Brazilian social reality and the setback in Mental Health

Dear reader, the Mental Health section of the Revista Latino-americana de Psicopatologia Fundamental - RLPF completes 15 years of existence in 2019. Ana Cristina Figueiredo’s Editorial (2018) will give you a glimpse of its history and tells that this section was created to become a vehicle for articles by professionals of the area at a promising time. Two years earlier, in 2001, Law 10.2016 had been approved, which is also known as the Brazilian Psychiatric Reform Law. Since the 1980s, this social movement (made up of professionals, users of mental health services, managers of the public health system and civil society) had struggled for the creation of a public network of community care services and strategies to promote social inclusion, overcoming stigma and revising the Brazilian mental health care model, which, at that time, was still centered on the large asylums and marked by violence and disrespect of fundamental human rights.

In her Editorial, Figueiredo (2018) highlights the achievements of the Psychiatric Reform in Brazil and states that there are three related trends that lead to a single path to the future: the need to work in teams and in interfaces with other public sectors, networking involving institutions, services and social control devices, including other sectors such as education, work, social assistance, culture, sports, etc., and a new concept of pathos that supports open territorial services centered on the reception, monitoring and social inclusion of users, leaving behind the asylum mentality.

What happened in the field of Mental Health (MH) in the world and in Brazil since the 2018 editorial?

As you might be aware, dear reader, systematic critiques of global mental health movements have increased worldwide since 2012. In that year (Bemme and D’souza, 2012), researchers from several countries met at an event organized by the Transcultural Psychiatry Department of McGill University (Montreal, Canada) to disclose, in an organized way and based on researches, the limits of global approaches that generalize and focus on the biological perspective alone. These researchers denounced the reductionism in the understanding and treatment of mental health problems as uniquely individual, disconnected from social, economic and ethnic contexts, and as being insensitive to the experiential characteristics of people in mental distress. The importance of user movements claiming that mental health care needed to be centered on their values, illness and life experiences, as well as on the perspectives shared by caregivers and users, kept growing and increasingly influenced health systems worldwide. Even in the area of drug research, e.g. the British national study on discontinuation of antipsychotics called RADAR (Research into Antipsychotic Discontinuation and Reduction), coordinated by Joanna Moncrieff (2015), expanded the evidence roster, associating idiographic evidences to the nomothetic ones.

In Brazil, society has witnessed the dismantling of public policies, including some pillars of the MH policy. We still know little about the impact of such changes on national MH care, which will take time to be assessed. However, some points may already be observed and analyzed and we invite you to examine them with us.

Social reality in Brazil shares with most of the remaining world the peculiarity of being hypermodern and dominated by an alliance between science and capitalism, but it still has its particularities. In the hypermodern age, according to Lipovetsky (2004, p. 53), the values of modernity - market, technical efficiency, the individual - are elevated to maximum potency. As a result, “global liberalism”, the “almost universal commodification of lifestyles”, the “exploration of instrumental reason” and the “galloping individualization” are the foundations according to which social ties and consequent forms of political functioning are structured. However, every country creates its own variety based on those foundations. In this social reality, what matters are the principles of democracy, because democracy requires consensual convictions, regardless of the fact that democratic values are subordinated to global market interests. Brazilians know this story.

Acknowledging the existence of an alliance between capitalism and science is to announce that science has been transformed. It is no longer the modern science founded by Descartes and Galileo. Psychoanalyst Jorge Alemán (2009, p. 49) is among those who conceive the radical metamorphosis of science by suggesting that, in a world dominated by capital as the highest value, science has become its “technical specter”. It must be emphasized that technique does not refer to the mere production and reproduction of objects or instruments, but rather to the appropriation of knowledge. By appropriating that knowledge, technique integrates it into a new project that is characterized by an “acephalous and limitless willpower”. Not even “war and its devastation can limit it” (p. 51). Therefore, it introduces the unlimited into the world, which becomes its stage for maneuvers of knowledge and practices. Alemán asserts that it emerged in modern times during the Shoah and its “making of corpses” in a serial and bureaucratically planned way. This was a time when limitless willpower came into the world.

