Abstract

A fundamental government initiative to change the living conditions of deinstitutionalized Brazilian people, the De Volta para Casa (Back Home) Program is formed by some elements, including the psychosocial rehabilitation financial aid. Thirty-four state and academic documents from ordinances to papers were gathered to identify which elements of the Program permeate the records and debates about it throughout the Brazilian Psychiatric Reform, converging with the studies of Juarez Pereira Furtado and Ligia Maria Vieira-da-Silva about the dynamics of scientific and bureaucratic fields, such as mental health. Furthermore, we ethnographed five events that gathered institutionalized people and other agents from this field. We noticed the remarkable presence of the Therapeutic Residential Services (SRT) as an element of the referred Program both in the records and the scientific debates, while the mentioned financial aid was highlighted mainly in the government records.

Key words:
Ethnography; Mental health; De Volta para Casa; Deinstitutionalization

Introduction

One of the dimensions of the Brazilian Psychiatric Reform process is the legal-political aspects¹1 Amarante P. Teoria e crítica em saúde mental: textos selecionados. São Paulo: Zagodoni; 2015., expressed in at least two legislative achievements: Law 10.216/2001, known as the anti-asylum Law, which redirects the mental health care model and concerns the rights of people with mental disorders; and Law 10.708/2003, which refers to the De Volta para Casa (Back Home) Program (PVC) and establishes the psychosocial rehabilitation financial aid, a benefit intended for patients discharged from psychiatric hospitals. The construction of these laws involved several public events, including National Congress sessions and hearings, and derived from other government documents, such as bills. This process included users, family members, and other members of the mental health field in the process of approving the so-called “substitutes”²2 Delgado P. São João del Rei: diálogo sobre os caminhos da Reforma Psiquiátrica. Entrevista com Pedro Gabriel Delgado, em 28/06/2013. In: Melo W, Rezende P, Baeta S, organizadores. Mobilização, cidadania e participação comunitária. Rio de Janeiro: Espaço Artaud; 2016.. Besides the laws mentioned above, other documents in which PVC is mentioned and the events it is discussed will help us understand it in the following pages. We propose to turn our attention to the records and debates around this initiative geared to the social inclusion of those discharged from psychiatric internment, a population segment in which many leading figures of the anti-asylum struggle are part³3 Luchmann L, Rodrigues J. O movimento antimanicomial no Brasil. Cien Saude Colet 2007; 12(2):399-407..

Besides the legal-political dimension, the Brazilian psychiatric reform process also consists of technical-assistance, theoretical-conceptual, and sociocultural dimensions. Its complexity includes the increased supply of extra-hospital mental health services, but not limited to it⁴4 Yasui S. Rupturas e encontros: desafios da reforma psiquiátrica brasileira. Rio de Janeiro: Editora Fiocruz; 2010.. Changing the view of most people about the so-called “mental issues” effectively requires shaking up ways of thinking, feeling, and acting sedimented over decades, generations, and even centuries, such as the expectations we tend to have vis-à-vis the behavior of former psychiatric hospital patients. We know that many of them are generally seen as potentially incapable and incurable, when not dangerous and irresponsible, and that PVC beneficiaries challenge this social status of madness⁵5 Rotelli F, Leonardis O, Mauri D. Desinstitucionalização, uma outra via. In: Nicácio F, organizador. Desinstitucionalização. São Paulo: Editora HUCITEC; 2001 [1990].. Experiences in different Brazilian regions show that they manage their assets totally or partially and keep their psychopathological symptoms stable for some that exceed the lapse they were hospitalized⁶6 Leite L, Oliveira M, Scarparo H. Programa de Volta para Casa na cidade de Porto Alegre: fortalecimento e tessitura de vínculos no meio social. Rev Psicol Foco 2015; 7(9):3-15.^,77 Silva JL, Valentim A, Lyra J. Loucura em território: experimentando produção de saúde com beneficiário do Programa de Volta para Casa. Rev Psicol Polit 2020; 20(47):51-64..

