Psychiatric Reform: Strategies to Resist the Dismantlement

The measures taken by the Brazilian Federal Government since 2016, during the Temer administration, which were furthered in the first months of the Bolsonaro administration, and their impact on some of the mental health policy indicators enable us to state that there is an accelerated process of dismantlement of the improvements achieved by the psychiatric reform. With all of the forward and backward steps of a complex process, which involves public management, social mobilization and cultural change, the reform of the care in mental health in Brazil had been progressing at a relatively steady and constant pace ever since the 1980s. This is the first time in roughly 35 years that we visibly move backwards.

Psychiatric Reform, a process in the making

Summing up this long history: the 1980s began with a financial crisis in the National Institute for Medical Assistance of the Social Security (Instituto Nacional de Assistência Médica da Previdência Social, INAMPS, in the Portuguese acronym), and with the revelation (which essentially did not surprise anyone) of the massive growth in the number of psychiatric beds during the military governments, and those beds had no form of technical monitoring whatsoever, being responsible for the greatest expenses within the system in terms of commitments. At the same time, more than one third of the population was excluded from social security citizenship, and only had access to the huge and practically derelict federal and state asylums. With the exception of rare outpatient services offered by INAMPS or some public universities, psychiatric care for those who were not rich was restricted to the commitments, establishing a hospital monoculture. Since there was no universal health care system, the psychiatric reform took two dangerous but self-limited paths: the humanization of the great public asylums (coupled with the criticism regarding the privatization of the suffering that the authoritarian State carried out through its 'madness industry') and an incipient outpatientization of the care in mental health.

The 1988 Constitutional Assembly established the social and institutional contract that enabled the great improvements of the 1990s. The psychiatric reform advanced then with the framework of a universal health care system, and under the ethical premises of citizenship rights. The new care model was debated with society in the 1990s, and resulted in the enactment of Law no. 10216 in 2001. The motto 'an insane asylum-free society', which was adopted by the social movement in 1987, worked as a safe ethical compass for the structural changes in the public management, which were the mark of the following decade: reduction in the specialized hospital beds, creation of services within the community, radical expansion of the access to treatment, and the opening of the borders of care in primary health care and in intersectoriality. Until 2015, the expansion in the access to care, both for serious and persistent mental illnesses and less serious (and ever more frequent) mental illnesses followed a steady line of regular increase in services and changes in work processes.

Regarding the changes in work processes, besides the programmatic incorporation of the intersectoriality (starting with the IV National Mental Health Conference - Intersectorial [Conferência Nacional de Saúde Mental - Intersetorial, in Portuguese], in 2010), the challenges of developing the care in the everyday life of the territory (and no longer under the strict ergonomic and architectural configuration of the institutional trinomial of emergency-outpatient clinic-hospital) were now the main content of the researches and reflections of the now so-called 'psychosocial care field.' An ongoing paradigm change. It is important to remember that before the psychiatric reform, issues such as the mental health of children and teenagers and issues resulting from the use of alcohol and other drugs were excluded from the mental health (Couto & Delgado, 2019) and public health policies (Brasil, 2003).

The dismantlement in motion

This process was interrupted in 2016, with the measures taken by the Temer administration, which were furthered in the Bolsonaro administration (there is a clear continuity in the field of health and of other social policies regarding both administrations, which were instated after a rupture in the democratic order in Brazil). The first measure is Constitutional Ammendment 95, which has already been causing the dismantlement of the Brazilian Unified Health System (Sistema Único de Saúde, SUS, in the Portuguese acronym) and of intersectoral policies (mainly welfare and education), with immediate impacts on the field of mental health. The results of the neoliberal agenda instantly impact public health and well-being and quality of life indicators: at the beginning of 2016, the unemployment rate was around 5.5%, and it reached 12.5% in the first quarter of the Bolsonaro administration. It is not necessary to recall the extremely vast literature that for more than a century has been correlating unemployment and mental suffering, which reach pinnacles that alter the suicide rates (as recently observed in Greece after the 2008 crisis).

Between 2016 and 2019, the Federal Government took the following measures: 1) it changed the National Primary Health Care Policy (Política Nacional de Atenção Básica, PNAB, in the Portuguese acronym) altering the population parameters and exempting the obligatory nature of the presence of the community health worker in the health of the family teams, with immediate consequences of decharacterization and weakening of the primary health care; 2) it expanded the funding for psychiatric hospitals, granting an adjustment of more than 60% in the cost of the daily hospital stays; 3) it reduced the registry of Psychosocial Care Centers (Centros de Atenção Psicossocial, CAPS, in the Portuguese acronym), in a proportion that is still imprecise, since the Ministry of Health stopped supplying data regarding the mental health service network; 4) it expanded the funding for more than 12 thousand vacancies in Therapeutic Communities; 5) it restored the centrality of the psychiatric hospital, in a regulation that has already been enacted, and recommended against the use of the word 'substitutive' to designate any mental health service (even though this measure is bizarre managementwise, it has a clear symbolic intention of denying the change in the care model); 6) it recreated the day hospital, an assistance archaism linked to psychiatric hospitals, without defining its purpose, clearly aiming to strengthen the deterritorialized model; and 7) it recreated the specialty outpatient clinic, also without a territorial reference.