Thus, we may deduce that technique is not the continuity of science, but rather drives it towards the capitalist social bond which, in turn, gets hold of the subject, of truth, knowledge and production, breaking its limits.

We review here the foundations of our social reality, dear reader, because they may not be ignored on the horizon of our ways of life, especially in our theoretical/practical universe. In addition, the recent publication of a document entitled Technical Note n. 11/2019 (Brazil, 2019) has triggered discussions on issues that are crucial for the MH policy, mobilizing both those in favor of the Psychiatric Reform and its critics, those who support the current government policy and their opponents. It was published by the Ministry of Health (Health Care Secretariat, Department of Strategic Programmatic Actions, General Coordination of Mental Health, Alcohol and Other Drugs) on February 4, 2019 to describe the changes in the National Mental Health Policy and the National Drug Policy Guidelines.

That document is the main source for mental health professionals who are looking for arguments to enter the debate. If every piece of writing can be interpreted in various ways, one of the possible readings here is to consider that this document is the result of critiques of the policies of that time, supported by the Psychiatric Reform, and their replacement by a vision that is considered to be “scientific”. In this document, the term “scientific evidence” comes up on several occasions, such as in the guidelines of the Public Health System (Sistema Único de Saúde - SUS), stating that “approaches and proceedings must be based on scientific evidences that is constantly updated” (Brazil, 2019, p. 3). It is also mentioned regarding the expansion of assistance, including proper policy monitoring and follow-up to “establish guidelines and protocols of assistance so that patient care provided by RAPS [Psychosocial Care Network] be based on scientific evidence” (p. 6). It is found in the affirmation of the commitment to the provision of quality treatment, where the “public health system (SUS) should apply the best clinical practices and the soundest and most recent scientific evidence” (p. 6). It is also used in the following statement, which emphasizes that “Preventive actions, Health promotion and Treatment for alcohol and drugs will be based on scientific evidence from now on” (p. 7).

What would be the consequences of sustaining a view of science that neither discusses its underlying values, nor reflects on uncertainty, that refuses to face the challenge of discussing values at stake and to allocate a space for debate? (Greenhalgh, 2014). In 2006, Rose, Thornicroft and Slade published an article entitled Who decides what evidence is? Developing a multiple perspectives paradigm in mental health in the Acta Psychiatrica Scandinavica that helps addressing this issue by highlighting three main points: a) the fields of Evidence-Based Medicine and Evidence-Based Policies do not overlap point by point, although there is an organic connection; b) a new paradigm for the field of MH should be based on acknowledging that there are different stakeholders (users, caregivers, managers, professionals, etc.) and different perspectives at stake in the field of MH; c) the different perspectives of the stakeholders should dialogue and contribute to the development of a new paradigm in the field of MH, supporting the multiple perspectives and evidences that currently exist.

These professionals could then support the group of thinkers that believe that in 2019 the Brazilian MH policy is marked by the forceful rise of a discourse that advocates technique taken as science, thus departing from systematic and historical knowledge and practice that are free from claiming to own the truth, which achieve value because they are developed based on an organized body of knowledge obtained through research and clear methods. And, in line with a current trend in the scientific world, according to which the brain and genes are increasingly being cited in the name of science transformed into technique, the pharmaceutical industry improves in inventing new diseases and offering new drugs as a remedy for all kinds of disorders. Therefore, such professionals will argue that, in this reality, scientific evidence is understood devoid of its complexity and that evidence based on the narrative and the subjective experience of every citizen, in his uniqueness, has no space and is disregarded.

