Hello, my name is Dr. Sarah Vincent and I'm the moderator for this session. I'm really pleased to have these presenters come before you. They have a wealth of knowledge from very, very different experiences and perspectives. Sociopolitical determinants of health have a considerable impact on trauma in individuals and in communities. Traditionally, psychiatry has focused on individual traumas and individual interventions. However, this approach is limited in many pertinent, frequent, psychologically damaging occurrences. Trauma can consist of political violence, community violence following disasters, and detention and immigration and correctional facilities, to name a few examples. This session will explore various aspects of community-level trauma, as well as the roles of mental health professionals in understanding, assessing, and addressing them within diverse populations. Our first speaker is Dr. Denise Shervington, and I'm just going to tell you a bit about what she's done. Of course, this isn't comprehensive, but if you don't know about Dr. Shervington's work, I wanted to make sure that you were familiar with it. So Dr. Denise Shervington is the Chair of Psychiatry and Behavioral Medicine at Charles Drew University School of Medicine. A graduate of New York University School of Medicine, she completed her residency in psychiatry at the University of California, San Francisco, and is certified by the American Board of Psychiatry and Neurology. Dr. Shervington also received a Master's of Public Health in Population Studies and Family Planning from Tulane University School of Public Health. She has an intersectional career in public health, clinical, and academic psychiatry. After Hurricane Katrina, she created a post-disaster emotional recovery and resilience division at the community-based nonprofit public health organization that she founded, the Institute of Women and Ethnic Studies. She has also held academic appointments as clinical professor of psychiatry at Columbia University in New York and Tulane University in New Orleans. She previously served as Department Chair of Psychiatry at Meharry University and as Director of Psychiatry at Harlem Hospital. She also served as the Deputy Assistant for Population Affairs at the Department of Health and Human Services in Washington, D.C. In 2018, Dr. Shervington received the Award for Excellence in Service and Advocacy from the American Psychiatric Association. Dr. Shervington is a member of the American College of Psychiatrists. She has authored several papers and peer-reviewed journals addressing health disparities, the social determinants of health, and resilience in underserved communities. And last but certainly not least, Dr. Shervington is the mother of two magnificent children and two amazing grandchildren. Thank you, Dr. Vinson. It is an honor to be with you on this panel and also Dr. Saul. My focus today is looking at trauma as a social determinant of health, applying the social and ecological model. I have no financial or other relationships that I need to disclose. So I'm going to start, as we think about trauma and why it's important in certain communities, I just want to acknowledge that there has been, in the United States, centuries of trauma based on a construct of white supremacy. We have the displacement of the first indigenous people and ongoing treat violations and economic marginalization. We have those who were enslaved and brought here and ongoing the resulting anti-Blackness at the interpersonal and institutional levels. We have the recent uptick in anti-Asian hate and certainly some of the anti-immigration sentiments and policies that are directed towards global BIPOC peoples. So these are the traumas that we are going to be considering today and then, therefore, thinking, how can we take an approach that addresses all of this and not just look at individual behaviors? I'd like to suggest that if we are going to undo racial traumas, we really have to adopt a healing justice framework and that requires that we adopt racial equity values, where we affirm that all people, regardless of their racial ethnic group identification, their skin color or physical traits, deserve an equal opportunity to experience well-being in a just society and that we also promote racial healing and it's a process that restores not only individuals but communities to wholeness, repairs the damage caused by racism and transforms societal structures into ones that affirm the inherent value of all people. So as I said in my title, I'm going to be applying the social ecological model to thinking about how we develop healing policies. The underlying theory of the social ecological model is that individual behaviors are influenced not only by individual factors, the knowledge and attitude and skills of someone, but social factors, the influence of interpersonal and social networks, community factors, the physical environment, including accessibility of healthy and unhealthy choices and also larger societal factors, the national and international level policies, cultural values and norms that impact people where they live. And why this is so very important that we broaden how we perceive trauma, I'm going to quote from Dr. Vincent Felitti, who was the major architect of the Adverse Childhood Experiences Study, and he said that traumatic events of the earliest years of infancy and childhood are not lost, but like a child's footprint in wet cement are often preserved lifelong. Time does not heal the wounds that occur in those years, time conceals them. They are not lost, they are embodied. And eventually, we know that through the evidence and science we do have now that eventually, all these levels of trauma eventually gets under the skin of the individual, whether that be through epigenetic changes, which is the modification of protein expression due to environment and and behaviors, or by allostatic loading, where someone has difficulty reestablishing homeostasis in response to stress through the excessive release of stress hormones, neurotransmitters, and immunocytokines. There's also telomere shortening, the stabilizing caps located at the end of chromosomes that protect DNA from aging and cellular stress, and also weathering, the cumulative impact of socially constructed stress from repeated social, economic, and political exclusion. These are how some of these levels of trauma eventually gets under the skin of individuals who are being traumatized and can lead to