An article published last week in the New England Journal of Medicine uses a case study in a Brazilian context to explore why so many young people feel blamed and stigmatized by mental health care. The authors of the study, Dominique Béhague, Raphael Frankfurter, Helena Hansen, and Cesar Victora, critique a purely cognitive-behavioral approach and considers how clinicians can address structural oppression through therapy. Building on insights from Brazilian mental health care reform, the authors show how therapists can address this problem by using principles of “dialogic praxis,” a theory of learning and social change drawn from the works of Brazilian philosopher and pedagogic specialist Paulo Freire.
“Dialogic praxis,”Béhague explains in a podcast interview with NEJM, “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 Freire encourages us to do also is imagine how actively engaging with and re-creating the social realm – how we inter-relate, what kind of society and key institutions we want — can be therapeutic in and of itself.”
The authors define dialogic praxis as “a process drawn from Freirean educational theory in which clinicians and patients engage in bidirectional critical analysis and learning.” It is a process by which a therapeutic alliance is established with an emphasis on collaboration. Through bidirectional communication of experience and knowledge, clients are encouraged to take steps towards altering the systems contributing to their experiences of distress and oppression.
Compared to more popular behavior-change approaches potentially limited by minimization of complex external forces influencing daily experience, Béhague and team report that dialogic praxis places more importance on the role of external stressors, promoting client agency and empowerment in altering such stressors. It is not a package nor a manualized approach – rather, an orientation.
“In the clinic, dialogic praxis reframes the therapeutic relationship as a bidirectional educational experience that centers on a definition of “insight” different from that used in conventional psychiatry. Whereas insight usually refers to patients’ awareness of their internal psychological processes, dialogic praxis emphasizes the clinician’s learning process and […] encourages patients to become important sources of knowledge about the situational causes of their distress and ways of modifying them.”
The notion of dialogic praxis has its roots in Brazilian educator and philosopher Paulo Freire’s theory of learning and social change. Though specific terms and expressions used to describe this concept vary, calls to reform efforts in the fields of psychology, psychiatry, medicine, education, and more to integrate better social and structural determinants of individual distress are not new. However, heightened appreciation for this idea in recent years is reflected in the United Nations’ Special Rapporteur’s recent declaration of the urgent need for mental health initiatives with a human rights focus.
Training models have been designed to prepare practitioners to understand the direct and nuanced ways external forces influence individual health. Some research has indicated that “structural competency training,” to promote understandings of the structures contributing to disparities in facets of health, wellbeing, and opportunity, may increase empathy among psychiatry residents.
In October 2019, researchers Rochelle Ann Burgess and colleagues authored a commentary in Lancet Psychiatry promoting the message that “[t]he time has come for the global mental health movement to acknowledge the importance of the sociostructural determinants of mental distress, and work alongside communities and policymakers in their efforts to address them.”
However, details of how structural competency might work in practice have yet to be fully explored. This articles suggests that a key clinical stance is for the therapeutic relationship to be guided by humility and grounded learning. In the case study outlined by Béhague and colleagues, a clinician, Dr. M establishes a therapeutic relationship with a 16-year-old client, J, founded on the early acknowledgment that the clinician does not know what it’s like to be J. This transparency paired with curiosity surrounding J’s perceptions of the structures that impact his everyday experiences lends itself to collaboration empowering J to influence his environment for the constructive.
The authors describe J’s history of anxiety and problem behaviors in school, leading up to his connection to an out-of-school provider. Before connecting to Dr. M, J met with his school’s psychologist and was unsatisfied with the circumstances of his referral for her services as well as her perceptions of his case. His interpretation was that she focused more on his deficits (i.e., aggression and attentional issues), emphasizing individual changes he should make instead of the larger-scale issues impeding his progress (e.g., his socioeconomic status).
Having declined continued services from the school psychologist, J agreed to see an outside provider primarily to express his frustrations. Though initially hesitant to engage, J found that Dr. M’s approach, integrating features of dialogic praxis, resonated.
Over time the two worked to untangle and explore the contextual and social sources of distress J had experienced throughout his life. J applied these new insights to school community-level activism by becoming involved in his school’s student council. While on the student council, he “advocated for better teacher-student relations and worked alongside school staff who ran initiatives to foster student participation and democratic teaching practices.”
Although there may be many oppressive features of one’s circumstances beyond one’s realm of control, Béhague and the team’s piece demonstrates how a sense of purpose may be supported in therapy through openness, critical analysis, and encouragement of engagement in community-level activism.
More information on this article can be accessed in a podcast interview featuring the first author hosted by the New England Journal of Medicine.
Béhague, D. P., Frankfurter, R. G., Hansen, H., & Victora, C. G. (2020). Dialogic Praxis — A 16-Year-Old Boy with Anxiety in Southern Brazil. New England Journal of Medicine, 382(3), 201–204. DOI: 10.1056/nejmp1909864 (Link)