Pedro Gabriel Delgado (2019a), known for his words and deeds in defense of the Psychiatric Reform, denounces the accelerated dismantling of progress made: “The Mental Health Care Reform in Brazil had followed a relatively sound and continuous line of progress since the 1980s. This is the first time in approximately 35 years that we have visibly marched backward.” Among his arguments, the following stand out: the changes in the National Policy of Primary Care that weakened it; the financing of psychiatric hospitals based on an increase in daily rates of over 60 percent; the strengthening of the strategic role of the psychiatric hospital, including the official recommendation that the term “substitute network” no longer be used to name any mental health service; the decrease in registering Psychosocial Care Centers and the funding of more than 12,000 vacancies in so-called “therapeutic communities”, institutions that have been the subject of several studies and newspaper reports, signaling crucial problems in the way they operate. Delgado also focuses on redesigning day-hospitals, which he considers an archaic form of care, as it serves no explicit purpose and reinforces the deterritorialization model, as well as on redesigning specialized outpatient clinics. He also criticizes hospitalization of children and teens, “the disconnection between mental health and the alcohol and other drugs policy, as well as the condemnation of harm reduction strategies” (idem), considered to trigger substance abuse. Moreover, although he does not condemns the use of electroconvulsive therapy as a therapeutic resource for certain severe and resistant cases - which has never been forbidden in specialized public treatment centers, such as university hospitals - he notes that the inclusion of the device in the list of the Equipment and Materials Management and Information System (SIGEM) of the National Health Fund shows, together with other announced changes, that biological methods gain prominence in relation to the psychosocial care model aimed at rehabilitation. The psychosocial care model is weakened in its role as a framework for the use of other methods available in the area, biological methods included (Delgado, 2019a; 2019b).

Arguments similar to Delgado’s are found in Martins (2018) and in Pitta and Guljor (2019), attesting the change of course in the Psychiatric Reform that has taken place since 2017 and was consolidated and specified by the Technical Note.

Thinkers who are familiar with those ideas state that between the lines of this document, a discourse is resumed that tries to prove that it is centered on the scientific method. However, it is understood as detached from any values and leaves no space for either uncertainty or examination and debate on values, neither for the controversy at stake (Greenhalgh, 2014). This caricature reveals the erasure of the singular in favor of the collective, the defense of a science that evades declaring its foundations or values, which pretends not to be part of this world. In the health care area, a kind of science is on the rise that ignores the studies of the last decades that show that nomothetic evidence is insufficient to ensure good health practices and the construction of care that results in health and satisfaction for both users and professionals (Greenhalgh, 2014).

On the other hand, the critics of the Brazilian Psychiatric Reform find in the Technical Note conditions to come up with solutions to issues that are related to the way the Psychosocial Care Network operates. There have been fierce critics at every stage of its existence. Valentim Gentil’s interview, presented by interviewer Monica Teixeira (2005) as a passionate opponent of the Reform and published by RLPF, is paradigmatic in this regard.

Academic studies that were published prior to the changes that started in 2017 and are consolidated by the Technical Note discuss the limits of the Psychiatric Reform and the points that require progress, such as the need to address the issue of the forensic psychiatric hospitals (Diniz, 2013), to deepen the process of expansion and regionalization of the service network and its coverage, which was intensified by the proposal for regionalization of psychosocial care networks (Macedo; Abreu; Fontenele; Dimenstein, 2017) and the need to consolidate a regular evaluation system of the Psychiatric Reform process (Dantas and Oda, 2014), just to name a few.

Currently, one may keep up to date with that topic by following the publications by the Brazilian Association of Psychiatry (ABP), an institution that since the early 2000s has adopted a critical position regarding the Psychiatric Reform.

As you are familiar with the state of the art of the MH policy and the scientific production of that area, we believe that you know, dear reader, that the publication of the Technical Note is the latest news, showing that Law 10.2016 and the course it recommends for the organization of MH assistance in Brazil are being questioned. Thus, there is an opportunity to systematize the debate and to perform detailed analyses and it needs to be taken advantage of. If we believe that politics is what is needed for the preservation humanity’s life, according to Hannah Arendt’s teachings, it becomes clear that we need to keep questioning its meaning, its impact on psychosocial care, on our work and on care.

Therefore, if this section of RLPF was created to publish practical, intellectual and reflective scientific production, to expose clinical and political aspects that make up the area of MH, to disclose the latest issues and new knowledge to drive and support the development of new professionals and researchers, as well as to be a space for the resistance against setbacks, this space remains open, interested reader, and remains committed to follow this path. Thus, we reassert the challenges of that section: to publish studies that allow us to systematically get to know the scope of changes in MH care and in the constitution of its area, as well as to share, among us, the course that the MH area follows internationally, so that we may keep up to date with the global knowledge that sustains the unwavering part of the interface between clinical practice and politics. We aim to publish qualitative and quantitative studies that illuminate unexplored topics and systematic reports of interventions and experiences that make come alive what seems to lose the luster.