physical and mental health disorders. I want to start with perhaps the first potential trauma that an individual can face, that of attachment and relational trauma. And why this is important is that if a child does not have or if their bond with their caretaker is disrupted through repeated interactions with unpredictable and inconsistent and unskillful caretakers, we know that this child will have a lot of difficulty eventually developing a coherent sense of who they are, their capacity to mentalize, understand how their mind and other people's mind work, will be impaired, they will have challenges modulating their emotions, and most importantly, when faced with trauma that all of us at some time in our life will possibly face, they will have a real difficult time bouncing back and being resilient. We know about the adverse childhood experiences study, I mentioned Dr. Felitti earlier, who found that if before the age of 18, a child is exposed to physical, sexual, or emotional abuse, if they've been neglected emotionally or physically, or if they grew up in a household with challenges where there was substance use or mental illness, suicide attempts, domestic violence, or parental imprisonment, it was found that after the age of 18, along their life course, there was a graded response to their vulnerability to develop certain physical and mental health disorders. That original study was expanded to include some other factors, community and societal factors, and in Philadelphia, this list of potential adversities was expanded to include witnessing violence, experiencing racism or discrimination, living in unsafe neighborhoods, experiencing bullying, or having lived in foster care. And in California, through the amazing work that's been done by the Surgeon General, Dr. Nadine Burks Harris, they have even expanded that list to include food insecurity and housing instability. Eventually, after children are exposed to these adversities, and they do not have adequate buffers, where there is prolonged activation of the stress response system in the absence of protective relationships, we know that this will very much alter the course of their life, not only their learning ability, but later on their vulnerability to more physical and mental health disorders. There is evidence now that childhood maltreatment significantly impacts mental health, and some of the early life stressors that I mentioned earlier, we know has the capacity to be a risk for the development of psychopathology, through some of those ways in which I mentioned that trauma gets under the skin. And eventually, we do know and have the evidence that such individuals are much more likely to develop mood disorders, to develop PTSD, substance use disorders, and personality disorders. Through some of the amazing work that's being done on toxic stress, we know that not only the neurologic and neuroendocrine system is impacted, but the immune system, the endocrine system, and I mentioned earlier, the genetic system. I want to just share with you real quickly a case study of a young boy that I saw. Unfortunately, I saw him when he was imprisoned at age 13. And he really is a Katrina baby, for those of you familiar with what happened in New Orleans in 2005. And unfortunately, what has happened again in New Orleans on the anniversary, 16th anniversary of Katrina. But in 2005, the city was just about destroyed. This young boy was born five days later, his mother evacuated to Texas. So you can imagine that already at point zero in his life, whatever stressors his mother was experiencing possibly was transmitted to him. There are studies now that show that women who are pregnant during disasters have an increased risk of passing on the vulnerability of PTSD to their children. At age five, this young boy witnessed a homicide and suicide. He witnessed his older brother and older sister being killed by his uncle, who after that, the uncle killed himself. It gets worse for him. At age six and a half, he saw his mother being killed outside. His father was also shot, survived and developed TBI. And at age 13, right before he was put in the juvenile justice system, his sister, one of his remaining sister who survived the shooting with him, almost died in a car accident. He received no mental health intervention. The only supports he had was in school. And the teacher sent me this picture of him. And I've had permission from him and his family, because this case was so important in terms of untreated trauma. After his siblings were killed and he was in school, very loving support, I must say, teachers were somewhat of a protective factor. They took a picture of him in kindergarten where he said, the world, it controls you. He already knew at age five that things were stacked against him. I also want to share with you some of the work I did in New Orleans after Katrina, where we started to collect data on young people in public schools, large numbers that we did in our study. And we found that young people about five years after Katrina were showing increased levels of symptoms of depression, post and post-traumatic stress disorder. They were also exposed to high levels of domestic violence. They were seeing the murder of folks around them. About 18% of them witnessed folks being killed. Many, over 50% of them saw, experienced, I'm sorry, the murder of someone close to them. And these kids were very worried about themselves being harmed and also being worried that they were not loved or valued or cared for. And each year we thought, okay, things are going to get better. And it continued and has persisted where we have seen these increased levels of trauma-related disorders in young children, primarily children of color. Now with the onset of COVID and all the disruptions and with Hurricane Ida happening on the 16th anniversary, I call it the sweet, the bittersweet 16th anniversary of Katrina, we can only imagine that these numbers are going to continue to stay, if not increase beyond baseline. And what we found in this study was that young people who were exposed to domestic violence, violence happening in your home or violence happening in the community, were much more likely to endorse symptoms of PTSD and depression than those who were not. And also at the interpersonal level, those young people who felt that they were not cared about, they were not loved, they were most likely to endorse these symptoms of depression and PTSD. So I want to just talk a little bit about what do we