Silenced stories: contributions of nurses to the Psychiatric Reform in Rio Grande do SulABSTRACT
Objective: To highlight the work of the nurses who worked at the São Pedro Psychiatric Hospital between 1960 and 1992.
Method: Qualitative study with genealogical inspiration and based on a post-structuralist framework. The data collection took place at the Cultural Memory Service of the São Pedro Psychiatric Hospital, a location dedicated to preserving materials about the institution's history and included interviews with seven nurses and one male nurse who worked at the institution. Concepts from Michel Foucault were used in the analysis.
Results: The São Pedro Psychiatric Hospital was a space of exclusion, where patients were dehumanized and neglected. With the inclusion of nurses, a process of transformation began, and the actions of these professionals were fundamental in driving the Psychiatric Reform, making Rio Grande do Sul a national reference in mental health.
Final Considerations: This is a silenced history that, when narrated, becomes an act of resistance and a means of valuing the history of nursing.
Descriptors:
Nursing History; Psychiatric Nursing; Psychiatric Reform
RESUMO
Objetivo: Ressaltar a atuação das enfermeiras que trabalharam no Hospital Psiquiátrico São Pedro, entre os anos 1960 e 1992.
Método: Estudo qualitativo, de inspiração genealógica, baseado no referencial pós-estruturalista. Os dados foram produzidos por meio de análise documental e entrevistas com base na história oral no período de 2021 a 2023. A coleta ocorreu no Serviço de Memória Cultural do Hospital Psiquiátrico São Pedro, local destinado a guarda de materiais sobre a memória da instituição e entrevistas com sete enfermeiras e um enfermeiro que atuaram na instituição. Foram utilizados conceitos de Michel Foucault na análise.
Resultados: O Hospital Psiquiátrico São Pedro era um espaço de exclusão, onde os internos eram desumanizados e negligenciados. Com a inserção das enfermeiras, iniciou-se um processo de transformação e as ações dessas enfermeiras foram fundamentais para impulsionar a Reforma Psiquiátrica, tornando o Rio Grande do Sul uma referência nacional em saúde mental.
Considerações Finais: Essa é uma história silenciada, que ao ser narrada se torna um ato de resistência e valorização da história da enfermagem.
Descritores:
História da Enfermagem; Enfermagem Psiquiátrica; Reforma Psiquiátrica
RESUMEN
Objetivo: Resaltar la actuación de las enfermeras que trabajaron en el Hospital Psiquiátrico São Pedro entre los años 1960 y 1992.
Método: Estudio cualitativo, de inspiración genealógica, basado en el referencial posestructuralista. Los datos fueron producidos mediante análisis documental y entrevistas basadas en la historia oral en el período de 2021 a 2023. La recopilación de datos se llevó a cabo en el Servicio de Memoria Cultural del Hospital Psiquiátrico de São Pedro, un espacio dedicado a la preservación de materiales sobre la historia de la institución, e incluyó entrevistas con siete enfermeras y un enfermero que trabajaban en la institución. Se utilizaron conceptos de Michel Foucault en el análisis.
Resultados: El Hospital Psiquiátrico São Pedro era un espacio de exclusión, donde los internos eran deshumanizados y desatendidos. Con la inserción de las enfermeras se inició un proceso de transformación, y las acciones de estas enfermeras fueron fundamentales para impulsar la Reforma Psiquiátrica, convirtiendo a Rio Grande do Sul en una referencia nacional en salud mental.
Consideraciones Finales: Esta es una historia silenciada que, al ser narrada, se convierte en un acto de resistencia y de valorización de la historia de la enfermería.
Descritores:
Historia de la Enfermería; Enfermería Psiquiátrica; Reforma Psiquiátrica
INTRODUCTION
In the 1960s, psychiatric hospitals were overcrowded, understaffed, and subject to allegations of mistreatment. Criticism of this care model spurred various studies and proposals for change regarding treatment outcomes for patients in long-term, full-time care. One of the main approaches that contributed to modifying the confinement system was Democratic Psychiatry, proposed by psychiatrist Franco Basaglia, which promoted an important reform in the Italian mental health system. This perspective sought to structure a model that aimed to break with and deconstruct the traditional psychiatric apparatus, based on citizenship rights as the central axis for psychiatric treatment1,2.
In Brazil, changes in psychiatric treatment began in the 1970s, in parallel with the health movement, which spurred the transformation of healthcare paradigms in search of a model centered on community health, equitable in services, and promoting the protagonism of both workers and users. In this context, inspired by the Italian Psychiatric Reform, the union between workers from Brazilian psychiatric institutions, family members, and some patients promoted different outcomes for mental health care in the country, inciting the movement known as the Anti-Asylum Struggle, which gained prominence in the second half of the 1980s. This mobilization allowed discussions about the rights of people hospitalized in psychiatric hospitals, stimulating the construction of a national policy on deinstitutionalization in Brazilian asylums3-5. Nise da Silveira and Paulo Amarante are considered precursors of the Brazilian Psychiatric Reform.
Rio Grande do Sul had the first psychiatric reform legislation in force in Brazil, State Law No. 9,716 of August 7, 1992, which provides for psychiatric reform in the state. The law proposed by Paulo Delgado prohibited the expansion of beds in psychiatric hospitals, public or private, and the contracting and financing of new beds by the public sector. The implementation of this regional legislation was a process marked by the action of different segments involved in mental health care, and it is important to highlight that the reformist initiatives arose mainly within the psychiatric hospitals themselves, at a time when the inpatient model was the only available form of psychiatric treatment6,7.
