Psychiatric reform in the SUS and the struggle for a society without asylums

T This article presents a historical and epistemological study of the construction of public policies about mental health and psychosocial care in Brazil ́s Unified Health System, the SUS. To that end, it proposes an approach that identifies actions and strategies related to social participation in the construction of policies, one of the founding principles of SUS, seeking to delineate its importance in the specific trajectory of the psychiatric reform process. Subsequently, it highlights the originality and importance of actions that used culture as a means and as an end, in the sense of not restricting psychiatric reform to a transformation limited to public services or health in the strict sense of the term, emphasizing the principle of construction of a new locus in society for madness. Finally, it provides a historical follow-up of the promulgation of mental health policies in Brazil, identifying the most important initiatives and their impacts on the transformation of the care model, and concludes by questioning the conservative restructuring that is currently taking place.


Introduction
Mental health (MH) and psychosocial care (PC) policies in the SUS (Sistema Único de Saúde, Unified Health System) are directly related to the idea-proposal-design-movement-process 1 of health reform taking into account the situation of the democratic transition and, consequently, the construction of a democratic state itself.But this has its own oddities!
The first Brazilian psychiatric care-related movements emerged in the 1970s when newly-graduated professionals encountered a situation of neglect and violence.Thus, the case of academics in Bahia in that period, as well as the memorial of the Association of Psychiatric in Bahia 2 and the "crisis" of the National Mental Health Division (DINSAM/MS) are emblematic.The "crisis at DINSAM" had great repercussions after manifestations of known entities in the national scene (OAB, ABI, CNBB, among others).The episode concerns the mobilization of fellowship holders and residents of the psychiatric hospitals of the Ministry of Health (MH), where the conditions were extremely precarious.As the result of a letter sent to the Minister of Health with complaints and claims, 260 professionals were laid off, unleashing a new complaints process, demonstrations and articles published in the press for several months.This all took place in the context of democratization and the fight against the dictatorship, relating to specific human rights struggles for the victims of psychiatric violence with the violence of the autocratic State, which became the most important social actor in the psychiatric reform (PR) process.Such a fact will influence in a meaningful way the construction of public policies, not only in health, but in other sectors (such as culture, justice, human rights, labor and social security).
This short paper aims to explore the perspective that mental health is part of the idea-proposal-project-movement-process 1 cycle, but maybe it goes beyond the analogous or interrelated cycle of health reform, consisting of a broader and more complex process.It is in this sense that the perspective of reflecting on mental health, psychosocial care and psychiatric reform, over the last 30 years of SUS, is adopted, seeking to identify strategies, tools and processes that were abundant in the SUS and which have reached other sectors remarkedly.We refer to the debate started by Sergio Arouca and reflected by Paim in his work "'Phantom of the missing class' and the new social subjects" 1 , where he affirms that the health reform movement failed to coordinate with the popular masses or, at least, with other social movements.This was a permanent and worrying issue in the PR, enabling the emergence of important initiatives in this scope.Our proposal is to reflect on this process in several dimensions that, although simultaneous and related to each other, aim to highlight and analyze the various tools and strategies that were adopted.

The process of social participation in the psychiatric reform: the "mentaleiros" make the difference
The first moment concerns the constitution of the Movement of Workers in Mental Health (Movimento dos Trabalhadores em Saúde Mental, MTSM), the first collective entity with the purpose of restructuring psychiatric care.It is important to add that, at the moment, the terms mental health or psychiatric reform were barely used.The first term was still practically restricted to the proposal of community mental health or preventive psychiatry, based on Caplan's 3 ideas, which was the target of much criticism, that were known and accepted by MTSM participants.Two of these criticisms were emblematic: Franco Basaglia's text, entitled "The New York Letter -fake invalid" 4 and the text by Joel Birman and Jurandir Freire Costa, entitled "Organization of institutions for a Community Psychiatry" 5 .The second term, psychiatric reform, would only be used at the end of the 1980s, the same period in which the term health reform began to be adopted 6 .
