The construction of knowledge in psychology: the legitimation of medicalization

Abstract

The medicalization is an ideological process that transforms social problems into biological ones and has legitimated by Medicine and Psychology in several historical moments to hide social inequalities, placing on the individual the responsibility for its failure. In the area of Education, the number of children diagnosed with learning and medical disorders is alarming, evidencing a period called the "Age of Disorders". In this article, we seek to uncover the role that relations between these two areas of knowledge historically played in the construction of the medicalization process in the Brazilian educational context

Keywords:
Psychologist training; history of psychology; medicalization

Resumo

A medicalização é um processo ideológico que transforma problemas de ordem social em biológicos e tem sido legitimado pela Medicina e pela Psicologia em vários momentos históricos para ocultar desigualdades sociais, colocando sobre o indivíduo a responsabilidade pelo seu fracasso. Na área da Educação é alarmante o número de crianças diagnosticadas com transtornos de aprendizagem e medicalizadas, evidenciando, assim, um período denominado de “Era dos Transtornos”. Tendo por referência autores que analisam aspectos da aproximação entre a Medicina e a história da Psicologia no Brasil, buscamos, neste artigo, desvelar o papel que as relações entre essas duas áreas do conhecimento desempenharam historicamente para a construção do processo medicalizante no contexto educacional brasileiro.

Palavras-chave:
Formação do psicólogo; história da psicologia; medicalização

Resumen

La medicalización es un proceso ideológico que transforma problemas de orden social en biológicos y ha sido legitimado por la Medicina y por la Psicología en diversos momentos históricos para ocultar desigualdades sociales, poniendo sobre el individuo la responsabilidad por su fracaso. En el área de la Educación es alarmante el número de niños diagnosticadas con trastornos de aprendizaje y medicadas, evidenciando, así, un período denominado de “Era de los Trastornos”. Teniendo por referencia autores que analizan aspectos del acercamiento entre la Medicina y la historia de la Psicología en Brasil, se buscó, en este artículo, desvelar el papel que las relaciones entre estas dos áreas de conocimiento han desempeñado históricamente para la construcción del proceso de medicalización en el contexto educacional brasileño.

Palabras clave:
Formación del psicólogo; historia de la psicología; medicalización

Introduction

According to Pessoti (1988), doctors through doctoral theses present the first contributions to the study of Psychology in Brazil. Soares (2010) also points out that from 1830 to 1920 doctors wrote the history of Psychology in Brazil. It was not until the 1920s that educators working in the Normal Schools influenced the history of psychology.

Patto (1988) reports that from the turn of the nineteenth century to the twentieth, medical researchers who understood social problems using the relationship between climate, race and personality taught classes in psychology and anthropology. This presence became even greater when the medical hygienists began to teach in the training places of the psychologists of the time, that is, in the Normal Schools, in the Faculties of Philosophy and in several undergraduate courses.

The approach between medicine and education culminated in a great influence for the constitution of the field of Psychology. This relationship established, mainly, through the hygienist movement and the use of psychological diagnostic tools through mental level tests. It became a fundamental part of this history the creation of disciplines of Psychology in Normal Schools and the installation of laboratories of Psychology applied to education, both in these schools and in the Psychiatric Hospitals.

Spazziani (2001) states that the process of medicalization directly related to the action of medicine within society. It observed that in the construction of modern society knowledge about the disease ceases to be in the divine hands and becomes the domain of medical knowledge. For Donnagelo and Pereira (1976), the expansion of medical practice refers to the variation of new modalities of services offered to society, to the increasing number of different populations served as medical clientele and to health normativity.

The standardization of health, according to Moysés and Collares (2008), "transforms problems of life in diseases, in disorders. Here, behavioral disorders, learning disorders arise as current problems" (p.3). In this sense, Medicine and Psychology are united in a medical project, initiated with the process of social and then mental hygiene, especially of the children inside the school.

Viégas and Freire (2015) point to the fact that the use of the term medicalization since 1960 has been growing in publications. It increased between 2000 and 2010 and expanded significantly after 2010, with the founding of the Forum on the Medicalization of Education and Society. However, in addition to the Forum, this issue mobilized several discussions, highlighting the Federal Counsel of Psychology that launched the campaign "No to Medicalization of Life" in 2011.