In the first mental asylum in Rio Grande do Sul (RS), the São Pedro Asylum, now the São Pedro Psychiatric Hospital, as well as in other similar establishments in the country, patient care was provided by nuns and lay people. Following Decree No. 20,109 of June 15, 1931, which established criteria for nursing training and regulated the use of the title of nurse as a certified professional, there was a gradual replacement of nuns and lay people with qualified nurses, trained in institutions regulated by national legislation. These certified nurses were essential in promoting changes in mental health care in the country, as Rio Grande do Sul is recognized for pioneering actions that propelled the Brazilian Psychiatric Reform.
This study originates from the thesis entitled "Memory of the Psychiatric Hospital: a history of nursing care practices." The history of psychiatric hospitals has been marked by exclusion and segregation, with little recognition given to the role of nursing in transforming this scenario. In this study, we attempt to give visibility to their work at the São Pedro Psychiatric Hospital, valuing those who resisted so that the lives trivialized in the asylum would not be forgotten nor their protagonists made invisible. Thus, the study proves relevant to understanding the contributions of nurses in the construction of deinstitutionalization policies and in the current conformation of the Psychosocial Care Network. Therefore, the objective is to highlight the work of the nurses who worked at the São Pedro Psychiatric Hospital between 1960 and 1992.
METHOD
This is a qualitative study, anchored in the post-structuralist framework and inspired by Michel Foucault's genealogy. In this field, the method is neither fixed nor predefined; it is (re)constructed according to the context, guiding specific ways of questioning and problematizing that distance themselves from universal essences and truths. Post-structuralist studies resignify existing ethical, investigative, and analytical procedures, giving them new configurations and questioning traditional methods associated with positivism. From this perspective, it is less important to explain what or why something occurs and more important to understand how phenomena are constructed and constituted8-10.
Genealogy is a special kind of history that opposes the starting point and attempts to describe a genesis in time. It is a form of historical analysis that does not seek origins, universal truths, or unified scientific discourses. Instead, it investigates the constitution of knowledge, discourses, and objects from local, discontinuous, and non-legitimized knowledge. It proposes to listen to history in its materiality, demonstrating that, behind things, there is no hidden and timeless essence, but historical constructions11,12.
To compose the genealogy, we proposed two data production methods: one documentary and the other composed of interviews supported by oral history. The documents were located in the Cultural Memory Service of the São Pedro Psychiatric Hospital, a place dedicated to preserving and recounting the history of this institution. The location houses a technical reserve of materials and documents, historical equipment, medical records, photographs, architectural plans, paintings (old and recent), books, ornaments, furniture, and utensils. The São Pedro Psychiatric Hospital is an institution located in the city of Porto Alegre, Rio Grande do Sul, founded in 1884 under the name Hospício São Pedro. In 1925 it was renamed Hospital São Pedro. Subsequently, in 1962, it became known as Hospital Psiquiátrico São Pedro.
Documents relating to the history of nursing at the institution between 1960 and 1992 were analyzed. The time frame was established in accordance with the period when the activities of the graduated nurses began, starting in the 1960s. The end of the time frame was determined by the beginning of the psychiatric reform in Rio Grande do Sul in 1992. As an exclusion criterion, documents that were illegible due to age, being torn, or having illegible writing were discarded. Regarding the 1960s and 1970s, there were few documents available; only one book for each of the following years (1967, 1973, 1976, and 1977), which were included in the analysis. From the 1980s onwards, the number of report books exceeded 100 volumes, gradually increasing until 1992. For the analysis of this material, a random selection criterion was adopted: three report books were chosen per year, one from a female unit, another from a male unit, and one from a mixed unit. The selection and reading process extended over almost two years, given the lack of cataloging and the dispersion of the documents, in addition to the difficulties imposed by the spelling of the time and the illegible handwriting of many records.
Associated with the documentary collection, oral history interviews were conducted with seven nurses and one male nurse who worked at the institution during the analysis period. Oral history contributes significantly to the recovery of memory, by recording accounts based on lived or witnessed experiences, valuing memory as the main source of narratives of ordinary people13.
The search for oral sources was carried out using the snowball sampling technique. This approach involves the intentional selection of the first participant and the inclusion of new interviewees suggested by him, from his personal network and so on14. However, as some interviewees did not have active contacts, other approaches such as searches on social networks based on names mentioned in the documentary records held in the memorial were necessary.
The interviews were conducted individually, either in person or remotely, according to the participant's availability, between March 2020 and September 2023. With the use of the Google Meet® platform, video calls were recorded. In-person interviews took place at a location selected by the participant and were audio-recorded for later transcription. The duration of the oral narratives varied from 30 minutes to 2 hours, and each participant recounted their story according to the time needed to speak, guided by the guiding question: "What would you like to tell about your experiences at the São Pedro Psychiatric Hospital?". Finally, the interviews were terminated based on saturation criteria, that is, when the information provided becomes repetitive15.