RLPF’s Mental Health section counts on the surprise and the value of your contribution.

Referências

• Alemán, J. (2009). Para una izquierda lacaniana Buenos Aires, Argentina: Grama Ediciones.
• Bemme, D., & D’souza, N. (2012). Global mental health and its discontents. Somatosphere Recuperado em 10 jun. 2019, de: <http://somatosphere.net/2012/07/global-mental-health-and-itsdiscontents.html>.
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• Brasil. Ministério da Saúde (2019). Nota Técnica 11/2019. Esclarecimentos sobre as mudanças na Política Nacional de Saúde e nas Diretrizes na Política Nacional sobre drogas Coordenação Nacional de Saúde Mental, Álcool e Outras Drogas. Recuperado em 10 jun. 2019, de: <http://pbpd.org.br/ministerio-da-saude-divulga-nota-tecnica-com-alteracoes-nas-politicas-nacionais-de-saude-mental-e-de-drogas/>.
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• Dantas, C. D. R., & Oda, A. M. G. R. (2014). Cartografia das pesquisas avaliativas de serviços de saúde mental no Brasil (2004-2013). Physis: Revista de Saúde Coletiva,24(4), 1127-1179. <https://dx.doi.org/10.1590/S0103-73312014000400008>.
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• Diniz, D. (2013). A custódia e o tratamento psiquiátrico no Brasil: censo 2011 Brasília, DF: Letras Livres, Editora da UnB.
• Figueiredo, A. C. (2018). A Saúde Mental em revista: o percurso de uma década na RLPF. Revista Latinoamericana de Psicopatologia Fundamental, 21(1), 11-15. <https://dx.doi.org/10.1590/1415-4714.2018v21n1p11.1>
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• Greenhalgh, T., Howick, J., & Maskrey, N. (2014). Evidence based medicine: a movement in crisis? BMJ, 348, g3725. <https://doi.org/10.1136/bmj.g3725>.
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• Lipovetsky, G. (2004). Os tempos hipermodernos São Paulo, SP: Barcarolla.
• Macedo, J. P., Abreu, M. M. D., Fontenele, M. G., & Dimenstein, M. (2017). A regionalização da saúde mental e os novos desafios da Reforma Psiquiátrica brasileira. Saúde e Sociedade,26(1), 155-170. <http://dx.doi.org/10.1590/s0104-12902017165827>.
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• Martins, L. M. (2018). Às imagens, as sombras do porvir: 30 anos da Reforma Psiquiátrica brasileira. Revista Diorito, 2(1), 88-121. <http://dx.doi.org/10.26702/rd.v2i1.44>.
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• Moncrieff, J. (2015). Antipsychotic maintenance treatment: time to rethink? PLoS medicine, 12(8), e1001861. <https://doi.org/10.1371/journal.pmed.1001861>.
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• Pitta, A. M. F., & Guljor, A. P. (2019). A violência da contrarreforma psiquiátrica no Brasil: um ataque à democracia em tempos de luta pelos direitos humanos e justiça social.Cadernos do CEAS: Revista crítica de humanidades, (246), 6-14. <http://dx.doi.org/10.25247/2447-861X.2019.n246.p6-14>.
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• Rose, D., Thornicroft, G., & Slade, M. (2006). Who decides what evidence is? Developing a multiple perspectives paradigm in mental health. Acta Psychiatrica Scandinavica, 429, 109-114. <https://doi.org/10.1111/j.1600-0447.2005.00727.x>.
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• Teixeira, M. (2005). A crítica à Reforma Psiquiátrica, da sua implantação e de seus fundamentos: os argumentos de Valentim Gentil. Revista Latinoamericana de Psicopatologia Fundamental, 8(2), 322-345. <http://dx.doi.org/10.1590/1415-47142005002009>.
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Editoras/Editors: Profa. Dra. Ana Maria Galdini R. Oda e Profa. Dra. Sonia Leite

Publication Dates

• Publication in this collection
  24 Oct 2019
• Date of issue
  Jul-Sep 2019

History

• Received
  01 Aug 2019
• Accepted
  12 Aug 2019