One of the records that we will investigate is the Law mentioned above that establishes the psychosocial rehabilitation financial aid, a government document informing that the benefit is an integral part of PVC and consists of a monthly cash payment aid intended for patients discharged from hospitals⁹9 Brasil. Presidência da República. Lei nº 10.708, de 31 de julho de 2003. Institui o auxílio-reabilitação psicossocial para pacientes acometidos de transtornos mentais egressos de internações, Diário Oficial de União 2003; 31 jul. [acessado 2020 jun 18]. Disponível em: http://www.planalto.gov.br/ccivil_03/Leis/2003/L10.708.htm.
http://www.planalto.gov.br/ccivil_03/Lei... , so that from now on we will designate it as aid. Another record that is also a government document is the PVC manual, in which the financial aid is presented as its main component, and this government strategy to encourage extra-hospital care also consists of Therapeutic Residential Services (SRT) and Psychosocial Care Centers (CAPS)¹⁰10 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Ações Programáticas e Estratégicas. De Volta para Casa" - Manual do Programa, s/d. Brasília: MS; 2003. [acessado 2020 jun 18]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/Manual_PVC.pdf.. Other records on PVC are scientific documents, and some studies on PVC may come to exclusively address SRTs, without even mentioning the aid as one of its components⁸8 Venturini E. "O caminho dos cantos": morar e intersetorialidade em saúde mental. Fractal 2010; 22(3):471-480..

Other scientific papers on PVC mention the aid in combination with other benefits, such as the Continuous Cash Benefit (BPC)⁶6 Leite L, Oliveira M, Scarparo H. Programa de Volta para Casa na cidade de Porto Alegre: fortalecimento e tessitura de vínculos no meio social. Rev Psicol Foco 2015; 7(9):3-15., and some people point out legal problems in the administration of these benefits in SRTs, hindering the expansion of PVC in some municipalities and states of the federation¹¹11 Freire F, Silva VN, Oliveira M. O "Programa de Volta para Casa" no campo da saúde coletiva e saúde mental: estratégias de desinstitucionalização e reabilitação psicossocial. Catussaba 2012; 2(1):51-62.. The change in the social place of madness is notable when those discharged from psychiatric hospitalization are no longer considered dependent within the family and become providers⁶6 Leite L, Oliveira M, Scarparo H. Programa de Volta para Casa na cidade de Porto Alegre: fortalecimento e tessitura de vínculos no meio social. Rev Psicol Foco 2015; 7(9):3-15.. However, this gendered social role also demands problematization in the field of mental health⁷7 Silva JL, Valentim A, Lyra J. Loucura em território: experimentando produção de saúde com beneficiário do Programa de Volta para Casa. Rev Psicol Polit 2020; 20(47):51-64..

In this sense, the field of mental health is at the same time scientific, political, and bureaucratic¹²12 Furtado J, Oda W, Borysow I, Kapp S. A concepção de território na Saúde Mental. Cad Saude Publica 2016; 32(9):1-15., similar to collective health¹³13 Vieira-da-Silva L. O campo da saúde coletiva: gênese, transformações e articulações com a reforma sanitária brasileira. Salvador, Rio de Janeiro: EDUFBA, Editora Fiocruz; 2018.. Thus, its agents circulate through academia, service, and militancy. Workers and users also operate at different levels of management and sectors of the Executive Branch. Family members and other spokespersons represent mental health, including in the Federal Legislative Branch, not to mention the research and extension projects linked to the social movement developed by professors at many universities. Besides the laws and manuals mentioned above, ordinances from the Ministry of Health and several other documents condense the viewpoint on the PVC of these agents in the field of mental health, called “mentalists”¹1 Amarante P. Teoria e crítica em saúde mental: textos selecionados. São Paulo: Zagodoni; 2015.. These government documents are discussed at scientific congresses, not just at National Congress sessions and hearings. As a result, documents and events permeate the referred field, records, and debates, sometimes making visible, sometimes concealing the components of PVC, such as the aid and SRT.

We aim to identify which PVC components are found in records and debates about it throughout the Brazilian Psychiatric Reform process by searching federal government documents where the PVC is mentioned, scientific papers on the PVC, and debates on the PVC in mental health events.