The video or audio recordings were sent to the participants for content validation and review of their statements. Three respondents requested adjustments, which were duly incorporated into the transcripts. Since the participants shared their life stories, it was deemed relevant to publicize their full names, which was consented to by all. Such decision is in line with current regulations for oral history and memory studies.
To ensure the quality and guide the development of the research, the recommendations of the Consolidated Criteria for Reporting Qualitative Research (COREQ) were followed. The research was approved by the Research Ethics Committee of Universidade Federal do Rio Grande do Sul, CAAE No. 467133218.0000.5347, under protocol No. 4.848.976, and the Research Ethics Committee of the São Pedro Psychiatric Hospital, CAAE No. 46713321.8.3001.5332, protocol No. 4.868.168. Resolutions No. 466 of 2012 and No. 516 of 2016 of the National Health Council were observed. The guidelines of Circular Letter No. 1 of 2021 from the National Research Ethics Commission, which addresses the rights, protection, and safety of research participants in virtual environments, were also followed. All participants signed the Informed Consent Form (ICF) either electronically or physically.
To analyze the collected data, the following tools and concepts from Michel Foucault were used: discourse, power, discipline, biopower, and biopolitics. The author uses the metaphor of the toolbox, highlighting that his writings can be used as tools to produce short circuits, and for him, people can use phrases, ideas, and analyses like a screwdriver or wrench. He considers discourse as practices that systematically form the objects they speak of. Words and things are related in a complex way, and this relationship is historical, full of constructions and interpretations, and permeated by power relations12,16. Based on these concepts, the data were organized into analytical axes related to disciplinary practices, surveillance strategies, and forms of resistance.
RESULTS AND DISCUSSION
Considering the historical context of the movements that drove changes in mental health care in the country and Rio Grande do Sul, the modifications at Hospital São Pedro occurred in accordance with this context. This fact was validated both by documented records and by the narratives of those interviewed. Since 1950, the lack of material and human resources, as well as overcrowding, was a situation questioned by the nuns of the São José Congregation, who did not have formal education in the field of nursing. The arrival of nurses at this institution provided significant changes in patient care, resulting in more humanized and dignified care, intensifying criticism and questioning of the therapies then used at the institution.
The documents analyzed did not provide more specific information about the first nurse to work at the institution. They only described that, between 1957 and 1960, 168 nursing professionals worked at the hospital, including nurses, nursing assistants and attendants, and some nuns, to care for more than 5,000 people housed there17. Therefore, the question remains as to who was the first certified nurse to work at Hospital São Pedro?
The second nurse to join the institution was Marilu Martins de Lima Cecchini, in 1966, and her accounts refer to the various situations she experienced during the years she worked at Hospital São Pedro. Marilu was the only nurse to share the care space with the nuns and points out how impactful this period was. The sisters, in addition to being examples of holiness, were responsible for a series of services, including cardiazol shock, insulin therapy administration, electroshock and other specialized procedures17. Marilu's account corroborates this information.
The nuns, along with staff trained by them, administered the dreaded electroshock therapy without anesthesia or medical supervision. They decided who should or should not undergo the therapy. They would say, "This one here; this one too; not this one; this one is aggressive, she needs it." The nuns were in charge, and the doctors only prescribed what they determined (Marilu - Interview).
The nuns had absolute control in the institution, but opinion about them was not unanimous, as some people saw them as extremely authoritarian18. An example of this is that the nuns altered medication dosages without consulting doctors and could decide when and on whom to administer electroconvulsive therapy. This power was not exclusive to nuns with nursing training, but also extended to some who only had practical experience in interacting with patients. They selected their own assistants, sometimes even choosing trusted patients. The nuns' actions were based on rigorous discipline to maintain order, and the fact that they used the most stable patients to supervise other patients in the ward illustrates how effective the fragmentation of power was. Expanding their influence within the hospital, these individuals acted as security guards, coordinating other observers and thus forming an extensive information network. The patient-assistant was selected by the nuns from among those with better mental conditions, stronger and with a better profile for authority. These individuals maintained order within the wards with such a high level of respect that physical intervention was unnecessary.
In his work Discipline and Punish, philosopher Michel Foucault describes that what is more important than observation is the awareness of being under surveillance. This model, which replaces physical punishments and penalties, aims to shape behavior through a relationship of power and knowledge over the body, established through practices of control, norms, and discipline19. Therefore, when we consider the exercise of surveillance as a tool for controlling the conduct of inmates, we see that these practices influenced the behavior of patients and maintained organization. The nuns, by defining the desired behavioral standards, imposed on the patients in surveillance tasks the authority to maintain such standards, saving them effort.
Another interviewee, Terezinha Ritter, joined the hospital in 1972 as a nursing intern and in 1974 began working as a hired nurse under the Consolidation of Labor Laws (CLT). Marilu and Terezinha witnessed treatments offered to patients in the early 1970s and apparently these practices did not align with the teachings they had learned in their training, pointing out risks and side effects of the therapies prescribed to psychiatric patients at that time. Both mentioned, as an example, insulin therapy, describing it as a risky technique, a fact that worried them, given their nursing knowledge.
Before the infirmaries arrived at São Pedro Hospital, it was the nuns who administered the glucose injections to the patients. The injection was meant to induce an insulin coma, and after administering the insulin, glucose had to be given intravenously to bring them out of that coma. It was like an electric shock. Afterwards, they would wake up saying: Where am I? What am I doing here? Usually the patients recovered, regained consciousness. But the problem was that sometimes we couldn't find a vein. The patients kept slipping into an insulin coma. It was terrifying (Marilu - Interview).