do? How do we think not just about individual treatment? And I hope that whatever I have presented so far suggests that we're going to have to support policies that support maternal child health. We have to, attachment is such an important part of someone's development, ultimate health development, that if we don't have policies that support a mother, a caretaker's mental health, her physical health, and her economic stability, it's going to be really difficult for caretakers to rise above the challenges. We're also going to have to promote healthy communities. And I put this picture up because these were the young kids after Katrina who taught me how to be a good psychiatrist for them. In addition to the degree that they were called Katrina babies also, and what we do know, but unfortunately didn't study at a large scale, but anecdotally that many of these kids, like the one I shared with you, his tragic outcome, there was not good enough attachment. Their parents were trying to get their lives back together, and unfortunately perhaps did not pay enough attention to these young people's need. So in addition to their, you know, and I've worked with them over a year, so I know that the attachment relational trauma, they were exposed to high levels of community trauma. And so we have to, when we think about helping any one of these young kids, we have to be concerned about the maternal child health environment in which they grew up. And we also have to be concerned about the communities in which they're growing up. Children live with their parents and their parents live in communities. And so to safeguard their mental health, we have to be concerned about the communities they're living in. And in trying to support community building, we need to step back and recognize that people in the communities are traumatized by poverty and racism and all the other isms. So we have to be careful that when we're trying to support policies, that we recognize the past and ongoing traumas in our communities. We accept and meet our community's members where they are. We try to empower them to recognize the importance of their own self-determination. And we try to support communities in their own capacity to be reflective and respond to new developments. And ultimately, as we think about policies, we need to recognize that the community itself must be the mechanism for change, not the site of change with outsider dominance. We also need to support policies that can help to eradicate community-level traumas. We have to support reinvestment in communities to build environment. So many young people in New Orleans told me that they wanted to live in nice neighborhoods. So when we're gentrifying, we need to make sure we're not displacing. And we really need to look at determinants of health like transportation and recreation as important. And of course, key in a capitalist society as the United States is, we have to support economic investments in our communities. And as a result of all these traumas, we know that sociocultural norms can become very negative. Aggression becomes sometimes a way that community members engage with each other. So we need to help communities repair those norms, recognize that we all belong to each other, that we're connected with each other. We need to make sure that in our communities, there's access to low-cost but high-quality trauma-informed healthcare. And we also need to support any complementary Indigenous-based healing practices that help our communities to heal. This is some work I did in New Orleans with all the data that we collected. And it was really that our kids are sad, not bad, and that untreated trauma ultimately can become the underbelly of violence. And I'm not going to go into brain science that explains that, but I know as mental health providers, we know that. So we need to approach our young children who might be showing emotional or behavioral dysregulation with different attitudes, attitudes that are concerned about what's happened to this child and not what's wrong with them. We have to create more equitable healthcare systems. Racism has to be addressed in the healthcare system, in the system itself, and at the interpersonal levels, the multiple studies that show how people of color are negatively treated in the healthcare system. And I recommend that we really adopt a structural competence approach, Metzel and Hansen in the work that they've done, to help where we need to understand how the upstream determinants of health affect marginalized, oppressed groups, and not just focus on individual behaviors. Some people call that social medicine, where we're looking at how social and economic structures impact health. And that's where we need to also seek solutions, not just at the individual level. And I will end that at the societal and structural level, we need to really think about policies that mitigate racism, racism that turns up in law, in our criminal justice system, in education and economics. I know as mental health providers, we might not be able to individually do this work, but we must support that work that's being done. We have to embrace racial and ethnic diversity and inclusion. We really have to challenge and at some point dismantle the prison industrial complex. It is a major source of trauma in our communities. In those young people that I show the picture of in school that I worked with for a year, every one of them had a parent who was incarcerated. And we need to promote positive images of all ethnic groups, not just one, and really begin to think about reparation for the centuries of racial oppression and injustices. We know that healthcare is better when those providing healthcare can relate to and look like the experiences of their communities. These were the young Tulane medical students at the Whitney Plantation in Louisiana. I applaud them. They said they were their ancestors' wildest dreams, and they are. And so I do want to end with the hope for the future, and I'm so grateful to be a part of looking at community trauma as a social determinant of health. Thanks for the opportunity, and thanks to the APA. I now have the pleasure of introducing Dr. Jack Saul, clinical psychologist. He is a psychologist and family therapist who has worked since the early 1980s in clinical and community settings, creating programs that address the psychosocial needs of children and families suffering from domestic, urban, and political violence. Dr. Saul co-founded the Bellevue