J., a 16-year-old boy, presented to a public outpatient clinic for evaluation and treatment for anxiety, learning disabilities, and behavioral problems. J. lived in a shantytown in a medium-sized city in southern Brazil and was referred by his school’s psychologist for evaluation by Dr. M., a psychiatrist at a community clinic.1 According to his mother, J. had a history of “aggressive behavior,” which intensified first after he failed 2 years of school when he was 13 and 14 years old and then when he was violently assaulted when he was 15. J.’s mother reported that shortly after the assault, J. began using drugs and alcohol, spending more time on the streets, missing school, and withdrawing socially.
J. attended a crowded public school where there was much student–teacher and peer-to-peer conflict and violence. Though he’d been referred several times to his school psychologist, he had not consented to continued treatment. The psychologist had offered behavior-modification suggestions, including anger-management strategies, but J. did not find these useful. He explained that although he felt anxious and got into too many fights, he felt frustrated by his teachers’ negative attitudes toward him and by the school psychologist’s emphasis on his “agitation” and “inability to focus.” J. claimed that students from the shantytown were more likely to be sent to the school psychologist simply because they “looked poor.”
J. explained that he had agreed to visit Dr. M. not because “there was anything wrong with” him, but to air his complaints. He expected that Dr. M. would “tell me what was wrong with me and how to change my behaviors,” as the school psychologist had done. J. also wondered whether the doctor might prescribe medications for attention deficit or depression, as had been the case for several of his classmates.
Instead, Dr. M. used open-ended questions to encourage J. to talk in an unstructured way about his everyday life and social relations in school, at home, and with friends. Early in their first session, Dr. M. communicated the exploratory and nonformulaic nature of his approach. J.’s initial hesitance to trust Dr. M. began to change when the psychiatrist humbly admitted to “having no idea” what it was like to live J.’s life.
Sessions with Dr. M. led to a shift in perspective on J.’s difficulties. His mother, teachers, and school psychologist had focused on his learning difficulties, behavior, and possible drug addiction. But what came to occupy most of J.’s own attention, in therapy and in general, were the conflicts and judgments he experienced as a “poor person” and his resulting feelings of anger and hopelessness. When he began to understand that these feelings originated from something other than his own psychological characteristics or biologic deficiencies, he felt more optimistic and had the “energy,” as he put it, “to battle through [his] struggles.” The clinic provided him with a safer environment in which to begin these battles. J. and Dr. M. often had different perspectives, but J. said he appreciated that Dr. M. was the first adult from the “upper-middle class” with whom he could interact with growing confidence, assertiveness, and equality.
J. began attending school regularly and eventually became active in the student council, where he advocated for better teacher–student relations and worked alongside school staff who ran initiatives to foster student participation and democratic teaching practices. Through his council participation, which took place outside the demands and stresses of the classroom, he and school staff interacted in ways that increased mutual understanding.
After a year of intermittent therapy, J. explained how therapy had amplified his “consciência,” or consciousness — a word he used to refer to awareness, self-worth, and ability to act in the world. He summed up the most significant change in his life by declaring, “I feel more like a person with value now.”2