When I did my psychiatry internship in 1972, they were still using insulin therapy at São Pedro Hospital. I was horrified because the patient received insulin to induce seizures and coma. Then, they received a high dose of glucose to bring them out of the coma. This caused desperate hunger in the patients, so all those undergoing insulin therapy gained a tremendous amount of weight, becoming obese due to the increased appetite (Terezinha - Interview).
When faced with such situations, they sought to follow what they had learned in their training, often refusing to participate in certain procedures with which they disagreed. With the arrival of the nurses, the nuns were gradually replaced and sent to administrative sectors. This transition in care seems to have occurred peacefully, since none of the interviewees mentioned conflicts or disputes over spaces with the nuns.
Nurse Maria Francisca Schiaffino joined the institution in 1976 and recounted in detail the moment she witnessed the application of electroconvulsive therapy (ECT) to hospitalized patients, conducted by psychiatrists. It is important to mention that all interviewees denied participating in or administering shock therapy during their experiences at Hospital São Pedro, attributing this practice to nuns and psychiatrists. However, a record observed in the minutes book of meetings at the Morel Unit, dated 1972, indicates that, in a patient assembly, there were complaints about the use of shock therapy by nursing staff. It seems that the application of ECT may also have been carried out by nursing staff as a means of monitoring conducts.
I witnessed an electroconvulsive therapy session when I was already working at São Pedro Hospital. It was horrible. I went there to watch because I couldn't believe they did that. There was no anesthesia or oxygen. It was in a large room full of beds, one next to the other. The patient would lie on a bed, the doctor would arrive, take a roll of gauze, put it in their mouth, take the device, turn it on, and apply it to the patient. Then, the consequence was a seizure. The patient in the next bed would see everything. Imagine, the patient next to them would be terrified, everyone watching, and each one would tell a story more horrible than the other. It was terrifying for us and for the patients (Maria Francisca - Interview).
At the general assembly, there was dissatisfaction on the part of the patients regarding the treatment they receive from the attendants. There are reports of mistreatment by the attendants and complaints that the nurses on nights I and II were administering electric shocks, claiming that the practice was in accordance with the doctors' instructions (Minutes Book of meetings of the Morel Unit, July 6, 1972).
Interviewees Regina Castro Mendel, Altamir Felix, and Mitiyo Shoji Araújo began their activities in the 1970s, and Vera Lúcia Silva Antunes after 1980. Both highlighted in their narratives discomfort related to the number of inmates and the poor hygiene conditions in which they lived. Their accounts draw attention to the practices prevalent at that time, mentioning that the inmates did not bathe, lived covered in feces, and were washed with hoses and brooms.
When I started working, upon entering the courtyard, I could smell a strong odor. Patients were cleaned with a broom and hose, regardless of whether it was winter or summer. In the unit I was assigned to, there were no showers or toilets. Baths were given every 15 days, and patients were washed with creolin, as many had dried feces on their bodies. I thought that that was unacceptable and that I couldn't allow this sort of hygiene to be maintained in that way. During my first ten days on the job, I cried and wondered how I could apply what I learned in college in such a horrible environment. It was then that I established a partnership with a group of volunteers from the Society for the Support of the Mentally Ill and asked for help. They collaborated by installing electric showers and toilets. Later, they began visiting patients every Wednesday and providing assistance as needed, donating hygiene products and clothing (Regina - Interview).
The conditions of the place and the patients were terrible, and rats roamed freely through the units. Baths were only given when they had clothes on; there were no showers, and they were done with hoses. It was impossible to continue like that. So I took action, repaired the unusable bathrooms, got electric showers, obtained donations of clothes, and established a routine of more frequent bathing with hot water. Over time, the patients themselves started asking to take baths. Today, it gratifies me to know that I was able to contribute in some way to try to change the situation in which the patients lived (Altamir - Interview).
In 1976, I did an internship at São Pedro Hospital while specializing in psychiatry, and at that time, most of the patients were residents. I swore I would never work in that place because of the environment and the way they treated people, which reminded me of the Holocaust. In winter, there was a line of naked patients waiting to shower, all barefoot. The shower wasn't hot, there were no towels for patients to dry themselves, and dirty sheets taken from the beds when they were changed were used. Furthermore, there weren't enough warm clothes for everyone, let alone shoes. But the need for work and employment led me to accept the position. I thought that being there I could do my best to try to improve the situation. And so, over time, I made changes and ended up staying there for 16 years (Mitiyo - Interview).
I arrived here at São Pedro through a college internship and was assigned to the adult unit. I looked down and saw a courtyard full of patients, which terrified me. I remember a patient asking me for a glass of water and then throwing all the water in my face, accompanied by several swear words. That day, I was deeply shocked and ended up going to the corner of a room to cry. The reasons were many; I was scared, terrified by the number of patients, and incredulous about the place. At the end of the day, I thought I would never return. But here I am, to this day. I did and continue to do my part to improve their lives (Vera - Interview).
