For young patients, therapy works best when they are encouraged to become co-experts in the search for answers, according to a Perspectives article published by the New England Journal of Medicine co-authored by Dominique Béhague, associate professor of Medicine, Health and Society and Reader at King's College London. The article is part of a series that aims to highlight the importance of social concepts and social context in clinical medicine.
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.
She found that 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. In this type of therapy, which Béhague and her colleagues call "dialogic praxis," therapists frankly acknowledge their limited understanding of the day-to-day challenges their young patients face and engage their patients to help them define their own concerns and develop solutions. Dialogic praxis is a concept drawn from the works of Brazilian philosopher and pedagogic specialist Paulo Freire.
"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," said Béhague.
One of the most common types of therapy, cognitive-behavioral therapy, tends to overlook broader external forces, such as racism or poverty, that could explain a patient's frustration, anxiety, and anger. Failing to acknowledge these forces while focusing on changing individual thought-patterns and behaviors can leave patients feeling blamed for having difficult emotions that, in the broader context of their lives, are perfectly reasonable.
With dialogic praxis, the focus is shifted away from reducing difficult emotions and toward working together to develop strategies that make the most sense to the patient and that engage his or her social environment. For example, patients might analyze the situations that trigger upsetting emotions-such as experiencing racial discrimination-and propose empowering ways to respond to those situations-such as by becoming active in student-led school initiatives or local grassroots organizations.
"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."
In some cases, Béhague said, patients may not come away from therapy feeling any less angry or sad, but they would be equipped with tools for channeling 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.
While her study followed the experiences of young people, 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."
Béhague's co-authors are Raphael G. Frankfurter, M.D.-Ph.D. graduate student at the University of California San Francisco, Helena Hansen, psychiatrist and anthropologist at New York University, and Cesar G. Victora, epidemiologist and global health expert from the University of Pelotas in Southern Brazil. You can listen to Béhague discuss her findings in a New England Journal of Medicine podcast available here.