It is worth emphasizing the plurality of the concept "medicalization". In this text we will use the concept proposed by the "Forum on the Medicalization of Education and Society", held in 2005, which sought to mean the term by highlighting the fact that social issues are treated as biological and medical problems.

Having made this brief introduction, and aiming at a more comprehensive discussion regarding the approximation between Psychology and Medicine in the project of medicalization¹ of education, as well as the implications of this relationship within the school, we will present the historical development of this medicalization process by dividing this article in three parts. In the first part, we will discuss the appropriation of the knowledge of the psychological science by Medicine through the hygiene of the school with emphasis on the discourse of the race. In the second one, we will highlight the role of Psychology and Medicine in the project of mental hygiene of the students. Finally, in the third part, the critical movement of Psychology in Brazil.

The analysis we have made takes into account authors who historically approach the formation of Psychology in Brazil, elucidating facts that evidence the process of medicalization and the interrelationship between Medicine and Psychology. In addition, we will highlight that Medicine was one of the first areas that began to gain legitimacy in the country and did so mainly through the individualization and biologization of the social problems that Brazil experienced in each historical moment.

Psychological knowledge and medicalization of education through school hygiene

After the independence of Brazil in 1822, a profound political-administrative change occurred, as the country moved from the position of colony to become an Empire. The proclamation of Brazil’s independence from Portugal meant a political emancipation of the country, which according to Schwarcz (1993) demanded the creation of a history proper to that nation. For that, D. Pedro I continues the work of building institutions to generate a class of intellectuals trained in Brazil, initiated by his father D. João VI. The Surgery Schools of Bahia and Rio de Janeiro transformed in 1832 into Faculties of Medicine. There is also the creation of law schools and other higher education institutions that have diversified the areas for the intellectual elite.

The formation of the "men of science", as they had known for their connection with scientific institutions of teaching and research, developed in Brazil mainly from D. Pedro II (Second Reign). Each institution turned to the study of the racial cross. Most of the research conducted by these centers showed that such a cross was a problem for the constitution of a modernized, Europeanized nation considered important for the nation's progress. Among the most important institutions were the ethnographic museums of Belém, São Paulo and Rio de Janeiro, the historical institutes, faculties of law, faculties of education and the medical faculties of Bahia and Rio de Janeiro. The faculty of Rio de Janeiro focused on the study of tropical diseases, considering the mixture of races and indicating that the mixture had a negative influence on the country's identity.

Schwarcz (1993) states that this science, at the end of the nineteenth century, will try to gain hegemony among the intellectuals of the time, trying to show how indispensable its action is. It demanded "a primacy of its activity against the will of the individual and in the name of the designs of the collectivity" (Schwarcz, 1993, p.144). Medicine is observed controlling the life of the people through the project of hygiene of the races and, later, of the breeding of the race, with eugenics.

As stated by the author mentioned above, in the Second Reign the emergence of several groups of Brazilian intellectuals was visible. These had as their intention to gain legitimacy in the society through the scientific knowledge that they acquired in the institutions of knowledge of that time. In addition, several changes occurred in Brazil in the 1870s, such as the change of its economic axis, leaving the Northeast (sugar cane cycle) and passing to the Southeast, mainly São Paulo and Rio de Janeiro (coffee cycle). This change, which began in 1850, gave rise to new political-financial elite among the coffee growers of Rio de Janeiro and São Paulo. During this period, there were changes that shaped the complexity of the time: the promulgation of the Free Womb Law, the Paraguayan War and the entry of scientific discourse based on evolutionism.

The discourse of evolutionism is gaining ground in Brazil as a result of an imperialist policy in Europe, which according to Schwarcz (1993) explained the country's backwardness through a deterministic view of the inferiority of the race. However, it was from the scientific explanation that differences between races and their determinations gained relevance in the Brazilian context.

It was through this discourse of the race, in the sense of selection of the most developed and trained, as well as of the breeding of the race with the influence of eugenics, that Psychology and Medicine united in a project of medicalization of society. This project guaranteed to these specialties the category of "recognized science" in the Brazilian reality, as they had already been in Europe (France) and in the United States. Therefore, in Brazil, the Psychology that began to gain space in the country from the second half of the nineteenth century onwards with the modernization project (europeanization) strongly influenced by biological determinism, the inferiority of race, defended by groups of intellectuals, known as "men of science".