NYU Program for Survivors of Torture in 1995, and was its clinical director until 1998 when he founded NYU School of Medicine's International Trauma Studies Program, now an independent post-graduate training and research institute in New York City, which he currently directs. In 1999, Dr. Saul established REFUGE, a resource center in New York for survivors of political violence and forced migration, and a member of the National Consortium of Torture Treatment Programs. Following the terrorist attacks on the World Trade Center, REFUGE implemented the FEMA-funded Downtown Community Resource Center, a demonstration project in community resilience for residents and workers in Lower Manhattan. REFUGE also developed African Refuge, a community drop-in center for African refugees and immigrants in Staten Island. He has been a member since 2000 of the Kosovo Family Professional Educational Collaborative, which has been instrumental in the development of the community mental health system in post-war Kosovo. Dr. Saul is currently researching the implementation of collective approaches to the moral injuries of the wars in Afghanistan and Iraq. He consults to media and humanitarian organizations on the development of stress management programs, and has a private practice in Manhattan in individual, couple, and family therapy. His book, Collective Trauma, Collective Healing, Promoting Community Resilience in the Aftermath of Disaster, was published by Routledge in July 2013. Thank you so much for joining us and for sharing your expertise with us, Dr. Saul. Hello, I'm Jack Saul, and I'd like to thank you, Dr. Benson, for organizing this conference today, and also thank you, Dr. Shervington, for presenting such an excellent presentation on a socio-ecological approach to structural oppression. What I want to do is to build on what Dr. Shervington has presented, and to speak about how to promote community resilience in response to disaster and structural oppression. So first, just from a socio-ecological approach, this includes kind of a critique of the dominant trauma discourse. And just to go over quickly, most of the trauma approaches tend to be reductive in that they focus on monocausality, single events, rather than the disruptive impact of multiple stressors. And with structural oppression, we see poverty and stigmatization and isolation, deprivation, lack of resources, as other kinds of stressors that people face, in addition to dealing with kind of traumatic events like the experience of violence. The dominant trauma discourse is also a pathologizing discourse. It focuses on vulnerabilities rather than resilience, and it's been criticized for medicalizing all of human suffering. And we can also see that the responses to atrocity or oppression are existential are existential responses as well as pathology. The critique of the dominant discourse includes kind of questioning whether some of the Western nosology really can be applied cross-culturally. And many of the medical anthropologists who study trauma cross-cultures have been critical of it because it kind of doesn't take into account local idioms of distress and the kind of inherent cultural coping strategies that a particular group may favor. And when you look at trauma across different cultures around the world, it tends to have be more have more to do with a disruption of the social and moral order. And then the other critique of the dominant discourse is that it's an over-individualizing approach. It locates trauma within personal functioning, but we know that organized violence as well as structural violence can lead to the destruction of human connection. And it primarily occurs within families, kinship, and communities. So I'd like to just first make a distinction between individual and collective trauma. The sociologist Kai Erikson made this distinction in his study of disasters in the United States and defined individual trauma as a blow to the psyche that breaks through one's defenses so suddenly and with such brutal force that one cannot react to it effectively. It's a deep shock and like much of what we see in the trauma field, it leads to people withdrawing into themselves, feeling numb, afraid, vulnerable, and very alone. Collective trauma, on the other hand, can be seen as the blow to the basic tissues of social life that damages the bonds attaching people together and impairs their prevailing sense of communality. It undermines their sense of belonging. It's the gradual realization that community no longer exists as an effective source of support and that an important part of the self has disappeared. It leads to a tremendous amount of distress that's not directly coming from a direct experience of trauma, but from this undermining of the social fabric. Collective trauma is relational. It disrupts significant relationships in their sense of trustworthiness, safety, openness, emotional quality. It can result in negative effects on interactions between persons and their context, as well as on intrapsychic aspects of experience, and it can occur even in the absence of individual trauma symptoms. Mindy Fullilove, a social psychiatrist, has studied the impact of collective trauma, the collective trauma of neighborhood displacement due to urban renewal in the United States, basically the destruction of almost 2,000 African-American communities, and has noted the impact of trauma, loss, and displacement in the disruption of social networks, the disruption of shared sentiments, and the collapse of morale. The long-term consequences that one can see over decades following such displacement can show up in the increase in structural and individual violence, the inability of a group to react to patterns of threat and opportunity, and cycles of social fragmentation. Collective trauma also involves multiple losses, and this can be in the form of losing significant persons and losing their roles in a family or society, significant relationships, heads of family or community leaders, intact family units, homes, and communities. People may lose a way of life or economic livelihood. They often lose their future potential, their hopes and dreams for what might have been, and they experience the shattered assumptions in their core worldview. So, what is resilience? We think of resilience these days as the capacity to access resources at the levels of body, psyche, family, community, society, culture, and for many, the level of the spiritual. Froma Walsh, who's done a tremendous