As early as 1978, when the MTSM was formed, there were several relevant and important activities, especially the 5th Brazilian Congress of Psychiatry, in Camboriu (Santa Catarina State), that almost became a sit-in by participants of the movement, and the I Symposium on Groups and Institutions Policies, at the Copacabana Palace Hotel, at which several internationally renowned personalities participated, including Franco Basaglia, Robert Castel, Felix Guattari, Ronald Laing, Donald Cooper, Howard Becker, Thomas Szasz and others.Some guests established strong links with local militants, which sparked a fruitful relationship, as was the case with Robert Castel, Felix Guattari and Franco Basaglia (who returned twice to Brazil, before dying two years later).
Also, in 1978, the MTSM approached the Brazilian Center for Health Studies (CEBES), and started to organize committees of Mental Health in some of the states where the entity was more present (Rio de Janeiro, São Paulo, Minas Gerais and Bahia).The report drawn up by the commission in Rio de Janeiro would be presented at the I Symposium of Health Policies of the Chamber of Deputies, on the same day that CEBES presented the document "The democratic issue of health", when the proposal for a Unified Health System (SUS) 7 was put forward.
Basaglia's last trip to Brazil had strong repercussions in the media.The event was shown on major communication media and led to important studies: In the dungeons of madness by Hiram Firmino 8 , a collection of chronicles published on Diário de Minas newspaper and the award-winning short film In the name of reason by Helvécio Ratton 9 .
The following year, 1979, the MTSM organized the I Congress of Mental Health in São Paulo, showing vigor and initiative, even with no financial support.This year, the approach with the newly-created Brazilian Association for Graduate Studies in Collective Health (Abrasco) would mean more a strategy of expansion in the articulation of the movement with the more general field of health.
In the early 1980s, with the financial crisis in Social Security (SS), there were proposals for reshaping medical care in this context, but also in the health arena, and many of the MTSM participants were involved in these processes, and, as a result of the political changes, especially with the New Republic, there was the convening of the historic 8th National Health Conference, which revolutionized the form of social participation in public policy development 10 .To the extent that the Eighth, as it was known, had a more general agenda (health as a right; Reformulation of the national health system; Industry funding) 11 , it was decided to convene specific conferences, among which one addressing the Mental Health.The organization of the I National Conference on Mental Health, however, took place after many difficulties including, paradoxically, the mental health sector of the Ministry of Health which was unfavorable to reforming ideas and even against the idea of social participation in the construction of public policies.The action of MTSM participants was decisive for its realization, which triggered other state conferences without the consent of the central Government.Furthermore, this was the only conference that did not happen in Brasilia, but in Rio de Janeiro, from 25 to 28 June, 1987 12 .
During the I CNSM a MTSM meeting occurred and decided to convene its II National Congress, in December that same year.As a head-quarter for this congress the town of Bauru was selected, as David Capistrano (one of CEBES and the Maganize Saúde em Debate founders and a firm defender of the PR) 13 was Health Secretary, which would promote the event.
The II Meeting emphasized the proposal of "a society without asylums", a motto proposed by the Network of Alternatives to Psychiatry after an important meeting in Buenos Aires was conducted in 1986, with the participation of some of the most important international members (Robert Castel, Felix Guattari, Franco Rotelli, Franca Basaglia)."A society without asylums" reveals two significant changes in the movement.One of them concerns its constitution, to the extent that it ceases to be a collective body of professionals to become a social movement, not only with its own "lunatic people" and their families, but also with other human rights activists.The other refers to its image-goal, sofar largely associated to the improvement of the system, to the struggle against violence, to discrimination and segregation, but not explicitly to putting an end to the concepts of psychiatric institutions and asylums.Since then the concept has turned into the Movement for the Struggle Against Aylums (Movimento da Luta Antimanicomial, MLA).