Theoretical-methodological framework

This study on the PVC involves document analysis and ethnography of events: the first is based on a national survey on the social inclusion of psychiatric inpatients, which unfolded into a document analysis on the concept of territory in mental health¹²12 Furtado J, Oda W, Borysow I, Kapp S. A concepção de território na Saúde Mental. Cad Saude Publica 2016; 32(9):1-15.; and the second based on ethnographies of psychiatry scientific congresses¹⁴14 Azize R. Notas de um "não-prescritor": uma etnografia entre os estandes da indústria farmacêutica no Congresso Brasileiro de Psiquiatria. In: Maluf S, Torniquist C, organizadores. Gênero, saúde e aflição: abordagens antropológicas. Santa Catarina: Letras Contemporâneas; 2010. and the so-called “interface ethnography”¹⁵15 Ortner S. Access: reflections on studying up in Hollywood, 2010. [cited 2019 nov 9]. Available from: https://journals.sagepub.com/doi/abs/10.1177/ 1466138110362006.. The two methodologies explain how PVC is apprehended in that field, the categories of perception and appreciation of the reality that its agents register in governmental and scientific documents, and those that they pronounce in public debates¹³13 Vieira-da-Silva L. O campo da saúde coletiva: gênese, transformações e articulações com a reforma sanitária brasileira. Salvador, Rio de Janeiro: EDUFBA, Editora Fiocruz; 2018..

We adopted the same methodological procedures as Furtado et al.¹²12 Furtado J, Oda W, Borysow I, Kapp S. A concepção de território na Saúde Mental. Cad Saude Publica 2016; 32(9):1-15. to gather documents: searching for ordinances and other federal government regulations and papers available in scientific databases. Thus, we also gathered government documents by searching the Ministry of Health’s Mental Health Coordination page and the Virtual Health Library (BVS) and scientific papers in journals indexed in the SciELO database. Our search was carried out in 2019 and used the following Portuguese descriptors: “Programa de Volta para Casa” (and) “saúde mental”; “Programa de Volta para Casa” (and) “desinstitucionalização”; “Programa de Volta para Casa” (and) “Serviço Residencial Terapêutico”; “auxílio reabilitação” (and) “saúde mental”; “auxílio reabilitação” (and) “Serviço Residencial Terapêutico”; e “auxílio reabilitação” (and) “desinstitucionalização”. Furtado et al.¹²12 Furtado J, Oda W, Borysow I, Kapp S. A concepção de território na Saúde Mental. Cad Saude Publica 2016; 32(9):1-15. searched official documents from 1992 to 2015 and scientific papers from 2005 to 2015. We expanded the latter to 2019 and the former to 1990, taking the deinstitutionalization concept⁵5 Rotelli F, Leonardis O, Mauri D. Desinstitucionalização, uma outra via. In: Nicácio F, organizador. Desinstitucionalização. São Paulo: Editora HUCITEC; 2001 [1990]. as a historical landmark for investigation. Only publications in Portuguese with full text were included, and we did not consult the LILACS, Scopus, and PubMed databases.

The analysis of the documents allowed Furtado et al.¹1 Amarante P. Teoria e crítica em saúde mental: textos selecionados. São Paulo: Zagodoni; 2015. ²2 Delgado P. São João del Rei: diálogo sobre os caminhos da Reforma Psiquiátrica. Entrevista com Pedro Gabriel Delgado, em 28/06/2013. In: Melo W, Rezende P, Baeta S, organizadores. Mobilização, cidadania e participação comunitária. Rio de Janeiro: Espaço Artaud; 2016. to distinguish four meanings of territory: a) an area of coverage and action of extra-hospital services; b) a set of therapeutic resources; c) the personal history of each individual; d) a system of objects and actions. The first two meanings underpin the so-called functional dominance pole, conducive to more concrete political domination, and the last two, the symbolic dominance pole, conducive to subjective and cultural appropriations. In our case, we isolated two PVC components: the aid and the SRT. Governmental and scientific documents emphasize both or just one of these elements. We also consider that when PVC is reduced to the psychiatric hospital discharge and the necessary implementation of substitute services, it is close to the functional dominance pole. The symbolic dominance pole is found when the components are placed as strategic devices for dismantling the assumption of disability and chronicity of those discharged from psychiatric hospitalization.