The accounts above highlight the inhumane conditions to which hospitalized patients were subjected. They were treated as disposable objects, according to the hygienist culture of the time, which aimed to clean, sterilize, and discard the undesirable, those considered abominable to life in society. Sweeping and washing with a hose, the lack of hygiene materials and clothing demonstrate the neglect with which human beings under the care of state-hired workers were treated. They, both men and women, who were mentally ill, were perceived as something that could be thrown away, the social outcasts. Therefore, those institutionalized were given the worst treatment, associated with a non-human condition and their bodies stripped bare like garbage. These were the undesirables, kept away from society, surrounded by walls that prevented their movement, through eugenic ideas that gained prominence in Brazil during this period, being responsible for various measures of prevention and social hygiene20.
The patients had no belongings. The only thing they possessed was their own bed and, at most, a small bag with a few things. They carried with them everything that was important. Most had no teeth, and with the help of volunteers we acquired dentures for those who needed them, but this was done little by little. One day, a certain patient kept his dentures under his pillow when he went to sleep, as he had nowhere else to leave his things. The next morning, the dentures had disappeared, and everyone was asking where they were. It turned out that another patient also wanted dentures and ended up taking them. That's how it was; they had almost nothing and ended up taking each other's things (Regina - Interview).
When you live in a place and find yourself under guardianship, you don't even have the right to privacy. There was a mute patient who walked around the courtyard with a lot of clothes inside her bra and under her clothes. She was very friendly, but she didn't speak. Her name on the medical record was Muda Maria (Mute Maria), because nobody knew her real name. She received many things from interns and put them in a small plastic bag under her mattress. The bed looked like a mountain. One day, they decided to clean out her things and burned everything. When she arrived at the unit, she had a breakdown because all her belongings had been thrown away. This is violence, a power exercised over the patient, ignoring everything. There is no right for a person, not even the right to privacy. Imagine, not having the right to personal belongings. What was their life like? So, she carried everything on her body. To me, it was extreme cruelty (Mitiyo - Interview).
The primary function of the asylum system is to impose and intensify reality, adding to it an element of power that enables action on madness in order to reduce, direct, and control it. The asylum and its dynamics act to establish control over the condition of madness. These spaces reinforce their power through devices of control and deprivation of identity. In them, items such as clothes, combs, towels, soap, razors, and other accessories can be removed or denied21,22.
In this approach, it becomes clear that the authority exercised by the psychiatric institution shapes and produces the mentally ill person as an object of intervention. The accounts of the interviewees and records reinforce that those institutionalized at São Pedro Hospital were treated as "non-humans" whose identities were stripped away and whose histories were erased.
When I started working as a nurse, I realized there were no mirrors in the units. One day, I decided to bring a mirror from home for the patients to use. There was a patient who had been at São Pedro for many years. I put her in front of the mirror and after years, she saw herself for the first time. That's when she told me: "That's not me, I'm 15 years old." That was heartbreaking (Francisca - Interview).
I remember receiving a beautiful oval-shaped mirror from the Society for the Support of the Mentally Ill, and we placed it next to the door of the nursing unit. A patient stopped, looked at himself, and said: "Nurse, how old I look! It's been years since I've seen myself in a mirror!" (Regina - Interview).
In this sense, the stories recalled and reported here refer us to a politics of death. Such death camps have been interpreted as the central metaphor for sovereign and destructive violence and as the ultimate sign of absolute power. In this case, not only letting die, but making die, which is part of the sovereign power that managed the lives of people. From this perspective, the asylum assumes the management of those who do not matter, those considered useless to society and who can be discarded. These people were the target of many interventions and the control techniques based on biopower could be applied to them. The main forms of exercising power in societies are discipline and biopolitics19. Discipline and biopolitics, when considered together, represent biopower, which focuses on biological life. Biopower works to the extent that it interferes in the control of men's lives, investing in those who are considered healthy and productive, discarding those who are not of interest23.
The thinker Achille Mbembe argues that biopolitics is insufficient to describe the living conditions that the State offers to the excluded, conferring upon them the status of the living dead. The author proposes that we reflect on a new concept, necropolitics, which is linked to those who hold power and can decide who can live, who can be killed, and who can be left to die. This notion stands out because of the way in which groups of people are exposed to life and death situations in different ways. Thus, the ultimate expression of sovereignty resides, to a large extent, in the power and capacity to dictate who can live and who must die. Therefore, killing or letting live constitute the limits of sovereignty, its fundamental attributes. To be sovereign is to exercise control over mortality and to define life as the implantation and manifestation of power. What is reported here summarizes what Michel Foucault understands by biopower: that domain of life over which power has established control, revealing the practical conditions in which the power to kill, let live, or expose to death has been exercised24.
In the process of humanizing care, after the 1970s there was a gradual movement aimed at reorganizing patient care, allowing them to experience life outside the walls of the institution. However, the return to social interaction required productive individuals capable of following social norms and rules. To this end, it was necessary to educate and discipline patients for simple activities, such as personal grooming and hygiene, or mastering a trade or skill that could be acquired. The documents analyzed showed discussions about work therapy, whether mandatory for the more lucid patients or when they wished to receive some remuneration for the activity performed. However, if the task was considered part of the treatment, there was no benefit or payment; it could only contribute to earlier hospital discharge, since by accepting the established rules, the patient would be fit for social interaction. However, those who did not adapt to work could have their hospital stay prolonged.