In the context of conferences, we should highlight that the MLA has always had a major role, both in local, state and national issues related to mental health.The field of mental health starts to practice a radicalism of the proposal for social participation, far beyond the idea formally provided for in the SUS statute, concerning the participation of users under law 8.080/90 14 .The II Conference, convened by Fernando Collor, was held (from 30 th November to 2 nd December 1992), five years after the first, and the III, now convened by Fernando Henrique Cardoso, took place between 11 th and 15 th December 2001, almost ten years after the previous one.And, paradoxically, denoting a total contradiction, in the first term of former President Luís Inácio Lula da Silva no conference was held.The fourth edition of this conference only occurred between 27 th June and 1 st July 2010, the final year of his second presidential term, after vigorous pressure from social movements that held several demonstrations that culminated in the historic Users'March on September 30 th of that year in Brasilia.Despite being convened as the first intersectoral conference, the participation of other sectors was restricted to elements of the government and did not expand to social movements linked to labor, human rights, culture, education, land rights, and so on.
In addition to the significant participation of the MLA in conferences, public hearings and others, this movement started to participate in the Intersectoral Commission on Mental Health of the National Health Council, in spite of the fact that the concept of an intersectoral approach was restricted to parts of the field of mental health (especially family and users).The meetings of the Committee were convened irregularly and MLA representatives criticized the lack of decision-making power from this committee.
Once constituted as a Movement of the Struggle against Asylum, the collective body began to organize core offices in capital cities and in almost all major cities of the country.The creation in Bauru of the National Day for the Anti-asylum Struggle was a decisive element for this expansion.The date May 18 th would serve to arouse critical thought in society about the institutional violence of Psychiatry and the exclusion of persons in mental distress.We may consider that the goal was successful to the extent that, since then, political, scientific, cultural and social science activities are conducted not only on that date, but throughout May, which turned out to be considered the Month of the Anti-asylum Struggle.Given the large impact of events organized by the MLA and also its significant participation in more general health issues, the term mentaleiros (in allusion to the heavy metal musicians in Portuguese, metaleiros) became widely used to characterize the "noise" caused by this social actor.
On the other hand, the MLA began to organize its own events, the first in 1993, in Salvador, and the latest in 2014, in Niterói, with relative regularity and expressive autonomy, both organizationally and financially and started to stimulate and contribute with the organization of national meetings of associations of users and family of mental health services which in 2014, held its 14th edition.In Vasconcelos's work 15 , precious information about the historical and political bases, tensions and tendencies of this social actor can be found.
The creation of the Brazilian Mental Health Association (Abrasme) represented a new element in social participation in the context of the PR.Created from the Mental Health working group of Abrasco, the purpose of Abrasme was to constitute a new actor that would reunite, at once, the multiple subjects involved, users and family and other activists linked to issues of ethnicity, gender, sexuality, cultural diversity and human rights, and all who were at services or other tools, and also joining those who work in the produc-tion of knowledge and policies.Abrasme, then, started to organize, every two years, national congresses as well as human rights and mental health meetings.Both congresses and forums began to assume more centrally the critique targeting the biomedical model in psychiatry and the interests that drives the sector.As an example, the entity made possible the coming of several international expressions of movements of criticism to the medicalization of daily life, of the "voice listeners", of the Open Dialogue, especially Robert Whitaker 16 , who has been here four times.
With the first signs of SUS dismantling, which took place before Dilma Rousseff 's impeachment, but as a result of the negotiations so that it did not occur, responsibility for the Health Ministry was taken over by conservative actors.At the same time, responsibility for the Coordination of Mental Health, Alcohol and Other Drugs, was given to the former director of a psychiatric hospital closed down by the Public Attorney's Officewho was a notorious advocate of the asylum model.In response, the MLA "occupied" for four months the facilities of Coordination that was only vacated by court order.This act, with international repercussions, showed the organizational skills and the political intervention of the "mentaleiro" movement.

There is so much life out there: a new social place for madness
The notion of PR as a complex social process, originally elaborated by Rotelli 17 to refer to the strategies of deinstitutionalization, has been adopted in Brazil 13,18 in order to highlight the breadth of the process, noting that it is not reduced to the reform of services and care technologies, in spite of their own relevance.Birman, when in the early stages of this process, observed that what was "on the table in a decisive way is the task to outline another social place for madness in our cultural tradition" 19 .Such an aspect can be considered one of the main references in order to build other strategies and political, social and cultural tools, and not only therapeutic and clinical ones.One of these strategies was potentially the stimulus for social participation in the construction of policies, both within the scope of services, and in the more general forums (conferences, public hearings, health councils, and other spaces) in addition, of course, to a strong role as subjects of the anti-asylum movement 20 , or empowerment 21,22 .