amount of work on family resilience, defines resilience as the capacity to rebound from adversity, strengthen, and more resourceful. It is an active process of endurance, self-righting, and growth in response to crisis and challenge. So, she includes in her definition both the component of bouncing back and bouncing forward. Trauma resilience is also about the opening up of new possibilities and growth. Community resilience, defined by Mindy Fullilove and I through our work after 9-11 in New York City and the region around New York, we define community resilience as the capacity of a collective to overcome shared trauma or adversity as manifest in social cohesion, mutual support, hope, and the presence of communal narratives that give the experience meaning and purpose. Community resilience can be seen as how people overcome stress, trauma, and other life challenges by drawing from social networks and cultural resources embedded in communities. But it also may look at the ways in which communities themselves exhibit resilience, responding to stresses and challenges in the ways that tend to restore their functioning. So, this second definition of community resilience, which includes the capacities of communities to be resilient, has been studied a great deal now over the last 20 years, and one of the most important frameworks has been developed by Fran Norris and her associates, and they see resilience as a set of network adaptive capacities. And if you can see this chart, I know it's quite small, but it includes four sets of these capacities. First of all, economic development, information and communication, community competence, and social capital. And if you're interested in learning more about all of these different sets of capacities, I would recommend going to her work. A community resilience approach when working in response to disaster or structural trauma, the client that we're working with is not the individual, but it's the social environment itself. Families and communities harbor strong mechanisms for resilience, and we can simultaneously promote resilience at different systemic levels of family, community, organizations, neighborhoods, and society at large. People themselves are seen as the greatest resources for healing, and the activities that are generated by community members themselves may help in reducing stigmatization, because they found activities that actually people, that are more acceptable to people and do not stigmatize. And the community harbors the spectrum of opportunities for healing, different age groups bring different capacities to the community, such as the elders may bring experience of having to adapt to previous adversity. Children bring a tremendous amount of energy and creativity to a community in stages of recovery or transition. People from different occupational groups bring different approaches and skills, and people with different cognitive styles lend a tremendous amount of diversity to resilient processes. So, we believe that a multi-systemic intervention will have the greatest impact on resilience, and a multi-systemic intervention will have the greatest impact in promoting recovery after disasters and after oppression. Not just focusing on one or two levels, like the individual level or the community level, but focusing on multiple levels simultaneously. The approach to disaster, I think, also is very relevant to addressing structural oppression. First of all, one of the major principles is that we use a psychosocial approach to providing basic services, basic resources that may be undermined in these different contexts, such as food, shelter, health, and security. There needs to be a psychosocial sensitivity in the way that these resources are provided. A major principle from this kind of approach is that we want to help strengthen already existing family and community support systems and help facilitate access to appropriate religious and cultural supports. The community needs to participate and be consulted at each stage of a development of interventions. Another principle is that we would like to maximize opportunities for groups of people to join together for support, meaning-making, and collective problem-solving. When people do join together at the level of community, they're more likely to identify people who are isolated or more vulnerable, and they can offer the kinds of supports needed to bring those people in for services or resources that those people may be lacking. The role of accompaniers is an important one in this approach, community approach. There are many different levels of interventions in working with communities. This is the inverted pyramid. It's used in international psychosocial response. At the top of the pyramid, it's applicable to most people in a society. This would include survival interventions and political interventions that promote well-being, promote security. Then as you move down the pyramid, you move toward more specialized services that are needed by fewer people in the community. Some of the mid-level interventions that I think are more applicable at the community intervention level include community empowerment interventions, training, capacity development, family and network building. Then as we move to more counseling approaches with individuals and families and groups, these include self-help groups or peer support groups, psychotherapy, and psychiatric treatment. When we set out to implement a community resilience approach, first of all, we need to ensure that we have invitation, authority, permission, and commitment from the community to engage with them in promoting such an approach. The second thing is that we need to ensure that we've engaged as much of the community as possible, including representation from different subsystems, different ethnic groups, different economic levels, different cultural and status strata, natural support systems of family, informal support networks, as well as the helping systems and local community organizations. We want to reach out to as many stakeholders as possible. Then when we bring people together, what we do is to identify the scripts, themes, and patterns across generations in community history, bringing in this kind of long-term perspective, asking what people have done in the past, what did the ancestors do in response to major traumatic situations. These are very important ways of orienting people toward accessing their resilience and preferred ways of coping. Then helping