A group of people sitting in a circle at the base of a Favela Hill, with their legs crossed engaged in a healing practice. A source of light beams up from the center of the circle.
Image Credit: Dall-E by OpenAI.

Editors’ note: This piece is from Nonprofit Quarterly Magazine’s winter 2024 issue, “Health Justice in the Digital Age: Can We Harness AI for Good?”

The Challenge

Sometimes, innovation is the discovery of eloquent simplicity. Sometimes, necessity really is the mother of invention. Sometimes, what’s new is rooted in what is ancient. Sometimes, novelty and significance emerge from the most forgotten places.

Attaining equity in health isn’t always about bringing the resources of the rich to the poor. Achieving health equity is more often than not about mobilizing the resources the people already have. And while technology can provide tools that can be very helpful to achieving our evolving healthcare and related social needs, human connection remains the pivotal key to healthcare as well as our overall health and wellbeing.

Informal networks of social supports do exist—as they have for millennia—and help people manage the challenges they face; however, under the atomizing pressure of our economy and culture, these supports are often too underresourced to fill in the gaps.

The United States is in a societal mental health crisis.1 We live in a world of increasing social fragmentation, trauma, and stress.2 In the face of extraordinary demands, many people have inadequate social supports, and what psychological resources they possess are overwhelmed.3 Social isolation has become so prevalent that the U.S. Surgeon General has called it an “epidemic.”4 The social infrastructure is precarious at best—under constant pressure from the polycrisis of the pandemic, economic and societal dislocation, racism and exclusion, political polarization, and climate change.5

America’s communities and people pay the price in suffering and ill health—but the distress generated is not equally distributed.6 People who lack formal education and people with lower incomes—and their communities, especially minoritized communities—carry the greatest burden, as they have historically.7 Young and old in these communities are especially at risk—they not only suffer the most but also have the fewest material resources for health promotion, healing, and care.8 Clinical services countrywide are stretched far beyond capacity.9 They are also expensive for many, even with insurance.10 And unfortunately, they are often untimely and ineffective.11 Most operate at the level of the individual rather than the community, so clinics also have very limited capacity to address the social drivers of health at any scale.

Informal networks of social supports do exist—as they have for millennia—and help people manage the challenges they face;12 however, under the atomizing pressure of our economy and culture, these supports are often too underresourced to fill in the gaps. The social fragmentation that our society is experiencing shows up first in the fraying of these networks. Innovation is necessary to address the structural challenges of social disconnection, exclusion, and isolation that are leading to the mass experiences of loneliness, trauma, and despair—but whether or not technology can be a positive, powerful force to that end remains to be seen and, in fact, currently is a big part of the problem (although not, apparently, as regards older adults experiencing isolation, for whom technology has been shown to be a boon.13) The critical question is, How can we ensure that innovations in technology are rooted in equity and become tools for justice, empowerment, and wellbeing, including in our healthcare systems?

The Hope

In the 1980s, in a Brazilian favela (shanty town) formed on the borders of the city of Fortaleza in (it is thought) the late 1970s, a desperately poor, multiracial community, displaced by climate change and under constant harassment by the police, had become overwhelmed with trauma, fear, and despair. At times they were able to support each other, but this was sporadic and underorganized. It was a dog-eat-dog existence, and the suffering was immense.14

Airton Barreto, a human rights lawyer working to end the police incursions that repeatedly tore down the peoples’ meager shacks, noted the casualties caused and exacerbated by this suffering. There was rampant alcohol and drug use, depression, crime, prostitution, domestic violence, and child and elder neglect. No health or human services were available, nor were there any clear solutions to the ongoing injustices and suffering. He engaged his brother, Adalberto Barreto, a psychiatrist at the Federal University of Ceará, to see what help he might be able to offer. Adalberto Barreto first tried to help by providing free psychiatric services in his clinic at the medical school, but residents of the favela did not have the means to get there. He decided to bring services to the favela instead. When he and a group of his medical students arrived the first day, they found over 100 people lined up in the sun waiting for them. There was no community place for them to wait inside.15

“In 1986, I arrived at the Quatro Varas community [in the Pirambu favela in Fortaleza, Brazil] with my medical students from the Federal University of Ceará,” recounted Adalberto Barreto.

A lady told us that she couldn’t sleep and asked for a medicine that we didn’t have. When I was going to prescribe a medication, she said she didn’t even have the money to buy food for her children, let alone expensive medicines. I realized that I was acting the way I was used to acting in the hospital.

The woman began to tell her story, to cry. Another came who supported her by giving her a handkerchief to dry her tears; another gave her a foot massage, another brought a cup of herbal tea, another began to share a similar personal experience. I realized then, that this woman started to be supported, that bonds of affection were created. She found what she came for: the support of the community, not my expertise. I realized that the community that has problems also has its solutions. Thus was born Integrative Community Therapy (ICT), a space for welcoming soul pain and collective suffering.16

Working together from that moment, the community and the psychiatrist built a large group method they call Integrative Community Therapy (ICT), which can consist of up to 100 participants practicing a dialogic method.17 The method uses an elegant, culturally sensitive five-step approach to help people expand their emotional literacy, empathy, and solidarity while solving problems in daily living and addressing broader community concerns.18

[Integrative Community Therapy] flows from the work of Paolo Freire, Gregory Bateson, Indigenous “healing circles,” and the human technologies of community organization, dialogue, peer relationships, nonhierarchical education, and focusing on strengths first.