Besides the documentary analysis of scientific and state production on PVC, we conducted an interface ethnography¹⁵15 Ortner S. Access: reflections on studying up in Hollywood, 2010. [cited 2019 nov 9]. Available from: https://journals.sagepub.com/doi/abs/10.1177/ 1466138110362006. in mental health events, a space familiar to the authors of this manuscript and those attending these activities as workers. Ortner¹⁵15 Ortner S. Access: reflections on studying up in Hollywood, 2010. [cited 2019 nov 9]. Available from: https://journals.sagepub.com/doi/abs/10.1177/ 1466138110362006. considers this type of ethnography a way to carry out participant observation in public events, focused on the uttered statements. It indicates that the events are located in an “in-between”, where people present themselves and report their experiences, and these statements remain in the public domain. In this sense, witnessing debates about PVC at events was a way to access public pronouncements on former psychiatric inpatients and themselves. In these situations, terms typical of the field of mental health - deinstitutionalization, for example - are shared externally since agents who do not necessarily belong to it are allowed in these spaces.

Stands and marketing related to psychopharmaceuticals gained prominence in the ethnography of the Brazilian Psychiatric Association event held by Azize¹⁴14 Azize R. Notas de um "não-prescritor": uma etnografia entre os estandes da indústria farmacêutica no Congresso Brasileiro de Psiquiatria. In: Maluf S, Torniquist C, organizadores. Gênero, saúde e aflição: abordagens antropológicas. Santa Catarina: Letras Contemporâneas; 2010.. The presentations of scientific papers and round tables stood out in our ethnography at mental health events. We selected events promoted by associations and other institutions, considering debates on deinstitutionalization in the title, thematic axes, or activity schedule. We adopted the same procedures as Azize¹⁴14 Azize R. Notas de um "não-prescritor": uma etnografia entre os estandes da indústria farmacêutica no Congresso Brasileiro de Psiquiatria. In: Maluf S, Torniquist C, organizadores. Gênero, saúde e aflição: abordagens antropológicas. Santa Catarina: Letras Contemporâneas; 2010.: preparation for the activity (theoretical study and previous meeting with some agents in the field) and presentation of the characteristics of the event and its participants (with selected age, gender, and background).

Upon listening to the debates, we noticed something not found in the records in documents, so that the events were a fertile space for us to reach the different PVC perspectives of the so-called “mentalists”. Participant observation of the events was implemented from 2018 to 2019, and the research project was submitted to the Research Ethics Committee, which authorized it under Opinion N° 3.386.261.

Results and discussion

The documentary analysis of the mental health field gathered 34 documents, 29 of them governmental and five scientific. Event ethnography involved participant observation of five events in this bureaucratic and scientific field. We will present below these records and debates about PVC, accompanied by analyses of what is visible and hidden in these social spaces of circulation of competing agents, particularly for the power to determine what should be financed by the government and studied by mental health researchers.

Governmental documents

The 29 documents (Chart 1) include ordinances, recommendations, resolutions, management reports, and mental health conferences, including the Law mentioned above and the manual⁹9 Brasil. Presidência da República. Lei nº 10.708, de 31 de julho de 2003. Institui o auxílio-reabilitação psicossocial para pacientes acometidos de transtornos mentais egressos de internações, Diário Oficial de União 2003; 31 jul. [acessado 2020 jun 18]. Disponível em: http://www.planalto.gov.br/ccivil_03/Leis/2003/L10.708.htm.
http://www.planalto.gov.br/ccivil_03/Lei... ^,1010 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Ações Programáticas e Estratégicas. De Volta para Casa" - Manual do Programa, s/d. Brasília: MS; 2003. [acessado 2020 jun 18]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/Manual_PVC.pdf..

The PVC portrayed in these regulations includes care actions in the territory, enabling housing, and other activities that refer to the pole of functional dominance¹²12 Furtado J, Oda W, Borysow I, Kapp S. A concepção de território na Saúde Mental. Cad Saude Publica 2016; 32(9):1-15.. Furthermore, the most emphasized aspect in these official documents is financial aid payment for those discharged from psychiatric hospitals. The aid can be geared to the residents of the SRTs and those who have returned to their family homes or even to their own homes. In other words, in these records, PVC is necessarily linked to assistance, although not necessarily to SRTs.