the community to map out its resources and recognize how these can be utilized to address the challenges they face as a community. People will prioritize different things that are needed at a particular point after a disaster or when they're in transition and are trying to transform their community. It's important to go through a process of prioritizing what the major challenges are that need to be faced and then turning those challenges into realistic tasks and then into practical projects. Often this takes the form in developing task forces and smaller community groups that can work on particular projects. This community resilience approach is often referred to as a link community resilience approach developed by Judith Landau, who is a social psychiatrist. She defines these community links as natural change agents, people within a community who have an inclination to become leaders and they tend to be non-polarizing and can bring people together to work toward solving the problems that they're facing. The last principle is that the success of the project belongs to the community itself. Outside supporters need to step back and allow the community to take over and move the project into its next stages. Just to end, the four themes that we saw about community resilience in this context were that building community, enhancing social connection is the foundation for recovery and it's important to re-establish the rhythms and routines of life for people and help them engage in collective healing rituals. It's important to collectively tell the story of the community's experience and response through these narrative approaches and to arrive at a positive vision of the future with renewed hope. I would like to thank you and if you have any questions I will be available to answer those later. Thank you. I'm pleased to introduce Dr. Ken Thompson. Kenneth S. Thompson, MD, lives in Pittsburgh, Pennsylvania. He graduated from Kenyon College and Boston University School of Medicine, where he was a National Health Service Corps scholar. He was a resident in psychiatry at the Albert Einstein College of Medicine and a postdoc in mental health services research at Yale. He has been faculty at Yale and the University of Pittsburgh. He was the director of the medical affairs at the Center for Mental Health Services in SAMHSA, and he is the chief medical officer of the Pennsylvania Psychiatric Leadership Council, a policy and advocacy organization. Hello, everybody. My name is Ken Thompson. I'm a psychiatrist in Pittsburgh, and I'm very, very pleased to be here today and talking about solidarity care, where community is therapy. I'm particularly pleased to do this for Sarah Vinson and the team of folks around my panel. I'm hopeful that what I have to say fits into what everybody else is saying, and that this is an opportunity for all of us to think differently and newly about what it is we can do about the sociopolitical collective traumas that we face. I'm going to talk about what is integrative community therapy, its history, and its relationship to collective trauma, what ICT looks like, and some reflections on the concept of solidarity care mutual aid and its use in the United States and in the Anglophone world. Let's start with where ICT, integrative community therapy, in Portuguese, it's terapia, terapia comunitária integrativa, or something similar. It started in a favela, the Pirambu favela in Fortaleza, Northeast Brazil. What's important about the Fortaleza and Pirambu in particular is that it's been a site of migration from people on the interior of Brazil, where there's been substantial amounts of drought and other challenges, into these dense urban settings. The favelas of Brazil are world famous for the challenges as they present to human life. This particular one is no different, except that it is sited right along the Atlantic Ocean. The story goes, and I'll just briefly kind of go through what Dr. Alberto Barreto in Portuguese says, in 1986, I arrived at the Quatro Valres community with my medical students from the Federal University of Ceará. A lady told us she couldn't sleep and asked for medicine that we didn't have. When I was going to prescribe a medication, she said she didn't have the money to buy food for her children, let alone medicines. I realized I was acting the way I used to act in the hospital. The woman began to tell her story to cry. Another woman came to support 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 was the problem also has its solutions. That's where ICT, a space for welcoming soul pain and collective suffering, was created. To say a little bit more about it, Cuauhtévara is a part of the Perambu favela. It's a place that was named because one of its founders told the story of how an old man had his sons. He was worried that the sons would not work together after he died. He asked each son to bring him a stick from the woods. The sons dutifully did. Each stick they brought, he broke and threw on the ground. The sons then went out. He said, go get me another stick. The sons then went out and got each a stick, but this time instead of handing him one stick each, they handed him all four sticks together. He could not break them. There was the idea that this community needed to stand together and to be together took hold. Why did they need to stand together? Because the favelas are places that are illegal settlements, essentially. They don't have any line hookups for electricity or sewer or all those kinds of things. They're just people coming and settling. This particular favela was frequently being raided by the police. Their shanties knocked down, their possessions taken. They had to stand together to find a way to stop the police, to allow them to develop the land, to become the owners of the place in which they lived. That process was informed because of the work that built the social solidarity and the community that Dr. Barreto describes here. ICT is a large group dialogic therapy that enhances social connection and emotional solidarity. Its key roots include Paulo Freire and the concept of conscientization and a variety of other approaches to thinking about cultural anthropology, et cetera. A few facts and some background. As noted, it was developed by Dr. Barreto. ICT participants' outcomes are driven through community-based and community-building therapy sessions. What happens is that people come together in a circle and spend about an hour and a half together. I'm going to go