The Five Steps19

Welcome

The simple rules of the session are introduced, and participants are asked to warm up by introducing themselves and noting anything in their lives for which they feel gratitude. The group then engages in music and (if people want to) physical movement to bring positive, welcoming energy to the group.

Identify

Participants share “the pebble in their shoe,” or what emotional challenges they are experiencing.20 The facilitator, with help from the group, captures the emotional essence of each challenge. The group as a whole then selects one of the topics that have been identified to explore further. (In a variant of this method, called “a thematic,” the facilitator proposes an emotional challenge that they know is impacting the community as a whole.)

Explore

The participant whose topic was selected for further exploration gives context to their situation or struggle, and then the topic is opened up for group members to ask clarifying questions. The goal is to ask questions that open the topic up to alternative perspectives.

Share

The group is invited to discuss the topic. Using only “I” statements, the group provides guidance by sharing their own narratives and experiences.

Closure

The facilitator proposes a wrap-up of the group’s sharing. The group is encouraged to thank others directly for their thoughts and giving gratitude for being heard, learning from others who share their experiences, and being held in and lifted by community support and belonging.

The Method

ICT flows from the work of Paolo Freire, Gregory Bateson, Indigenous “healing circles,” and the human technologies of community organization, dialogue, peer relationships, nonhierarchical education, and focusing on strengths first. The Brazilians call this large group dialogic peer approach “solidarity care.” The facilitator is not an expert but a coparticipant, usually a trained lay person. The method’s foci are the emotions and lived experience of the participants. It is open to the whole community and held in public (but can be used more narrowly in populations requesting privacy). It is not based on pathology but instead on shared experiences. Practitioners follow the precept that community is therapy. In this way, ICT overcomes the structural forces that isolate and disempower people in communities dealing with daily emotional struggles.

ICT is a funded service of the Brazilian United Health System.21 Groups typically meet in public places once a week for 90 minutes. Originally designed to be done in person, ICT has been adapted to online practice.22 Primary health, mental health services, and community organizations are the common referral sources and often are the sites where the groups are held. Literature (most of it in Portuguese) documents ICT’s individual and community impact23—which includes a marked reduction in the number of people needing specialty mental health services after participating in a series of ICT sessions.24 At present, there are at least 12,000 trained facilitators in Brazil, most of whom are community health workers, not mental health professionals.25

***

ICT is now in use in over 27 countries26 and was recently introduced to the United States by a newly formed nonprofit in Pittsburgh, PA: Visible Hands Collaborative, which was organized to pursue equity in health and wellbeing.27 Originating in a city that the invisible hand of the market dropped 40 years ago when steel died, it was the visible hands of solidarity that saved many lives and many communities there. The collaborative seeks to expand that history by helping to bring solidarity care to the United States. After adapting ICT to an American context, Visible Hands Collaborative is now engaged in a large pilot project in another old steel region, the Lehigh Valley of eastern Pennsylvania, in partnership with the Lehigh Valley Health System, to incorporate ICT in their community engagement and empowerment activities at a large enough scale to test out how ICT can work in the US cultural context. Another is in the planning stage, for Pittsburgh, PA. The task of bringing ICT to the United States—finding the support needed to adapt it to the various cultures here—has been a challenge. But it has been aided by the fact that the Brazilians are passing on all their knowledge and materials for free. This is an ethos practitioners of ICT intend to stick with, to ensure that ICT is accessible to all at minimal to no cost.

This is the kind of innovation that is sorely needed. Americans are literally dying for community and connection. But sadly, we have created an economy and a culture that have demonstrated little room for solidarity and limited capacity to promote it. It is far easier to pay for a new app. And so much less human.

ICT and the concept of solidarity care offer a way to help create community, solve personal and community challenges, alleviate suffering, cultivate love and solidarity, and move us toward health equity and justice. That’s a tall order, but it’s within the capacity of the people. In fact, that is the only place it exists.

 

The author is deeply grateful to Adalberto Barreto, MD, PhD, Fortaleza, Brazil; Vitória Figueroa, MA, Fortaleza, Brazil; Alice Thompson, MD, Austin, Texas; Brigit Hassig, MPA, Missoula, MT; Sylvia London, MA, Mexico City, Mexico; and Irma Rodriguez, MA, Mexico City, Mexico, for their extraordinary work and unflagging belief in the power of human connection.