The PVC complies with Law nº 10.2016/2001, thus involving social inclusion, the exercise of rights, and autonomy actions¹⁶16 Brasil. Presidência da República. Lei nº 10.2016, de 06 de abril de 2001. Dispõe sobre a proteção e os direitos da pessoa portadora de transtorno mental e redireciona o modelo assistencial em saúde mental. Diário Oficial da União 2001; 6 de abril. [acessado 2020 jun 18]. Disponível em: http://www.planalto.gov.br/ccivil_03/leis/leis_2001/l10216.htm.
http://www.planalto.gov.br/ccivil_03/lei... . The actions provided for by PVC are strategic for the deinstitutionalization process, and we highlight the following comment on Law No. 10.708/2003¹⁷17 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Legislação em saúde mental: 1990-2004. 5ª ed. ampl. Brasília: MS; 2004.:

Besides the Law and the manual that collaborated to establish the historical mark of our investigation, we found three other documents that guide the PVC: a) “Therapeutic Homes: what are they and what are they for?” (English translation), manual on the SRTs, from 2004; b) Ordinance N° 3.088, of 2011, which defines PVC and SRTs as a deinstitutionalization strategy, a component of the Psychosocial Care Network (RAPS); c) and Ordinance N° 2.840/2014, which establishes the Deinstitutionalization Program, recommending actions to access financial benefits, as one of the attributions of the deinstitutionalization team. These documents share guidelines on the PVC, namely, its definition, objectives, criteria for including users in the program, and its implementation. Furthermore, the PVC is mentioned alongside “deinstitutionalization”, confirming that the former is an integral part of the latter.

Considering that deinstitutionalization is polysemic¹⁸18 Venturini E. A linha curva: o espaço e o tempo da desinstitucionalização. Rio de Janeiro: Editora Fiocruz; 2016., we can attribute different meanings to it. Among them are strategies that enable hospital discharge, social reintegration, and the revival of the power of social contractuality and care in the territory. These strategies range from administrative actions (closing psychiatric hospitals, reducing beds, and financing a territorial care network) to changes in the care model involving SRTs and the PVC. Thus, understanding that government documents deal with PVC guidelines and orientations and that these same documents underpin the PVC with deinstitutionalization strategies, we can state that deinstitutionalization and the PVC cannot be separated.

We also found other government documents that determine the adherence of municipalities to the PVC, which is the condition for developing of actions and even for receiving specific funds: Ordinance GM/MS N° 52/2004, which establishes the Annual Psychiatric Assistance Restructuring Program; “Mental health and solidarity economy: social inclusion through work” (2005, English translation), which affirms the PVC as a social inclusion project; Ordinances GM N° 1.169/2005 and N° 678/2006, related to supervision programs; and Ordinance MS N° 3.088/2011, on the financial incentive for the implementation and costing of the SRT. All these documents emphasize the pole of functional dominance¹²12 Furtado J, Oda W, Borysow I, Kapp S. A concepção de território na Saúde Mental. Cad Saude Publica 2016; 32(9):1-15..

On the other hand, the symbolic dominance pole¹²12 Furtado J, Oda W, Borysow I, Kapp S. A concepção de território na Saúde Mental. Cad Saude Publica 2016; 32(9):1-15., related to the deconstruction of the ideas of disability and chronicity, would be well illustrated by the “Going Home Program Photographic Show” (English translation)¹⁹19 Brasil. Ministério da Saúde (MS). Secretaria Executiva. Mostra fotográfica Programa de Volta para Casa: cartilha de monitoria. Brasília: MS; 2008. [acessado 2020 jun 26]. Disponível em: https://saudementalrn.files.wordpress.com/2012/07/mostra_fotografica_programa_volta_casa.pdf.. It makes a geographical selection in the history of Brazilian mental health and emphasizes the role of aid for the beneficiaries’ lives. The document brings two fundamental aspects of PVC, that is, it emphasizes its place on the tripod that is the foundation for deinstitutionalization and its indemnity aspect:

Together with the Long-Term Hospital Bed Reduction Program and Therapeutic Residential Services, the Going Home Program (PVC) is the essential tripod for the effective process of deinstitutionalization and rescue of citizenship for people affected by mental disorders subjected to deprivation of freedom in Brazilian psychiatric hospitals¹⁹19 Brasil. Ministério da Saúde (MS). Secretaria Executiva. Mostra fotográfica Programa de Volta para Casa: cartilha de monitoria. Brasília: MS; 2008. [acessado 2020 jun 26]. Disponível em: https://saudementalrn.files.wordpress.com/2012/07/mostra_fotografica_programa_volta_casa.pdf.. (p. 15)

The report of the last National Conference on Mental Health, a public event in the bureaucratic field of mental health held a decade ago, also highlights the link between the PVC and deinstitutionalization. The document ties the PVC to SRTs rather than help. Its summary includes three axes, and the second axis contains an item entitled “Deinstitutionalization, inclusion and social protection: Therapeutic Residences, Going Home Program and intersectoral articulation in the territory” (English translation)²⁰20 Brasil. Sistema Único de Saúde. Conselho Nacional de Saúde. Relatório Final da IV Conferência Nacional de Saúde Mental - Intersetorial, 27 de junho a 1 de julho de 2010. [acessado 2020 jun 18]. Disponível em: http://conselho.saude.gov.br/biblioteca/Relatorios/relatorio_final_IVcnsmi_cns.pdf.
http://conselho.saude.gov.br/biblioteca/... . None of the 31 proposals presented in this item explicitly address the financial aid. Only tangentially, the item mentions the “benefits”, that is, the aid, in the passage about “accessibility”²⁰20 Brasil. Sistema Único de Saúde. Conselho Nacional de Saúde. Relatório Final da IV Conferência Nacional de Saúde Mental - Intersetorial, 27 de junho a 1 de julho de 2010. [acessado 2020 jun 18]. Disponível em: http://conselho.saude.gov.br/biblioteca/Relatorios/relatorio_final_IVcnsmi_cns.pdf.
http://conselho.saude.gov.br/biblioteca/... (p. 83). Meanwhile, all sections present suggestions for expanding and changing the SRTs, from the item “general principles and guidelines” to “financing”.

The series of official documents called Saúde Mental em Dados (Mental Health in Data) includes PVC either within the item “Deinstitutionalization strategies” (from 2012, that is, from its number eight to twelve) or under the item Psychosocial Care Network (before the date mentioned). In both cases, it presents the number of the Program’s beneficiaries without highlighting the financial aid. Also, in the first case, the first sub-item is about the number of SRTs, not financial aids. In the second case, the place of PVC as an indicator of the Pacto pela Vida (Life Pact) is highlighted.

This rich bureaucratic production on the PVC indicates a variety of actions conditioned by the adherence of municipalities to it. Is the scientific production on the PVC in convergence with what was found in our last National Conference on Mental Health document?

Scientific publications

We have many scientific publications in mental health, including case studies, literature reviews, quantitative and qualitative research results, and experience reports. We noticed a relationship between experience reports and government documents in mental health, referring to the fact that it is scientific and bureaucratic at the same time¹²12 Furtado J, Oda W, Borysow I, Kapp S. A concepção de território na Saúde Mental. Cad Saude Publica 2016; 32(9):1-15.. We understand that government documents are built from scientific findings, per the needs of the workers’ practices, in order to regulate, finance, and boost them. Government publications can induce scientific publications and vice versa. We conducted our investigation in scientific documents from these inferences and found five papers.

Before moving on to other analyses, we would like to highlight an important finding. The documents indicated in Chart 2 by numbers 3, 4, and 5 are excerpts from the same research, which involved scholars from different Brazilian public institutions. This study, and the one indicated by number 1 in the chart above, refer that they found data similar to our results: the small number of studies in bibliographic research on the PVC. The four studies, unlike ourselves focusing only on papers, also targeted theses, dissertations, and book chapters. In total, there are five dissertations, a thesis, and a book chapter. Since papers identified by works 3, 4, and 5 are the same as those we found, that is, 1 and 2.