At the I National Meeting in Salvador, a fundamental guideline was consolidated towards the PR in the direction of the construction of a new social place for madness.It relates to the idea that if the object of the change is in the field of culture and cultural practices, the strategy should also be cultural.Then, the proposal to work with culture as a medium and culture as a goal arises 23 .The use of art and culture, besides being a merely therapeutic resource or a clinical aid, turned out to assume the size of production of subjectivity and life 24 .In this line of business, the PR process is taken by a huge contingent of artistic and cultural initiatives in order to promote transformations in social imaginary and discursive practice on madness, diversity and difference 25,26 .
In 2007, the workshop "Crazy for diversity" was held, chaired by Minister Gilberto Gil 27 , from which an announcement was made in which approximately 400 cultural initiatives were enrolled, the expression of form of art-culture in the PR.Finally, the strategy via cultural-artistic activities enabled a more creative dimension in the context of mental health at SUS, both related to the daily services and to the cultural intervention in the city, in the public scope of social relations.

From replacing services to RAPS
In the 1970s and early 1980s, the PR movement developed critical thinking in the institutionalization of madness.The concepts of institutionalism, institutionalizing power and total institution prevailed in the speeches in that period.It was in the late 1980s that the prospect of creating services that would initiate innovative practices emerged.
In São Paulo, the first Psychosocial Care Center (Centro de Atenção Psicossocial, CAPS) was created and other initiatives began to emerge.These are services that serve the unprecedented function of providing intensive care to users with severe psychiatric conditions without using hospitalization or the fragile ambulatory model (which consisted of sparse visits for the renewal of prescriptions or a timid psychotherapeutic offer).An alternative or intermediate function to the predominant hospital model in that period 28 .
With the inclusion of SUS principles in the 1988 Constitution, a new perspective was opened for the autonomy and development of municipal health policies, and a strong expression of this latter was what happened in the city of Santos in 1989.Although still under the Unified and Decentralized Health System (SUDS), the newly elected managers in the municipality decided to expedite the installation of SUS and perform an intervention in a psychiatric hospital where serious violations of human rights had occurred.Contrary to previous interventions in the same hospital or in general, in the country, the outcome would not indicate improvements, but the closure of the hospital, with the consequent creation of a so-called substitute network, composed not only of decentralized services, distributed throughout the territory, but also of tools that could contemplate other dimensions and demands of life, such as housing, leisure work, culture, etc.In addition to the creation of five Centers for Psychosocial Care (Núcleos de Atenção Psicossocial, NAPS), medical residencies were opened for the hospital's graduates, a work cooperative, a radio, TV and theater cultural project, as well as several other intersectoral programs with children and young people, sex workers, reduction of harms, domestic violence, among others.
In a short time, the network of substitute tools created in several municipalities of the country, and regulated by directive 189, in 1991, started to have visibility, introducing the NAPS/ CAPS codes in the SUS table and by directive 224, in 1992, which defined them as local/regional health units responsible for the coverage of a population defined by the local level to provide intermediate care between the outpatient network and hospital admission.Many other tools are created, such as day hospitals, centers of coexistence and culture, centers of reference, therapeutic workshops, among others.This growth reveals the richness and creativity of the PR's actors within the scope of SUS.It is important to highlight that, at the same time that the directives led to the increase of the network, on the other hand, they limited their autonomy in terms of innovation and resolution.
In 1989, with the Santos process and the demonstration of the feasibility and efficacy of the substitute network to the asylum model, Bill number 3.657/89 was presented.The Bill had been under discussion for almost 12 years but, even though it was rejected, a substitute was approved, introducing significant changes in the sector policies, even though they did not fully address the PR's wishes.
Law 10.2016 was sanctioned on 04/06/2001, the year in which the III National Conference on Mental Health was also held, which helped to design a very favorable and promising scenario for the field of mental health at SUS.