At that moment, the formation of psychological knowledge given primarily in the Faculties of Medicine. According to Pessoti (1988), medical professionals are concerned "with scientific questions and are explicitly linked to a specific area of knowledge, the so-called Psychology" (p.21).

According to Massimi (1990), Medicine of the late nineteenth and early twentieth century was extremely important for the development of scientific psychology, due to the influence of positivist thinking and psychological content developed in doctoral theses. The works of Henrique Roxo with the thesis "Duration of the Elementary Psychic Acts", 1900, and the thesis of Mauricio Medeiros entitled "Methods in Psychology", 1907. Henrique Roxo's thesis considered the first order investigation scientific in Psychology, since according to Gomes (2003), psychology had pointed out as a fundamental science of psychiatry.

Massimi (1993) verified in the analysis of theses developed until 1870 of the Faculty of Medicine of Rio de Janeiro, that already in the nineteenth century the psychological knowledge appropriate by medicine is of "social control of individuals and populations and for the definition of behavior" (Massimi, 1993, p.71). In the 19th century, that the first theorizations (science) built that had as their theme, the hygienic practices involved the knowledge of Psychology, Medicine and Education, and the entrance of Psychology in the courses of teacher training through teaching in the Normal Schools (Barbosa, 2012).

According to Larocca (2009), the hygiene project started in the mid-nineteenth century focused on combating disorder and developing nations' progress and regeneration. Disorder appears as the etiological agent of diseases, requiring a medical hygienist intervention in the social body. Hygiene was then a strategy adopted by physicians as a way of becoming relevant in society and guarantee spaces within the public power. In addition to sanitizing and healing bodies, Medicine will intervene in urban spaces and within institutions, such as the school.

The measures initially employed were "preservation of vegetation cover, cleaning of streets and squares, sewers, clearing of hills for air circulation, reforming houses" (Wanderbrook Junior, 2009, p.25). Medicine enters the urban area and travels to people's lives. Thus, it will act through hygienic measures in the various institutions where a considerable number of people are concentrated, since these sites could be effective in the proliferation of diseases. The school is one of those places. With this perspective, medicine acts in education, initially from the improvement of the physical and structural structures of the school and, later, among the professionals (teachers and principals - contracting, exams, selection) and students, developing hygiene habits and also disciplinary the behavior of the subjects through the indication of physical exercises (Gondra, 2004; Zucoloto, 2007).

Patto (1996) reveals that the first explanations of school failure began in Brazil, anchored in the racial theories that circulated in Brazilian lands as early as the 19th century. However, it was from 1850 to 1930 that these theories reached their peak in explaining school problems. According to Patto (2008), the project of hygiene initiated in the Empire and intensified in the First Republic, had as its political object "to save the nationality" and to "regenerate the race", because only a mixed nation is a sick nation, so it would be possible to "Europeanize" (synonymous with modern) Brazil. As Diniz (2009) states, the first three decades of the twentieth century characterized by a project for the nation, focusing attention on the physical and moral formation of the Brazilian people.

It is then that the medicalization of education gained strength from the second half of the nineteenth century. Configured as social hygiene, it permeates the urban area and enters school institutions, legislating on structural, physical, content and moral principles.

Psychology and the medicalization of education through the school's mental hygiene

In the context of the country's changes from the Empire to the Republic, education has seen as a place not only to control epidemics, but as a place of formation for the civilized individual. Therefore, hygiene will direct not only at the preservation of physical health, but also at the subject's mental education. In this sense, as Wanderbrook Junior (2009) affirms, the project moves from the eradication of epidemics, to the development of a healthy mind, which meant the transformation of the medical action from the physical aspect to the subjective one.

At the end of the 19th century and beginning of the 20th century, the movement of Mental Hygiene emerged and the movement for children, in view of the need to maintain social order and the civilizing ideal. According to Menezes (2011), the hygienist movement sees in children the possibility of forming a healthy citizen, in favor of the new social and political order (Republic), so their action will be "associated with educational thinking, about physical, intellectual formation and moral of the citizen, through educational practices and the child's pedagogical perspective "(p.4).