It was noted that the behavior of lucid patients is becoming increasingly demanding regarding medication and diet, and that they do not want to do any work. The staff believes that patients should not be paid, since work is part of the treatment and a form of rehabilitation (Minutes of Meetings of the Morel Unit, November 31, 1970).
Patient F. attempted to flee the unit, but was brought back by the receptionist. I told her that she shouldn't act that way and should calmly await her discharge, when she can leave peacefully. The patient said she was tired of washing greasy pots and pans (São José Unit Report Book, May 10, 1973).
As an alternative treatment, occupying idle time with work therapy was considered a replacement for the adopted procedures. However, it is recognized that work therapy applied in psychiatric hospitals had objectives beyond therapy, being clearly considered an alternative to the insufficient staff due to overcrowding and cost reduction for inpatients. In the excerpts above, there are indications of forced or compulsory labor for patients, again showing incompatibilities with the principles and guarantees of the rights of people hospitalized in psychiatric hospitals.
Considering the outcome of granting freedom to those institutionalized in psychiatric hospitals, in addition to preparing the patients through work, there was a need to test their behaviors beyond the walls of the institution. To this end, attempts were made to reintegrate those considered adapted into their families, even if for short periods, which the nurses called "outings." However, these cases depended on the willingness of the family or their guardians to receive them, as well as their assumption of responsibility for their actions during these days of social interaction. Nevertheless, many were unable to return to their homes, even when discharged from the hospital.
At 12:20 AM, the father of patient A. brought his son, who had been on an outing. He reported that the patient had been agitated all afternoon and that he had given him his medication at 9 PM, along with the medication that was supposed to be given at 7 AM. He stated that it had no effect. When speaking with the patient, he informed them that he had drunk wine and beer (Morel Unit Report Book, March 5, 1977).
Patient A. was taken back to her workplace, and upon receiving her, her employer called her crazy and depraved. She said she had already spoken several times with the doctor and that he was aware of her situation, and that she was unwilling to take responsibility. She stated that, if necessary, she would go to the governor, as she had no obligation to care for her at home. Then, the employee who brought the patient said she would have to speak with her doctor again. The employer retorted, saying she had already spoken more than fifty times and that the doctor was crazier than the crazy people themselves. Then, she slammed the door in the face of the employee who brought A. back to the hospital (São José Unit Report Book, July 10, 1973).
The difficulty in readapting psychiatric patients into society can be understood as a legacy of the isolation model from the outside world proposed at the beginning of the 19th century, imperative for treatment to occur properly, removing all interferences that could hinder accurate observation and a correct diagnosis25. From this perspective, the logic of returning to collective living could be considered dubious for both the family and the social environment, since separation from society was until then seen as a therapeutic approach.
In the excerpts above, it is clear that, although for a short period, some family members were willing to assume responsibility for the institutionalized patient through hospital outings aimed at reintegration into society. However, those responsible had to ensure control of the patients in situations of disorganization, and in this case, medication was an alternative for crises.
Maintaining the goal of resuming the socialization of institutionalized patients, it was also necessary to observe their behaviors and social interaction. Thus, if the patient was unable to return to family life due to abandonment, it was the nursing staff's responsibility to resocialize them outside the walls of the psychiatric hospital.
I took five patients for a walk. We went to St. George's Church and the supermarket. I took a route and showed them how to shop. The supermarket employee was amazed by the patients, who were very interested. They really enjoyed the walk and were amazed by all the cans of jams they had there. I took them to the fruit stand and we bought oranges for the others. On the way, they only talked about the supermarket, how big it was and how many good things it had, how beautiful everything was and how many people were shopping (São José Unit Report Book, July 17, 1973).
We took seven patients for a walk around the hospital. Patient E. behaved very badly and spent the entire time provoking the others. Upon returning, the provoked patients threw stones at E., who retaliated by hitting them with her flip-flops (Mario Martins Female Unit Report Book, April 1, 1981).
When G. participated in the outing outside the hospital, she tried to board a bus to escape, but was verbally restrained and closely monitored until her return to the hospital. The other patients who were out for the outing behaved very well, without incident (Mario Martins Female Unit Report Book, April 1, 1981).
Following outings aimed at exploring social life in the institution's surroundings, patients were allowed to experiment with different behaviors in more distant locations. This preparation and adaptation to different lifestyles enabled patients to recall their old habits before institutionalization, or even to try new experiences. In these cases, the nurses attempted to broaden the patients' socialization, breaking down the barriers of the treatment model based on isolation (Figures 32 and 33).
One day, I encouraged the team to take forty-five patients on a trip to the zoo. Despite some reluctance, they eventually agreed. I secured support from a company that provided a bus for transportation, and we brought meat for a barbecue. We had patients who had been hospitalized for many years, and it was a surprise for the team to discover that some still remembered how to grill. I let them be responsible for lunch and prepare everything. I took all my patients, and none stayed in the unit. Everything went well, and we had no problems. That's how we started some activities that deviated from the norm. We had to persevere because the management often didn't want it. Later, other units started following our example, which we consider a very important step (Altamir - Interview).
We always took the patients out for some kind of activity, and they loved getting out of São Pedro. One day we went to a restaurant. However, at the hospital they only had spoons to eat with, and the question was: how would they behave? When we looked, they were using forks and knives on their own. Then we realized that the memories of a life they had before being hospitalized were still there, carefully stored in their minds. It was all a matter of encouraging them to remember and relive those things (Dóris - Interview).
