A case study in the New England Journal of Medicine, co-authored by Dr Dominique Béhague, from the Department of Global Health & Social Medicine at King’s College London, critiques a purely cognitive-behavourial approach to mental health care and consider how clinicians can address structural oppression through therapy.
In this type of therapy, which they call ‘dialogic praxis’, therapists frankly acknowledge their limited understanding of the day-to-day challenges their young patients are facing and engage them to define their own concerns and develop solutions.
While the study followed the experiences of young people, Dr Béhague said this approach to therapy could benefit anyone.
When therapists approach patients with humility and actively engage them to learn more about their lives, they can empower their patients to make positive changes that make the most sense to them– Dr Dominique Béhague
The case study follows a Brazilian teenager sent to a psychiatrist because of aggressive behaviour and social withdrawal. He is empowered by the doctor’s dialogic approach and addresses his anger and anxiety by working on the school council to change the conditions that led to his symptoms.
The authors argue that this shows the most transformative kind of therapy actively incorporates open-ended two-way conversations about how a person’s life is influenced by various social, political and economic forces.
Dr Béhague said: “Dialogic praxis isn’t a clinical approach or even a pedagogic method as much as it is a commitment to learning from social theory and bringing the social domain quite centrally into the clinic and public health initiatives.
“Usually, when the social domain is considered in medicine and health policy, it’s an add on, resorted to when a more biological and clinical model isn’t quite working. Even then, social forces tend to be understood as risk factors for mental illness, as in the case of poverty, inequity, discrimination, and so on.
"This is important, but what this case study shows us is that patents’ attempts to actually change social circumstances can be more meaningful and therapeutic, even as some symptoms do not abate as a consequence.”
Dr Béhague spent several years conducting research with young people in Brazil in order to identify why some young people had positive therapeutic experiences while others had more negative ones.
In some cases, she found patients did not come away from therapy feeling any less angry or sad, but they would be equipped with tools for channelling those feelings in meaningful ways that begin to change their social relationships.
Therapists, in turn, learn that therapy can do more than reduce symptoms or build resilience – in small steps, it can start to change the structures that cause harm.