through that process in a minute just to give you some idea about it. There are now about 40,000 people in Brazil who are trained facilitators. They are not necessarily professionals. In fact, probably the vast majority of them are not. It's now being used in other parts of Latin America and spreading into Africa, Asia, Europe. It has not, however, made any dent into North America or the Anglophone world in general. Just last winter and spring, we initiated a project through something called the Visible Hands Collaborative to introduce ICT to the United States. This is what it looks like. That's an ICT round in Brazil in the upper left. The lower right is an ICT round on Zoom in the United States. What does ICT do? The Brazilians say, and it's commonly said in an ICT round or session, when the mouth is silent, the body speaks. When the mouth talks, the body heals. What do you do when you're in a session? This may give you some sense of it. It isn't the mountains ahead to climb that wear you out. It's the pebble in your shoe, as Muhammad Ali once noted. What we do in an ICT is to have people talk about the pebbles in their shoe. Some of those can be boulders, maybe even mountains. They can be even more just day-to-day experiences that they have in their emotional lives that they find to be challenging. There's some rules. Speak only in the eye, so you only speak from your own experience. You don't give advice, judgments, or interpretations. In AA and other groups, they would call that no crosstalk. Be silent and listen, and use all the means provided by your culture to make and demonstrate how you feel. An ICT, as I said, is about 90 minutes long. There have been ICTs that have gone up to 200 people. It's broken into five stages. There's the welcoming, which includes a particular focus on hearing from people about their recent celebrations or things that have happened in their lives that they're happy about or things that they're particularly feeling gratitude about. Something to open people up about good things in their lives. There's a discussion of the ground rules, and then there's a voting on the sessions topic. What happens here is that we invite people to talk about their challenges and ask people to present what is the pebble in their shoe. We do not ask people to share things that they want to keep secret. An important fact of ICT is that this is not a confidential, anonymous group. This is done in a public space. There's no effort to assure privacy. People are talking in the frame of that what they're saying may be repeated by other people. In fact, in some ways, it's the stance against privacy and the notion that our emotional lives can, in fact, be publicly espoused and expressed and supported that ICT, I think, is a sort of new way of thinking of the work that we do. People are asked to put forward what their pebble is, and we usually collect somewhere between three to five pebbles from the people who are participating. Then there's a vote on which of the themes, which of the pebbles themes, the group wants to speak about. This vote is a way to get a sense of what the overall group would like to speak about. People who are not voted, their themes are not voted for, are told you're welcome to come back and present it at another time, and the likelihood is that at some point your theme will be discussed if you'd like to. We are welcoming and consider it an offering from everybody who offers a pebble, but we focus on just one of them, and one of them is chosen democratically as a group. Then there's the process of contextualization, and we go a little bit more into detail about what the theme is and what was behind it and what happened exactly that led the person to want to present it. The participants are able to ask questions of the person who's put the theme forward, and then we take that and get to a point where we ask folks who in this room has had a similar experience and what have they done to overcome it. Then across the room, people will share things that they've experienced that are in a similar theme. They already know that they have some interest in this because they voted for it, and they express that particular theme and what they've done to overcome it. At the end, so that's the sharing phase, at the end everybody is recognized for what they've contributed to the group. People are asked to say what they've taken away, what they've heard that makes a difference in how they think or feel, and everybody is broken off. If somebody has a challenge that they don't feel like they can present or there's some other issue that's going on that was unable to be addressed, the facilitators do stay around after the session to have any private conversations that need to happen with people who were not capable or felt incapable of talking about it in the group at the time. That's how it works. It's wellness oriented. It's not built on any pathology. It values diversity and experiences, and it focuses on emotional literacy. Being able to talk about and express what your feelings are is a key thing that people learn as they go in the process. We have evidence from studies in Brazil that people who attend these sessions feel that their problems are addressed, even if they're not talked about directly, that they feel a sense of support and they feel more capable of self-regulation and more likely to feel less depressed. At least at the individual level, we believe that it has some efficacy in reducing challenges that people feel. It's important to note that it isn't just at the individual level that we are looking for outcomes. We are also hoping to encourage and drive increasing connections and comfortableness, if I can use that word, solidarity maybe is a better word, between people who are participating in the groups and living in community or in connection. Ideally this is not just helping people feel better, it is in fact helping people have better linkages and connections and relationships in the communities that they live in or relate to. So the primary benefits of this shared suffering is providing a place of inclusion, diversity, sharing experiences, developing healthy coping strategies, and developing support networks. By emphasizing community building, we're looking also to address the effects of collective trauma by promoting collective healing and the proliferation of resiliency. The participatory and emancipatory elements of ICT really, I think, make this a very useful tool to use in communities in