Once, the patients who had money asked me to take them to the opening of the Carrefour supermarket. They wanted to go there to do some shopping. So, two attendants went with me. Another time, these same patients asked to go to a steakhouse. Well, to begin with, they didn't use knives or forks in the unit, only spoons. I wondered how these patients would behave in a steakhouse if they didn't know how to use a fork and knife. Well, we found a steakhouse with enough space for the patients and for us to have lunch. To the team's surprise: all the patients knew how to use a fork and knife. So, that's when I discovered that we knew nothing and that we still had a lot to learn. Well, I learned incredible things from the patients (Altamir - Interview).
Analysis of documents and interviews revealed that between the 1980s and 1990s, attempts to resocialize patients intensified at the institution. Dóris Fonseca Engel was the only interviewee who joined the institution after the 1990s and witnessed the trajectory of the Anti-Asylum Movement towards Psychiatric Reform in the country and in Rio Grande do Sul. It seems that the reformist movements originated at Hospital São Pedro, stemming from the questioning and confrontations of the nurses. It was observed that the role of nursing expanded within the institution beyond maintaining order in the units and controlling the patients' bodies. Considering life outside the institution, the nurses assumed the role of resocializing the institutionalized patients, allowing them to increasingly approach a life away from the institution.
Some interviewees went beyond what they could do for the patients under their care and worked to improve the living conditions of those in asylums, as well as to promote the value of nursing work. Terezinha Ritter and Mitiyo Shoji Araújo played important roles in the Anti-Asylum Movement.
The Psychiatric Reform took place in the late 1980s and early 1990s. That was when I left São Pedro Hospital and went to the School of Public Health. At that time, the entire reform movement was already underway. Later, I went to the state's Mental Health division and traveled throughout Rio Grande do Sul preparing for the Psychiatric Reform. Afterwards, we held the first Mental Health Conference in Tramandaí. I remember that on the last day of the Tramandaí Mental Health Conference, we spent the night drafting the final document. I didn't sleep that night, and the next day we went to the assembly. I coordinated the general assembly for approval, and afterwards, we went to Brasília to participate in the National Mental Health Conference. So, I actively participated in the entire Psychiatric Reform in Rio Grande do Sul and in Brazil. At São Pedro, the reorganizations began according to the guidelines written in the documents, and later, housing was built for patients in suitable conditions. These residences were houses located in that village behind the hospital. Also, patients who came for admission began to have their discharges scheduled as soon as they improved. After that, in 1994, I started directing the state's Mental Health division and then, I felt I had given all I could and retired. But I continued going to the hospital supervising the nursing residents (Terezinha - Interview).
The entire discussion surrounding the Diretas Já movement and the Eighth National Mental Health Conference was a democratizing milestone in healthcare and, consequently, in mental health. The Psychiatric Reform in Italy, with Franco Rotelli, was a great inspiration for us, but with the dictatorship in Brazil, it wasn't possible to receive books from outside the country, except those from the United States. So, everything that came from Europe came through Uruguay. From this, a movement was created in Latin America, a solidarity movement for Psychiatric Reform, which bolstered this entire historical movement that had already been happening in other countries. Rio Grande do Sul had close connection with to Uruguay, Argentina, Colombia, Bolivia, and Venezuela, which facilitated this rapprochement. And so we identified with this Reform, with the development of patient autonomy, and we were supported by the director at the time. However, other directors succeeded him, and then we suffered a dismantling. We even experienced political persecution. They said: you want to close São Pedro. And we countered: but what do you mean close it? On the contrary, we want to open São Pedro to the community and to the world. In short, despite everything, it was worth it (Mitiyo - Interview).
The accounts above demonstrate the active participation of nurses in breaking with the long-term institutionalization model. While some followed the proposal to try to humanize the space, others sought to transform the system by seeking support from instances beyond the institution. The 1980s were the cradle of the Psychiatric Reform in Brazil, which was anchored in proposals from other countries that advocated the need to establish a treatment model based on deinstitutionalization and care within a territorial network composed of services that could replace institutionalization in asylums.
Historically, psychiatric knowledge was based on the asylum model, in which the articulation between treatment and custody perpetuated hospitalizations, promoting the annulment of individuals' subjectivity. The transformation of institutions marked by violence, such as psychiatric hospitals, required a break with punitive, coercive, hierarchical, and authoritarian practices. However, such transformation also demanded a critical reflection on the social role of these institutions and the actions of the professionals within them, implying the rejection of the traditional models that sustained their logic of operation. In this context, the concept of deinstitutionalization is consolidated, conceived as a movement to overcome the asylum model, guided by the deconstruction of asylum-based care and treatment devices 26-28.
Both of the authors cited above had their theories directed towards the need for an institutional transformation that should emerge from within the institution itself, using the available resources, including its problems, to deconstruct existing structures and then gradually reconstruct them outside the institution. However, the process would involve the creation of a territorial network based on the multiplicity of social interactions and the formulation of new mental health policies that would take into account the rights of patients 28.
