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Purpose In this paper, we explore how Brazilian socially sensitive therapy can respond to care-users’ desire to change the social and political forces shaping their lives. We use this case to demonstrate the limits of the “social determinants of health” agenda which, when operationalized, tends to leave questions of lasting structural change aside. Methods We report on mixed methods ethnographic and epidemiological results from the 1982 Pelotas (Brazil) birth cohort study, a prospective study of 5914 children. Ethnographic analysis explored the cyclical relationship between schooling, mental health care, conceptualizations of mental distress, social and political engagement, and experiences with diverse forms of discrimination. Epidemiological bivariate and multivariate analyses examined differences in socio-political participation and the reporting of discrimination at different time-points for participants who used therapy with those who did not. Effect modification analysis tested the hypothesis that the socially empowering effects of therapy were greater for marginalized and minoritized youth. Results Most young people living in situations of precarity experienced therapy, particularly when based in schools, to be a blame-inducing process. A more fulfilling and impactful therapeutic experience took shape when young people were able to shift the focus away from symptom reduction and behavioral management toward narrative life analyses, social debate, and political agency. Use of socially sensitive therapy was statistically associated with increased political participation and reporting of discrimination after controlling for confounders. The empowering effects of therapy were greater for those with less formal education and family income, but not for young people who identified as black, brown, or non-white. Conclusion The findings underscore the importance of considering agency, sociality, and politics when theorizing “the social” in clinical practice, and health and social policy.
Purpose In this paper, we explore how Brazilian socially sensitive therapy can respond to care-users’ desire to change the social and political forces shaping their lives. We use this case to demonstrate the limits of the “social determinants of health” agenda which, when operationalized, tends to leave questions of lasting structural change aside. Methods We report on mixed methods ethnographic and epidemiological results from the 1982 Pelotas (Brazil) birth cohort study, a prospective study of 5914 children. Ethnographic analysis explored the cyclical relationship between schooling, mental health care, conceptualizations of mental distress, social and political engagement, and experiences with diverse forms of discrimination. Epidemiological bivariate and multivariate analyses examined differences in socio-political participation and the reporting of discrimination at different time-points for participants who used therapy with those who did not. Effect modification analysis tested the hypothesis that the socially empowering effects of therapy were greater for marginalized and minoritized youth. Results Most young people living in situations of precarity experienced therapy, particularly when based in schools, to be a blame-inducing process. A more fulfilling and impactful therapeutic experience took shape when young people were able to shift the focus away from symptom reduction and behavioral management toward narrative life analyses, social debate, and political agency. Use of socially sensitive therapy was statistically associated with increased political participation and reporting of discrimination after controlling for confounders. The empowering effects of therapy were greater for those with less formal education and family income, but not for young people who identified as black, brown, or non-white. Conclusion The findings underscore the importance of considering agency, sociality, and politics when theorizing “the social” in clinical practice, and health and social policy.
Medical students’ efforts to learn person-centered thinking and behavior can fall short due to the dissonance between person-centered clinical ideals and the prevailing epistemological stereotypes of medicine, where physicians’ life events, relations, and emotions seem irrelevant to their professional competence. This paper explores how reflecting on personal life experiences and considering the relevance for one’s future professional practice can inform first-year medical students’ initial explorations of professional identities. In this narrative inquiry, we undertook a dialogical narrative analysis of 68 essays in which first-year medical students reflected on how personal experiences from before medical school may influence them as future doctors. Students wrote the texts at the end of a 6-month course involving 20 patient encounters, introduction to person-centered theory, peer group discussions, and reflective writing. The analysis targeted medical students’ processes of interweaving and delineating personal and professional identities. The analysis yielded four categories. (1) How medical students told their stories of illness, suffering, and relational struggles in an interplay with context that provided them with new perspectives on their own experiences. Students formed identities with a person-centered orientation to medical work by: (2) recognizing and identifying with patients’ vulnerability, (3) experiencing the healing function of sharing stories, and (4) transforming personal experiences into professional strength. Innovative approaches to medical education that encourage and support medical students to revisit, reflect on, and reinterpret their emotionally charged life experiences have the potential to shape professional identities in ways that support person-centered orientations to medical work.
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