Psychology and Medicine unite to justify the behavior of those individuals who do not conform to this society. The problem shifted from the social and economic reality of the country to the subject, and then goes to the hygienist explanations that go beyond the squares, the streets, the external environments to the mental life of the people. The medicalization takes place in the aspect of life in general and progresses in specific spaces, as in Education that, according to Moysés and Collares (2014), culminates with the "invention of the diseases of not learning with the medicalization of behavior" (p.52).

As we have stated, the psychological science formed within experimental laboratories attached to the Normal Schools and psychiatric hospitals, had used by the doctors in their strategies of hygiene of the population. According to Massimi (1990), the discipline of Psychology in Normal Schools focused on the functioning of the human mind in the study of "sensory and motor activity, intelligence and its operations, moral sensitivity and will, habits, of learning" (Massimi, 1990, 36).

In the case of laboratories, Rosa (2016) claims that Psychology would be a partner in Medicine: "1. To deal with the normal and pathological manifestations of the faculties of the soul, 2. As a diagnostic and prognostic aid, and 3. Incorporating means and techniques for the prophylaxis and cure of mental illnesses " (p.6). In addition, the laboratories present in the courses of the Brazilian Normal Schools were very important for the development of the instruments of measurement of Psychology, an important support for the medical hygienic project of Medicine in Brazil.

This movement of Mental Hygiene at school intensified in the 1920s, from the creation of the Brazilian League of Mental Hygiene, which saw the school and other institutions of childcare as spaces to prevent mismatches and lead to socially adapted behaviors, in a diagnostic, clinical and individualized perspective, with the use of psychological instruments (Wanderbrook Junior, 2009). In this sense, psychological knowledge appears as a strong ally acting in the identification of students with school difficulties.

According to Menezes (2011), Mental Hygiene based on medical-hygienist thinking based on disease prevention, social prophylaxis and the preservation of a healthy mind, which believed in the inferior race's heredity and mental degeneration. Thus, for these doctors, childhood appears as the privileged object of their action. It was the golden age for mental hygiene.

According to Silva (2003), the role of Psychology in this project of medicalization through mental hygiene will be to "evaluate mental activities, either through psychological tests or through clinical observation, so that appropriate hygienic programming is recommended" (p.145). The psychology that diffuses in the educational system related to the quantification and identification of mental capacity, with the objective of "early detection of factors predisposing to mental illness" (Silva, 2003, p.147).

The psychological reduction in the explanation of the learning difficulties advanced even more from the 1930s. In that decade, Psychology had begun configured in the country as a practice of diagnosis and treatment of psychic deviations, thus justifying school failure or at best try to prevent it through preventive psychology programs based on the early diagnosis of disorders in children's psychological development (Patto, 1996, p. 63).

Patto (1996) states that these doctors imbued with psychological knowledge about childhood will occupy mental health institutes, clinics and leagues, in the following decades. They will work in the school medical inspection services, the child guidance clinics, and then go to the departments of the Education Departments.

With regard to the training environments of psychologists and teachers, doctors will work in Normal Schools, specialization courses in Psychology in Faculties of Philosophy and in undergraduate courses in Psychology. These “psychologists” sometimes due to the organic, hereditary, or personality bias, due to the influence of psychoanalysis, which according to Patto (1996), diffused in the psychiatric environment², will attribute school failure.

The movement of mental hygiene reinforced with the insertion of psychoanalysis in the field of medicine. The medical influence psychoanalyst attributed to the children considered as abnormal the denomination of problem children. The emphasis shifted from natural aptitudes (inherited traits - racial determinism) to personality deviations, focusing on problems arising from the environment, especially the family environment.

The psychologists, because the profession was not yet legally recognized, acted in the assessment of the mental states of learners along with other professionals (doctors, social workers, and teachers). Its focus was to attend to problem children, that is, children with problems of school adjustment in both learning and behavior, caused by adverse conditions of the social and family environment.

Therefore, we can say that the hereditary and genetic dimensions of school failure explained the problems of learning, more predominantly until 1930. Add to this the "personality problems", a denomination that emerged under the influence of psychoanalytic explanations. In 1939, physician and hygienist Arthur Ramos published his work on "The Problem Child." In this work, of great repercussion, focusing on the studies of the determinants of personality, it substitutes the "abnormal child" for the "problem child."