In February 2019, the Ministry of Health of the Bolsonaro administration issued a 'Technical Note' that had the goal of 'clarifying aspects of the new mental health policy' (Brasil, 2019). Reasserting the continuity of the management that began with the Temer administration, and signed by the same coordinator that worked for the former government, the document indicated the changes made in the orientation of the policy. Besides the generic criticism regarding the 'ideology' present in the mental health policy (replicating the ideological 'anti-ideology' rhetoric of the Bolsonaro administration), which was replaced by a 'scientific' perspective, some topics must be highlighted, because they represent a direct measure of dismantlement of the psychiatric reform: strengthening of the strategic role of the psychiatric hospital; emphasis on the commitment of children and teenagers; emphasis on biological methods of treatment, such as eletroconvulsotherapy; disjunction between mental health and the policy for alcohol and other drugs; and the disapproval of damage control strategies.

The policy for alcohol and other drugs is now under the management of the Super-Ministry of Citizenship, which encompasses Social Development, Culture and Sports, whose head, a former minister for the Temer administration, expresses a clear policy of support to the therapeutic communities and against the damage control strategy.

Reflecting over and putting into practice the resistance against the dismantlement of the reform

The psychiatric reform has a slow and steady development, but it is at risk. There are good reasons to believe that resistance against the dismantlement is possible, and that it will be successful. In order for that to happen, we must take certain topics into consideration. Firstly, this is the worst crisis in Brazilian democracy ever since the 1964 coup d'état, and it represents a rupture in the social and democratic contract established with the 1988 Constitution. The authoritarian neoliberalism that seized control of the State is firmly supported by the Armed Forces, by the media conglomerates, partially by public opinion and religious organizations, by the Judiciary, by the US Government, and by the conservative wave that dominates part of the planet currently. Privatization of the State, dismantlement of the social welfare project, impoverishment, wealth concentration, punitivism, suppression of individual freedoms, incitement of hatred and inequality: those are components of the tragic context in which we are currently living. Resistance must come from an acute awareness of the current political situation. After the defense of democracy, combating the weakening of the SUS (the 'minimal SUS' proclaimed by the Minister of Health) is a duty of the resistance. In the field of psychosocial care, there is a vast resistance movement, comprised of tens of thousands of professionals directly involved with the services, and supported by students, users and their family members. The trenches of resistance reside in the territorial services.

Referências

• BRASIL. Ministério da Saúde. Secretaria Executiva. A política do Ministério da Saúde para Atenção Integral a Usuários de Álcool e Outras Drogas Textos Básicos. 2003. Disponível em: <http://bvsms.saude.gov.br/bvs/publicacoes/politica_atencao_alcool_drogas.pdf>.Acesso em: 18 mar. 2019.
  » http://bvsms.saude.gov.br/bvs/publicacoes/politica_atencao_alcool_drogas.pdf
• BRASIL. Ministério da Saúde. Nota Técnica 11/2019. Esclarecimentos sobre as mudanças na Política Nacional de Saúde Mental e nas Diretrizes na Política Nacional sobre Drogas Coordenação Nacional de Saúde Mental, Álcool e Outras Drogas. 2019. Disponível em:<https://www.abrasco.org.br/site/wp-content/uploads/2019/02/11_23_14_123_Nota_Te%CC%81cnica_no.11_2019_Esclarecimentos_sobre_as_mudanc%CC%A7as_da_Politica_de_Sau%CC%81de_Mental.pdf>. Acesso em: 18 mar. 2019.
  » https://www.abrasco.org.br/site/wp-content/uploads/2019/02/11_23_14_123_Nota_Te%CC%81cnica_no.11_2019_Esclarecimentos_sobre_as_mudanc%CC%A7as_da_Politica_de_Sau%CC%81de_Mental.pdf
• COUTO, Maria Cristina V.; DELGADO, Pedro Gabriel G. Crianças e adolescentes na agenda política da saúde mental brasileira: inclusão tardia, desafios atuais. Psicologia Clínica, Rio de Janeiro, v. 27, n. 1, p. 17-40, 2015. Disponível em: <http://www.psi.puc-rio.br/site/images/psi_puc/publicacoes/Psicologia_Clinica_27-1.pdf>. Acesso em: mar. 2019.
  » http://www.psi.puc-rio.br/site/images/psi_puc/publicacoes/Psicologia_Clinica_27-1.pdf

Publication Dates

• Publication in this collection
  06 May 2019
• Date of issue
  2019