With these data, we found few studies and works published about the PVC, especially if compared to the number of publications about SRTs and deinstitutionalization. Two hypotheses can justify this scenario: 1) reduced number of experiences with the PVC, especially with the help or even the non-publication of these experiences; 2) the existence of a split between aid and deinstitutionalization as a deconstruction of the asylum logic⁵5 Rotelli F, Leonardis O, Mauri D. Desinstitucionalização, uma outra via. In: Nicácio F, organizador. Desinstitucionalização. São Paulo: Editora HUCITEC; 2001 [1990].. The PVC would remain only as an administrative action, that is, the inclusion of users as a step for accrediting services and receiving funds. The financial aid would refer to using the benefit for general needs, such as small renovations in the SRTs and purchasing basic materials.

Lima and Brazil²¹21 Lima SS. Brasil SA. Do Programa de Volta para Casa à conquista da autonomia: percursos necessários para o real processo de desinstitucionalização. Physis 2014; 24(1):67-88. point out that the possible causes of the reduced number of works would be related to the little importance given to the program by professionals and that they cannot understand it as a deinstitutionalization operator. These reflections coincide with the numbers found on the website of the National Coordination of Mental Health. In 2017, 701 municipalities were registered in the PVC with 4,499 beneficiaries.

The program manual provided for around 15,000 beneficiaries. The same authors²¹21 Lima SS. Brasil SA. Do Programa de Volta para Casa à conquista da autonomia: percursos necessários para o real processo de desinstitucionalização. Physis 2014; 24(1):67-88. help to reflect on our second hypothesis: the lack of a relationship between the help of the PVC and deinstitutionalization as a deconstruction. Their research evidenced that the financial aid is instead aimed at meeting general needs than life projects. Thus, they lack strategies to develop autonomy and empowerment for use.

In this research, we identified that professionals from both the SRTs and the CAPS claim that the networks lack other strategies to enable deinstitutionalization, such as funds and sufficient territorial network, hindering the use of the financial aid as an instrument to achieve contractuality. The authors emphasize that deinstitutionalization is not contained in the PVC’s objectives, nor is it found in the manual or the Law. In its place are “social reintegration”, “social integration”, “rehabilitation”. In this sense, the question is: how does the use of these terms in place of “deinstitutionalization” weaken the PVC?

We were struck by the fact that the PVC is normative in all the publications selected for our discussion: they address an analysis of the effects of implementing the PVC in municipalities and the lives of beneficiaries. Thus, a strong influence of the bureaucratic field on the scientific field is observed. One of them evaluates the PVC as a public policy and its impacts on the beneficiaries’ lives²²22 Guerreiro AV, Bessoni EA, Cardoso AJC, Vaz BC, Braga-Campos FC. O Programa de Volta para Casa na vida cotidiana dos seus beneficiários. Saude Soc 2019; 28(3):11-20..

In this paper, the authors identify the need to revise the PVC manual and actions to guide and train managers for the implementation of the program and inclusion of users; they point to the need for more significant publicity of the beneficiaries’ stories to show the gains provided by the PVC, especially in terms of redeeming the power of social contractuality.

Other studies on the PVC²³23 Franco RF, Cornelis JS. Desinstitucionalização psiquiátrica: do confinamento ao habitar na cidade de Belo Horizonte. Psicol Soc 2015; 27(2):312-321.

24 Bessoni E, Capistrano A, Silva G, Koosah J, Cruz K, Lucena M. Narrativas e sentidos do Programa de Volta para Casa: voltamos e daí? Saude Soc 2019; 28(3):40-53.^-2525 Koosah J, Moreira, MIB, Braga-Campos FC. Construindo histórias em tessitura lenta: desinstitucionalização e narrativas em pesquisa. Saude Soc 2019; 28(3):29-39. emphasized the normative character of the PVC while stressing its importance as a deinstitutionalization operator. All these works highlighted both poles of the PVC, the functional and the symbolic. The symbolic dominance pole exceeds the acquisition of material goods and the implementation of actions and services. It refers to the acquisition of symbolic goods: social contractuality, self-care, circulation in social spaces, establishing affective relationships, life project, managing one’s own money.