Patto (1984, p.11), highlighting the work developed in Mental Hygiene Clinics of the time, states that:

Counseling clinics were mainly focused on the investigation of problems in the students (neurological, psychological, speech-language, psychiatric), which allows them to be characterized as clinical offices based on the medical model of action. The institutional dynamics, the teacher-student relationship, the methods and contents of teaching as dimensions inscribed in a social whole marked by power relations had not taken into account in their activities and reflections. In other words, the school, its procedures and objectives had not questioned, not even as variables that could lead to learning and adjustment problems. It was up to the therapeutic services in the various areas to lead the child to acquire the conditions to adapt to unquestioned or worked school requirements. The orientation of the teachers made with the primary purpose of obtaining their collaboration with the problem children.

Psychology in the critical construction of the medicalization logic

From the beginning of the 1960s, learning difficulties, previously explained by the biological aspect, became cultural, replacing the inferior cultures with the poor cultural environment of stimulus, values and rules, which will interfere with learning. These explanations take their culmination, according to Patto (1984), through the theory of cultural deprivation in the 1970s. As Asbahr and Lopes (2006) explain, this theory is an extension of racial theories. It emerged in the 1960s in the United States and comes to Brazil to justify the fact that poor black children cannot advance in school and work life.

At this point, Psychology will explain the problems of learning from social issues, understanding that the causes of difficulties arise from the environmental poverty in which poor children live. Even if this explanation denounces social inequality, it continues to strengthen the liberal ideology that will reinforce the idea that these inequalities would eliminate only through economic development. To justify the school failure of these poor children, Psychology makes use of tests, anamneses, interviews and questionnaires of a fully clinical model within the school proposing, together with Pedagogy, an education through compensation.

In 1962, Law 4.199 enacted in Brazil, legally ensured the professional status of Psychology and the training of psychologists in Universities. In that same year, the Federal Council of Education created Opinion 403/62, based on the Resolution that establishes the Minimum Curriculum and the duration of the Psychology course. For the Formation of the Psychologist, this Opinion places the need to include, besides the core disciplines (Physiology, Statistics, General and Experimental Psychology, Personality Psychology, Social Psychology and General Psychopathology), two fixed materials denominated " Psychological Counseling - TEAP "and Professional Ethics. In the case of Examination Techniques, the opinion states that:

It identifies itself with the work of the Psychologist, expressed in the analysis and solution of individual and social problems, while the latter flows from the nature of this work, which has profound ethical implications, for developing in a plan of interpersonal relationships and attaining, not infrequently , the deeper spheres of personality. (OPINION 403/62, 1962, n. p.).

It is evident that the training ends up favoring more the identification of problems than ways to solve it. From the 1970s, Psychology began to suffer criticism, especially in what concerns its performance in the educational area. The criticisms related to the application of tests to the students, highlighting their stigmatizing, ideological aspect and that reduced the school problems in the figure of the student, his family, the socioeconomic conditions. These criticisms came from educators and from psychologists themselves. According to Antunes (2003), the psychologists criticized the medical model of performance, which relapsed into a more individualizing (psychotherapeutic) and less collective intervention.

The 1980s were the culmination of many criticisms of the psychologist, specifically the school psychologist, in which the focus, according to Antunes (1998), was school adjustment. Checchia and Souza (2003) point out the pioneering works of criticism that denounce the practice and the formation of Psychology with avenues to this adjustment and the theoretical-methodological bases that comprise the ahistorical and naturally determined subject. The work of Maria Helena Souza Patto (1984) entitled "Psychology and Ideology: A Critical Introduction to School Psychology", as well as that of Mello (1975) entitled "Psychology and Profession in São Paulo" and the work of the Council (CFP, 1988) and the book "Brazilian Psychologist: Emerging Practices and Challenges for Formation" (CFP, 1994).

In the 1990s, school space began to be occupied by the alleged neurological dysfunctions, to the point that even today most of the medical discourses refer to dyslexia, attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), oppositional defiant disorder (ODD).

Faced with the critical discussions in the field of Psychology and its relationship with education, Souza (2010) states that school failure becomes a new object of study of Psychology. As Souza et al. (2014), there is a predominance of this theme among Brazilian authors who discuss the training and practice of the psychologist in school, since it is the main demand for care among professionals.

