The IAPCField Letter

A word that became a framework

In Paraguay, Spanish and Guaraní coexist in a way that is difficult to describe through the idea of two separate languages. People move between them constantly, creating jopara, a dynamic linguistic form that belongs to everyday Paraguayan communication. We became interested in jopara as more than a linguistic phenomenon — it gave us a way of thinking about integration itself.

What if different clinical languages could coexist without one having to erase the other? What if the technical precision of evidence-based psychotherapy could remain fully intact while the way we communicated those concepts became more recognizable to the people we were trying to help? The idea developed slowly. For much of the first eight months, the real work was making sure we weren’t building something azaroso — a haphazard combination of interventions risky enough to backfire on the very people it was meant to help. That meant a great deal of reading into how to combine evidence-based modalities responsibly rather than simply borrowing pieces that sounded compatible, and it meant leaning on input from international collaborators, whom I am not able to name here due to a non-disclosure agreement. Only after that groundwork did we move into four months of writing, testing, and rewriting the first edition. Jopara Terapéutico was developed by me as lead author together with Dr. Juan Jimenez, Dr. Sofía Alvarenga-Giosa, MSc. Giselle Román, and psychologists Celia Ortiz, Vivian Gunsett, and Nicolas Sepulveda.

What emerged was not a new psychotherapy. It was a transdiagnostic and integrative clinical skills framework designed to build a bridge between evidence-based therapeutic mechanisms and the linguistic and cultural environment in which they are practiced. The distinction matters: we did not want to dilute evidence-based interventions in the name of cultural adaptation. We wanted to preserve what makes them therapeutically useful while making their language, examples, and delivery more accessible.

Our premise was that therapeutic fidelity does not require linguistic rigidity.

“Therapeutic fidelity does not require linguistic rigidity.”Dr. Aramí Rojas

Why a single diagnosis was not enough

The more we developed the framework, the more a second question emerged: if the language of treatment needed to become more flexible, perhaps our understanding of the person receiving treatment needed to become more flexible too. Our approach to Integrative-Functional Psychiatry & Psychotherapy grew from this concern. By “functional,” we mean something close to precision — understanding what is actually interfering with a person’s functioning, what processes contribute to the difficulty, what maintains it, and what needs to be addressed therapeutically.

Diagnosis remains important; it gives clinicians a shared vocabulary and real value for communication, research, and treatment planning. But a diagnostic label does not always tell us what we need to know about the person sitting in front of us. Two people can receive the same diagnosis and arrive with entirely different problems to solve. This is one reason we find dimensional approaches such as the Hierarchical Taxonomy of Psychopathology (HiTOP) conceptually useful: rather than assuming psychopathology always fits neatly into discrete categories, HiTOP describes symptoms and psychopathological processes along dimensions and hierarchies, addressing some of the limitations created by extensive comorbidity and heterogeneity within diagnoses. Our own approach is not an implementation of HiTOP, but the underlying question resonates with our clinical experience:

What is actually happening here, and what does this particular person need?

Our formulations consider biological, developmental, psychological, relational, functional, and contextual dimensions together before determining therapeutic priorities, and this also changes how we use therapeutic skills.

We use the core structure of Dialectical Behavior Therapy because its organization of skills provides an exceptionally coherent framework for teaching and practicing complex therapeutic concepts. Within that structure, we draw from Radically Open DBT, Acceptance and Commitment Therapy, Rational Emotive Behavior Therapy, Cognitive Behavioral Therapy, Compassion Focused Therapy, neurodivergent adaptations, and additional clinical considerations involving areas such as violence, empathy, enmeshment, ecpathy, and interpersonal functioning. The result is not meant to be a collection of therapies placed side by side; the formulation determines which elements become most important. A group struggling primarily with emotional dysregulation may spend more time developing regulation skills; another may need greater emphasis on interpersonal boundaries; a group with substantial neurodevelopmental diversity and sensory sensitivities may require significant adaptation in how skills are presented and practiced.