which there is a broad range of disenfranchisement and disadvantage in the face of emotional challenges and distress. So that's ICT. Let me just reflect a little bit on solidarity care and mutual aid. Solidarity as you'll see is defined as unity or agreement of feeling or action, especially among individuals with a common interest, mutual support within a group. Social literacy is the ability to understand your emotions, the ability to listen to others and to empathize with their emotions and to express your emotions productively. Care is the provision and the necessity of what is necessary for people to thrive. And conscientization, a term that originated, I believe, with Freire in Brazil, is the action or process of making others aware of political and social conditions, especially as precursors to challenging inequalities of treatment or opportunity. So essentially understanding the circumstances in which you live and what produces them. So those elements are really very different than from what we do in psychiatry. Personal emotional literacy is something that we do on an individual basis, but this is an effort at larger group emotional literacy. Certainly we do very little to support solidarity within our clinical practices. We do provide care, but we are limited in the care that we are able to provide on our own and we are not that well able to help people understand or think about the circumstances in which they live and to do that in any kind of meaningful way in which they are part of a group or feel connected to efforts to address the situations they have in their daily lives. So why ICT and solidarity care now? And I want to suggest that a lot of this has to do with the wages of neoliberalism. Neoliberalism in and of itself is fragmenting, but the hyper capitalism of neoliberalism in which the state supported market fundamentalism and profiteering, the power of inequity and austerity that we have seen exercised over the last 40 years with extraordinary wealth going to the folks who have all the money already and efforts to continually trim any sort of public spending are hallmarks of the era we have been living through. The destruction of labor power, particularly of unions, particularly of the idea that people have a connection with each other. The destruction of the commons, the idea that the lands that we hold as a common could be sold off and used for profiteering, that the wealth of the nation belongs to only those folks who can pay for it, to exploit it. All those kinds of things have been clearly driving a destruction of solidarity and of linkages between people in our country and across other parts of the world as well. We have produced a wave of loneliness, isolation, and precarity with the rise of the racist right and nativism going hand in hand with that. This, of course, has been made even worse with COVID, which dissolves social connections, a solvent of social connections. In 1984, a movie came out I watched with my children many times called The Never Ending Story. What The Never Ending Story was about was the growth of the nothing. The nothing was a thing that consumed all things that were related to each other. It made the world of fantasy disappear in particular in this movie, but it essentially just sucked out relationships from each other. It has always reminded me of a comment from Maggie Thatcher in 1987 that there is no such thing as society. I think the reason that we need ICT and things like it is because absolutely there needs to be something called society. There needs to be connections between people, and the market cannot dissolve everything. We can see the ways in which we are now collectively challenged. I'll just go through this horror film right here, or this horror slide, Deaths from COVID. The increasing challenge of climate change due to carbon being pumped into the atmosphere. Black lives matter in the death of George Floyd and the ongoing racism that we experience in the United States. The deaths of despair from opiates, alcohol, and suicide with the destruction of our industrial base and employment that came with it and the industrial order. The demise of neighborhoods with the absence of any inward investment. The Tree of Life Synagogue and the mass shooting there, which is just a mile from my house in which my dentist was killed. January 6th with a confederate flag in the capitol and perhaps a slightly incongruous but still representative slide of refugees in Pittsburgh who came from their ethnic cleansing in Bhutan when they were driven from their homeland and represent the hundreds of thousands to millions of people now on the move because they are not able to stay where they were living because of ethnic cleansing and war. All those collective traumas we are living with and suffering through right now. I'm hopeful that ICT is something that we can use to address this as a small part of building the communities that we need. Visible Hands Collaborative is going to be working to develop ICT in the United States to develop participants and facilitators and to support the use of ICT in a variety of community settings across the United States and other parts of the English speaking world. One of the folks from Brazil was an Indian from the Tremembe tribe, participated in ICT and his comment about what he experienced there was that a spider without their web is like an Indian without land or a community without solidarity. I think solidarity care and the capacity to help knit relationships between people on the emotional level, on the level that connects us as human beings is the kind of thing that American psychiatry may want to think about participating in as an effort to not only address what makes people ill but to address what might make people healthy and what might link us together not only as healthy individuals but as a healthy community. If you have any desire for more information, please look up visiblehandscollaborative.org and email Alice, my daughter, who has been actively involved with me in this and helped me do all the work that I've done on this. Alice at visiblehandscollaborative.org. She is, by the way, going to become a psychiatrist and I look forward to hearing from you and any questions that you might have. Thank you very much.

sociopolitical determinants of health

trauma

individuals

communities

healing justice framework

racial traumas

community resilience

integrative community therapy

mutual support

collective trauma

emotional literacy