neighbors right into the community.

Like Zimbabwe’s famous “friendship bench,”²² ICT asks us to enter a more human, more engaged social encounter. Sit down, stay a while!

Resources

Dr Barreto’s work is now available in English:

1. Barreto AP. Integrative Community Therapy: Step by Step, Al Jamal, HO, trans. ICR; 2019.
2. 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.
3. Barreto, AP, Camarotti H. Integrative community therapy. In: Okpaku SO, ed. Innovations in Global Mental Health. Springer; 2021:1-20.
4. 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 co-author 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 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 Soc Psychiatry. 2024;6(1):6-13.
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6. Barreto, AP, Camarotti H. Integrative community therapy. In: Okpaku SO, ed. Innovations in Global Mental Health. Springer; 2021:1-20.
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14. Levinas E. Entre Nous: Thinking-of-the-Other. Smith MB, Harshav B, trans. Columbia University Press; 1998.
15. Buber M. I and Thou. Kaufmann W, trans. Charles Scribner’s Sons; 1970.
16. Cyrulnik B. The Whispering of Ghosts: Trauma and Resilience. Fairfield S, trans. Other Press; 2005.
17. Foucault M. “The Confession of the Flesh” (1977) interview. In: Power/Knowledge Selected Interviews and Other Writings. Gordon C, ed. Harvester Press; 1980:194-228.
18. Boal A. Theater of the Oppressed. Theatre Communications Group; 1993.
19. Boff L, Hathaway M. The Tao of Liberation: Exploring the Ecology of Transformation. Orbis Books; 2009.
20. Di Nicola V. The Global South: an emergent epistemology for social psychiatry. World Soc Psychiatry. 2020;2(1):20-26.
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