The core framework provides coherence. The formulation determines where we place the emphasis.

“The core framework provides coherence. The formulation determines where we place the emphasis.”Dr. Aramí Rojas

Finding the Paraguayan voice of a therapeutic skill

People do not experience distress in the language of a manual. They experience it in their bodies, relationships, memories, thoughts, environments, and everyday conversations — and the words they use to describe those experiences can be very different from the terminology used in psychotherapy textbooks. When a clinical concept remains too far removed from a person’s everyday language, the clinician ends up doing the work of translating everything in real time.

Jopara Terapéutico tries to build that bridge into the material itself. The workbook uses Spanish to provide conceptual structure while incorporating Guaraní expressions and jopara constructions to connect therapeutic concepts with familiar ways of describing experience. This is especially useful when teaching skills that initially seem abstract: instead of asking a participant to adopt an entirely new clinical vocabulary before they can begin practicing a skill, we start from the language they already use and connect it to the therapeutic concept.

The goal is not to make therapy “more Paraguayan” for the sake of cultural symbolism. The goal is to make the skill more usable.

“The goal is not to make therapy ‘more Paraguayan’ for the sake of cultural symbolism. The goal is to make the skill more usable.”Dr. Aramí Rojas

And then the patients started changing the manual

One of the things we have learned during this process is that cultural adaptation cannot happen entirely at a desk — it has to happen in contact with the people who are actually using the material. That is why Jopara Terapéutico is deliberately unfinished. We are currently working on a second edition that expands the emotional-regulation material and introduces a new, expanded section on self-compassion informed by Compassion Focused Therapy, along with concepts that emerged directly from our clinical experience.

One example is Keikó?, a new approach within the mindfulness section of the DBT skills material. The name combines qué (“what”) with piko, a Guaraní colloquial expression that can intensify a question and also give it a lighter, more playful quality. The idea was to create a different way of approaching the question of what is happening in the present moment.

The first time we introduced it in group, people laughed. Then something shifted — they grasped it almost immediately, in a way the formal “what skill / how skill” language had never quite landed. Participants started using it on themselves between sessions, describing moments where they would catch an impulse or an emotional wave building and think, in their own words, “keikó estoy haciendo” — a colloquial way of asking “what on earth am I doing?” That small, half-joking phrase put the entire what-and-how skill directly at hand, early enough to use before the wave gained ground. It became something the group started saying to each other, not just something we had taught them.

This is how we want the framework to develop: not by assuming the first edition is the final answer, but by allowing clinical experience to continuously challenge what we have written. We try something. We observe. We listen. We modify. We try again.

Jopara Terapéutico is therefore not presented as a finished protocol, but as a continuously evolving clinical framework.

A workbook eventually became a question about systems

At some point, another realization became unavoidable: a therapeutic framework can be well designed and culturally appropriate and still fail if the system around it cannot deliver it. Who teaches it? Who supervises the clinicians? How do professionals coordinate? How do we know whether it is helping? How do we make it available to people who cannot afford it? And how does the model continue to improve once the original developers are no longer in the room?

Those questions pushed the project beyond the workbook. Our broader clinical model includes interdisciplinary formulation and structured supervision, patient-facing training materials, and pedagogical infrastructure. We are currently developing a more extensive therapist manual and formal clinical competencies that could eventually allow the framework to be taught and evaluated more systematically. This is an important transition; an idea remains fragile when it depends entirely on the person who created it. For an approach to become transferable, it needs a structure through which other professionals can learn it, practice it, question it, and eventually improve it.

The question of who gets to participate

The same question eventually led us to access. If we were serious about building an integrated mental healthcare ecosystem, we could not treat access as someone else’s problem.