 

Notes

  1. “Protecting the Nation’s Mental Health,” S. Centers for Disease Control and Prevention, August 8, 2024,www.cdc.gov/mental-health/about/what-cdc-is-doing.html.
  2. “Stress in America: Money, inflation, war pile on to nation stuck in COVID-19 survival mode,” American Psychological Association, accessed December 27, 2024, apa.org/news/press/releases/stress/2022/march-2022-survival-mode; and Lasse Brandt et al., “The effects of social isolation stress and discrimination on mental health,” Translational Psychology 12, no. 1 (September 2022): 398–411.
  3. Ibid.
  4. Our Epidemic of Loneliness and Isolation: The S. Surgeon General’s Advisory on the Healing Effects of Social Connection and Community (Washington, DC: Office of the Surgeon General, 2023).
  5. Michael Lawrence et , “Global polycrisis: the causal mechanisms of crisis entanglement,” Global Sustainability 7 (January 2024): e6.
  6. José Escarce, Health Inequity in the United States: A Primer (Philadelphia, PA: Leonard Davis Institute of Health Economics, University of Pennsylvania, 2020).
  7. Ibid.
  8. “Stress in ”
  9. From Crisis to Solutions: Policy Catalysts for Improved Outcomes (Washington, DC: National Association of Counties, 2024).
  10. Stoddard Davenport et , Access across America (Seattle, WA: Milliman, 2023).
  11. Jamie Ducharme, “America Has Reached Peak Why Is Our Mental Health Getting Worse?,” TIME, August 28, 2023, time.com/6308096/therapy-mental-health-worse-us/.
  12. June L. Brown et al., ”Seeking informal and formal help for mental health problems in the community: a secondary analysis from a psychiatric morbidity survey in South London,” BMC Psychiatry 14, no. 1 (October 2014): 275.
  13. Mfon Umoh et al., “Impact of technology on social isolation: Longitudinal analysis from the National Health Aging Trends Study,” Journal of the American Geriatrics Society 71, no. 4 (April 2023): 1117–23.
  14. Adalberto de Paula Barreto, Integrative Community Therapy (Fortaleza, Ceará, Brazil: Adalberto de Paula Barreto, 2019), 153–61.
  15. From author’s personal communication with Adalberto Barreto, June
  16. Ibid.
  17. Harlene Anderson and Diane Gehart, eds., Collaborative-Dialogic Practice: Relationships and Conversations that Make a Difference Across Contexts and Cultures (New York: Routledge, 2022).
  18. The full approach is six steps, with the sixth being an evaluation after the five See Barreto, Integrative Community Therapy; and Adalberto Barreto, Henriqueta Camarotti, and Nicole Hugon, “Integrative community therapy: The power of sharing in communities,” in Oxford Textbook of Social Psychiatry, Oxford Textbooks in Psychiatry, ed. Dinesh Bhugra, Driss Moussaoui, and Tom J. Craig (Oxford, UK: Oxford University Press, 2022): 610–C63.P125.
  19. These steps have been adapted from the original by Visible Hands For original steps, see Barreto, Integrative Community Therapy.
  20. From quote attributed to Muhammad Ali, “It isn’t the mountains ahead to climb that wear you out; it’s the pebble in your shoe.”
  21. Sabrina Ferreira de Lima Czornobay et , “Factors Associated with Participation in Integrative Community Therapy Circles in Brazil: A Case-Control Study,” World Social Psychiatry 6, no. 1 (January–April 2024): 45–52.
  22. Franciele Delurdes Colatusso, Júlia Feldmann Uhry, and Giovana Daniela Pecharki, “Online Integrative Community Therapy in Latin America: Health Promotion in Times of COVID-19,” Health Education & Behavior 51, no. 1 (February 2024): 32–42.
  23. See, for example, Adriana Olimpia Barbosa Felipe et , “Integrative community therapy for the promotion of mental health in adolescents: A quasi-experimental study,” Counselling & Psychotherapy Research 23, no. 1 (March 2023): 96–104; Chiara Sabina et al., “Evaluation of Integrative Community Therapy with Domestic Violence Survivors in Quito, Ecuador,” International Journal of Environmental Research and Public Health 20, no. 8 (April 2023): 5492; and Ianine Alves da Rocha et al., “Community integrative therapy: Situations of Emotional Suffering and Patients’ Coping Strategies,” Revista Gaúcha Enfermagem 34, no. 2 (2013): 155–62.
  24. See, for example, Barreto, Integrative Community Therapy, See also Allan Tasman and Kenneth S. Thompson, “Addressing Loneliness and Social Isolation as Essential Components of Public Health Approaches to Ameliorate the Adverse Social Determinants of Mental Health,” World Social Psychiatry 5, no. 2 (May–August 2023): 129–31.
  25. From author’s personal communication with Adalberto Barreto, June And see Milene Zanoni da Silva et al., “The Scenario of Integrative Community Therapy in Brazil: History, Overview and Perspectives,” Temas em Educação e Saúde 16, no. esp. 1 (September 2020): 341–59.
  26. Adalberto de Paula Barreto and Henriqueta Camarotti, “Integrative Community Therapy: A Space for Communitarian Resilience,” Innovations in Global Mental Health (September 2021): 1–20.
  27. See “Community Heals,” Visible Hands Collaborative, accessed December 27, 2024, www.visiblehandscollaborative.org.