In 2004, the Curricular Guidelines of the Psychology courses approved by Opinion 062/2004, in which the Psychology training covers the professional performance, the research and the teaching of Psychology. According to Marinho-Araújo (2007), the Guidelines were a step forward in relation to the Minimum Curriculum, in the sense that it turns to the construction of a professional profile committed to social demands, not just marketing, as well as social recognition of profession as a "... specific professional category, with its own objectives, history and characteristics" (Marinho-Araújo, 2007, p.18).

However, even after this advance and the movement of criticism, it is observed by the researches of Chiodi (2012), Lessa (2010) and Viégas (2016) that the performance of the school psychologist is still configured in a pathological way. For this reason, it is necessary to unveil the ideological discourse of this medicalizing logic that covers the forms of social control. This implies the continuous need to discuss the commitment of the constitution of Psychology in Brazil and the naturalization of the psychological phenomenon.

Conclusion

As we have seen in this brief history about the formation of psychological knowledge in Brazil and the process of legitimizing the medical practice, the partnership between Psychology and medical practice builds an important instrumental knowledge field for social control and human subjectivity.

In the context of the school context, such "scientific knowledge" means that the learning difficulties are medicalized, pathologized and supported by biological and personal explanations about why the student does not learn. This vision consolidated through a professional practice based on quantification and diagnostic activities, with the abusive use of psychometric activity.

At present, there is still a scenario in which psychological phenomena has treated in an abstract and naturalizing way, as they are characteristic of the human species. The relations of the human beings situated in a historical moment, under conditions of specific lives, permeated by means and conditions of production of survival, have not evaluated. It seems the humans displaced from reality and the historical conditions. The medical and psychological practice has disconnected from the political and social reality, directed to the subject or to behavior must conserved or re-established according to the dominant interests. In addition, this ahistorical and naturalized conception of man places the Psychology professional functionally oriented towards adaptation and social control.

This reality is in line with Bock's (1997) warning, when he says that the formation in Psychology is committed to a concept of health that brings in its bosom an adaptive vision in the sense of what man has to have in order to find himself well. This vision addresses human development a priori; ideal medical conceptions of a "healthy" organic state that starts from the unrealistic opinion of what it means to be healthy.

It is not by chance, and increasingly frightening, the number of children currently medicated in and out of the school context. As can be seen from data from ANVISA (Forum on Medicalization of Education and Society, 2015) and the Ministry of Health (2015), Ritalin consumption has increased almost 800% in the last 10 years.

On the other hand, there seems to be a light at the end of the tunnel, since the 1980s we find critical works on the relationship between psychology and school. School failure has become an object of study in psychology, and that is good. Among the Brazilian authors that discuss the formation and the practice of the psychologist in the school, there is the predominance of this theme. With regard to the discussion on medicalization, the debate has expanded significantly since 2010, with the creation of the Forum on Medicalization of Education and Society as the framework, being the first national collective focused on tackling the problem. Because of this collective, we can point out the articulation between researchers, professional councils, public managers and professionals who work in the area of Psychology and Education, who became an important protagonist in this process of formation and critical action.

Given the complexity of the current situation, there is no doubt that psychologists need to engage in the struggle for a Psychology that does not ignore the political and social reality of inequality that contextualizes the subject and considers the development of the socially constituted psyche. Therefore, it is important to defend a formation based on a Critical School Psychology, which shifts the analysis axis from the individual to the school and the set of institutional and historical relations. From this perspective, the psychological aspect has not analyzed in isolation. It is not only a matter of expanding the context of observation, but considering education as a human production built in the relationship with society.

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• 1
  According to Viégas and Freire (2015), the interrelationship of the medicalization process with the concept of pathologic, use psychological resources in excess and criminalization, although they are not synonymous, present in common the fact of individualizing "complex issues, disregarding the multiple factors that constitute them " (p.114).
• 2
  n 1918, psychoanalysis had already discussed and disseminated in the Faculty of Medicine of São Paulo by Franco da Rocha.

Publication Dates

• Publication in this collection
  03 June 2019
• Date of issue
  2019

History

• Received
  13 Oct 2017
• Accepted
  13 Oct 2018