In response, we developed SabiaMente ComUnidad, a community initiative that provides scholarships within our therapeutic groups for people who would otherwise be unable to participate. The initiative operates through what we refer to locally as mecenazgo, a community-supported funding mechanism: former patients and other donors contribute to a solidarity fund, while larger organizations and businesses participate as impact partners. Donated professional hours and space, together with symbolic compensation at this stage, allow the initiative to operate while we work toward greater sustainability. In English, I would describe this as a community-philanthropy or community-supported funding model rather than simply “patronage” — the underlying idea is that someone who has benefited from care can help make care possible for someone else.

Access was never only a financial question, though. In our context, mental health still carries real stigma, and group formats brought their own resistance on top of that: people worried about being seen walking into a group, and many arrived expecting something closer to the version of group therapy they had seen in films — a circle of chairs, open-ended sharing about whatever was troubling everyone that day. Jopara Terapéutico groups are not that. They run more like structured teaching sessions, with rules closer to standard DBT skills groups and firm limits on what gets disclosed and when. Part of building trust meant making that structure visible and predictable from the first session — down to small rituals, like a Tibetan singing bowl we sound whenever the group drifts into judgment or needs to re-ground its attention.

Since early 2025, that combination — subsidized access plus a format people could trust — has translated into roughly 800 individual consultations and 200 completed group sessions under ComUnidad: 24 scholarship holders moving through groups that each run 27 to 32 weeks.

“The community does not only receive care. It can participate in sustaining it.”Dr. Aramí Rojas

Access therefore becomes part of the architecture rather than an external consideration. The community does not only receive care. It can participate in sustaining it.

From care to a learning system

This brings us to the part of the model that remains perhaps the most challenging: measurement. We already collect baseline information and have planned follow-up assessments, and we maintain communication with participants’ individual therapists to understand whether participation in the groups appears to support, complicate, or otherwise interact with individual treatment. But we have not yet found a single Spanish-language instrument that captures the entire picture we want to understand — which has forced us to think more carefully about what we actually want to measure.

We are interested in the participant’s experience, but also in functioning, the therapist’s perspective, the interaction with individual treatment, caregiver burden, community implementation, and the performance of the system itself. The question becomes larger than “did the patient’s symptoms improve?” We also need to ask: did the person’s life become more workable? Did the therapeutic system become more coordinated? Could another professional implement the intervention? Did the community become more capable of supporting mental health?

Our long-term vision is a feedback loop in which clinical experience generates data, data informs research, research modifies practice, practice informs training, and training improves care. In that sense, Jopara Terapéutico became the starting point for something much larger: a model of mental healthcare designed to learn from itself.

What can travel beyond Paraguay?

The obvious temptation when presenting a culturally specific model internationally is to ask whether other countries can reproduce it. I think that is the wrong question. Another country does not need Jopara. It needs its own equivalent of the question that led us here:

What happens when the evidence-based intervention we are offering does not fully belong to the people receiving it?

The answer will look different in every context. The relevant language may be different. The cultural assumptions may be different. The healthcare infrastructure and the barriers to access may be different. What may be transferable is the architecture: preserve the therapeutic mechanisms, adapt the expression, start with formulation, integrate disciplines intentionally, allow the needs of the population to determine emphasis, build systems for supervision and education, design access into the model, measure what matters — and then allow what you learn to change the model again.

That is ultimately what Jopara Terapéutico has taught us. Integration is not the accumulation of therapies. It is the intentional connection of people, disciplines, institutions, communities, and knowledge around the person receiving care.

We began with a very local question: how could evidence-based therapeutic skills speak more naturally to the people we were trying to help? The answer led us far beyond language — it changed how we thought about formulation, interdisciplinary practice, cultural adaptation, professional education, community access, and measurement. And perhaps that is the most useful lesson we can offer from Paraguay: a clinical model should not be something we finish and then protect from change. It should remain close enough to practice that the people using it can continue to change it.

The goal is not simply to bring evidence-based care to a community. It is to build a system in which evidence-based care can genuinely belong to that community.

“Resource constraints … do not limit human resilience; rather, they drive creative, technology-enabled solutions.”Helen Kwanashie