But while the bill was still in process, many state and municipal PR laws were passed in capitals and major cities across the country, and other innovations were introduced.One of them was the constitution of the Residential Therapeutic Services (Ordinance 106/2000 and 1.220/2000).The implementation of a network of RTSs was greatly favored with the advent of the Volta Para Casa Program (Law no.10.708, July 31, 2003).
After the RTSs, the National Program of Evaluation of the Hospital Services -PNASH/ Psychiatry was created in 2002, which initiated a regular process of evaluation of the psychiatric hospitals, including public ones and private ones with agreements with SUS.As a result, hundreds of hospitals were closed and a few thousand beds absolutely inadequate for health care.
Other important milestones of mental health policies at SUS were established by Ordinance/ GM nr 336, dated 02/19/2002, which redefined the CAPS in relation to their organization, to the size and specificity of the clientele served.CAPS I, CAPS II, CAPS III, CAPSi (infant or infant/ youth) and CAPSad (alcohol and drugs) began to exist.Another milestone came from theDirective 154 of 2008, which established the Family Health Support Center (Núcleo de Apoio à Saúde da Família, NASF), with the objective of providing "matrix support" to Family Health teams, fulfilling an important role of providing both technical and institutional support in primary care 29 .
In 2011, the RAPS (GM/MS Ordinance No. 3.088 of December 23, 2011) was instituted, which provides a new dimension to the set of actions in mental health at SUS, whose main objectives were defined as the expansion of access to the population's psychosocial care, at different levels of complexity, promoting the access of people with mental disorders and needs arising from the use of crack, alcohol and other drugs and their families to the points of care; and guaranteeing the coordination and integration of health care points of care in the territory, improving the care through the reception, continuous monitoring and emergency care.
Despite the importance of the RAPS and the organization in the network that it implemented, it is important to highlight that for the activities of culture and work and incomegeneration, the budget resources were not defined, revealing, thus, the little strategic meaning assigned to such initiatives that could be better used, taking into consideration the resolution of the Income Generation and Labor Program (Resolution CODE-FAT nr 59/1994) and the Points of Culture (Law nr 12.343/2010).

Final comments on the evolution of mental health policies and psychosocial care in the scope of SUS: the winds blow to the past
The report of the Cebes Mental Health Commission presented in 1979 at the I Health Policy Symposium of the Chamber of Deputies pointed out that 96% of all resources spent on psychiatric care were earmarked for the payment of hospital rates in the more than 80,000 beds in the country in 1977.He also observed that from 1973 to 1976 psychiatric hospitalizations increased by 344% 7 .
The last report from the National Coordination of Mental Health, Alcohol and Other Drugs of the Ministry of Health was published in 2015 30 , and since this period the changes began which redefined public policies, not only in the health and mental health sector, but also the conception of the State provider and State rights.
Whatever the criticisms and comments, that were sometimes necessary and fair fordelivering the policy, it is important to recognize many advances that have occurred in the Brazilian PR.One of them is the significant decrease in psychiatric beds: from 80,000 in the 1970s to 25,988 in 2014.Considering the investment in psychosocial care services, especially at CAPS, which in 2014 surpasses 2,000, and reaches a coverage of 0.86 CAPS per 100,000 inhabitants,hospital spending fell from 75.24% in 2002 to 20.61% in 2013, while, reversing the policy, spending on psychosocial care increased from 24.76% to 79.39% over the same period.In 2014, 610 SRTs were registered with 2,031 residents from psychiatric institutions and the Volta Para Casa Program started to have 4,349 beneficiaries and the income generation initiatives reached 1008.
But the winds already began to change in 2015 with the Ministry of Health being the object of political negotiation as well as the principles of SUS.And, finally, after the installation of the state of exception by which the country passes at the moment, the SUS and the PR have undergoneradical changes and important setbacks.In the field of mental health, the Tripartite Interagency Committee 31 approved the resolution in December 2017 that practically restores the asy-lum model and begins a process of dismantling the whole process that had been constructed over decades within the scope of the Brazilian psychiatric reform.

Collaborations
P Amarante and MO Nunes also participated in all stages of the article.