Following this trend, in Brazil discussions about models of community-based mental health care, based on experiences in other countries, began to gain prominence. During the First National Mental Health Conference, debates arose regarding the hegemonic role of the psychiatric hospital and proposals for reform in the existing care system. In 1989, Bill No. 3657, led by Paulo Delgado, proposed the construction of an extra-hospital care network for the treatment of mental disorders and the progressive elimination of beds in institutions with asylum-like characteristics. However, the proposed plan remained in the National Congress for more than 10 years and was only recognized as legislation in 2001, through the Brazilian Psychiatric Reform Law.
Prior to the 1990s, Rio Grande do Sul, like other Brazilian states, did not have legislation that addressed the reality of institutionalized individuals. Only in 1992 did State Law No. 9716 changed the model of psychiatric care in the state and prohibited the construction or expansion of public or private psychiatric hospitals. This legislation gradually replaced the hospital-centric system of care for people with mental suffering with an integrated network of care, health and social services, such as: outpatient clinics, psychiatric emergencies in general hospitals, psychiatric beds or inpatient units in general hospitals, day hospitals, community centers, psychosocial care centers, residential intensive care centers, sheltered homes, public community boarding houses, constructive activity workshops and similar facilities6.
At the São Pedro Psychiatric Hospital, the period was marked by an acceleration in the process of discharging patients home who had family ties, in addition to other initiatives that resulted in the project entitled São Pedro Cidadão (São Pedro Citizen). This proposal was conceived to deconstruct the São Pedro Psychiatric Hospital through initiatives that enabled the resocialization of inpatients and the construction of residences to house those who, due to various circumstances, did not have the opportunity to return home. These changes were anchored by the Caracas Declaration of 1990, a document produced by the Pan American Health Organization and the World Health Organization, and the II National Mental Health Conference, which approved the creation of a Comprehensive Mental Health Network to replace psychiatric hospitals.
The deinstitutionalization process for patients institutionalized at the São Pedro Psychiatric Hospital was gradual, culminating in 2023 with the transfer of the last patients to other facilities linked to the Psychosocial Care Network. These long years, necessary to implement the objectives set in previous decades, demonstrate the importance of the involvement of different actors for the people institutionalized there to achieve their freedom. Various documents and studies point to the importance of this process; however, little is said about the participation of nurses in this achievement.
From this perspective, the constructed narrative attributes to the São Pedro Psychiatric Hospital the condition of a space in which the lives of human beings were trivialized, where individuals were stripped of their humanity and segregated in a place that offered minimal chances of survival, keeping them forgotten, ignored, and on the margins of life. These individuals were not recognized as human beings, being neglected, stigmatized as insane, and, because of this condition, considered unworthy of dignified treatment, remaining in this situation until the arrival of the qualified nurses, who gradually began to seek the transformation of that reality.
The nurses, upon assuming this role, dedicated themselves to changing the scenario they found, opposing a society that had relegated these individuals to abandonment. While some worked to humanize the space, others sought structural transformation, engaging with entities outside the institution. Therefore, the care initiatives developed by these professionals, especially from the moment they began to replace the nuns, were fundamental in fostering movements that enabled changes in mental health care in the country, considering that the state of Rio Grande do Sul consolidated itself as a reference through pioneering actions that propelled the Brazilian Psychiatric Reform.
FINAL CONSIDERATIONS
The present study highlighted the importance of the work of registered nurses at the São Pedro Psychiatric Hospital between 1960 and 1992, as protagonists in the transformation of mental health care and, possibly, precursors of the movements that enabled changes in mental health care in Rio Grande do Sul, which helped to drive the Brazilian Psychiatric Reform. Their practices, based on ethics, commitment, and the pursuit of humanization, represented a break with the asylum model, contributing to the deconstruction of exclusionary practices and the construction of new paradigms in the field of mental health.
This is a story that, for a long time, remained silenced, invisible in official records, and little recognized in accounts of the Psychiatric Reform. Narrating this trajectory is, therefore, an act of resistance, of historical reparation, and of valuing the nursing profession that, through its work, transformed practices, gave new meaning to care, and left a fundamental legacy for mental health in Rio Grande do Sul and Brazil.
In light of these findings, it is clear that the history of mental health cannot be told without acknowledging the fundamental role of these nurses, whose trajectories need to be known, recognized, and valued. This constitutes a legacy that remains alive in the construction of contemporary practices, guided by the principles of dignity, freedom, and human rights in mental health.
We emphasize that the past does not come to us; we only look at it with the eyes of the present. We seek to present one of the possible versions of this story, its operation, its materiality, not to search for an essence or a secret, but to distance ourselves from absolute truths. Other narratives can be told from new angles and different subjectivities.
Acknowledgments
In the context of the story narrated in this article, we express our recognition and sincere gratitude to the research participants, whose availability and trust were essential for the construction and development of this scientific work.
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Availability of data and material
Access to the dataset may be granted upon request to the corresponding author to ensure the protection of participant confidentiality and the ethical use of information. This measure allows for the evaluation of the purpose of the request and ensures that sharing occurs responsibly, in accordance with the ethical and regulatory guidelines applicable to research.
Access to the dataset may be granted upon request to the corresponding author to ensure the protection of participant confidentiality and the ethical use of information. This measure allows for the evaluation of the purpose of the request and ensures that sharing occurs responsibly, in accordance with the ethical and regulatory guidelines applicable to research.