We can summarize the findings of the analysis of the papers: 1) besides having found few studies on the PVC, they do not emphasize the financial aid; 2) the PVC is presented mainly in its functional dominance pole: program implementation, the inclusion of beneficiaries and the actions facilitated by the Program; 3) the Program contributes to the deconstruction of the stigmas of madness: disability and chronicity. We will complete the debate proposed here by analyzing below how the PVC is activated by actors in mental health in public events.

Public events

We attended five mental health events from 2018 to 2019, identifying how its agents activated the PVC in the debates (Chart 3).

The Regional Monthly Event of the Bureaucratic Field frequently debates the organization of extra-hospital services for de-hospitalization. It also discusses the relationship between mental health and the legal field and some strategies that contribute to deconstructing the stigmas that describe madness. We commonly find the expression “the patient should leave the hospital and live in the city, with guaranteed education, leisure, and housing”; “this patient should be included in the network”. However, the PVC is not addressed.

While national, the other events have different characteristics. The discussion on mental health is particular to each of them: most are instead focused on the technical-assistance dimension, emphasizing care processes in CAPS, SRTs, solidarity economy projects, and other social inclusion workshops; others comprise this dimension and two others, the legal-political and the sociocultural, with more politicized themes of confronting social, racial, gender, and militancy inequalities in mental health. In general, the PVC is approached in its technical-assistance dimension or its functional dominance pole. In other words, it is discussed based on the SRTs, which are the subject of many studies.

The Biennial National Scientific Field Congress consisted of short courses, workshops, conversation wheels, debates, round tables, and artistic and cultural interventions, such as theatrical and musical presentations. Deinstitutionalization was not included among the thematic axes organized by the event. The closest topic referred to the clinic and comprehensive care in the RAPS. There were many works with the theme “deinstitutionalization”, many others talking about the SRTs, about the implementation processes, but none directly about the PVC. More specifically, we did not participate in the debate that addressed the aid. In the presentations we participated in, a lot was said about autonomy and empowerment as deinstitutionalization operators, but the PVC was not approached as an instrument to stimulate these qualities.

We can highlight at this event a photo exhibition celebrating 15 years of PVC. The financial aid is emphasized on the exhibition banners, which together with the SRTs and CAPS are the tripod that guides the deinstitutionalization:

In 2019, we participated in the Biennial National Scientific Field Event. As in the previous event, several presentation and debate modalities were included: round tables and conversation wheels. Deinstitutionalization was one of the thematic axes. At this event, the works presented were divided into two categories: research reports and experience reports. As in the 2018 event, there were many presentations on deinstitutionalization, totaling, in both categories, eighteen works. Seven works on SRTs appear in the experience reports, presenting care practices and social inclusion strategies. A paper about the PVC was found in the research report category. It assessed health production strategies in the territory, with former psychiatric inmates who now live in SRTs. Work, autonomy, culture, and artistic expression were highlighted among these strategies, with no emphasis on the financial aspect of the PVC.

The Triennial Scientific Field National Congress also organized the debates in different modalities. There were two Theme Groups on mental health. Some works on deinstitutionalization were presented, which, in part, discussed the SRTs. However, aid was not addressed. It is interesting to note that much was said about autonomy, social inclusion, and deinstitutionalization, but the PVC was not mentioned.

Finally, the Annual Regional Scientific Field Event organized a table on deinstitutionalization. There was no presentation of specific work on the PVC, but two points deserve to be highlighted. The first one refers to defining deinstitutionalization, characterized by the implementation of services. Among them, the SRTs were emphasized without mentioning aid. The second concerns the discussion on transinstitutionalization. In this discussion, the theme of housing appears as a condition for deinstitutionalization for many long-hospitalized patients. However, the management difficulty for implementing and accrediting the SRTs is mentioned. In this sense, trans-institutionalization was placed as an alternative to improve the quality of life of these people, who would have no other alternative to de-hospitalization than the SRTs. Furthermore, it is stated as a strategy for reducing psychiatric beds and closing private psychiatric clinics. The researcher states that “transinstitutionalization is a strategy created for us to survive and improve the lives of hospitalized individuals”.

The setting found in the ethnography of the events uncovered some important data: 1) it confirmed the findings of the scientific field research about the professionals’ lack of knowledge about the PVC as a critical element for deinstitutionalization; 2) the low emphasis on the aid, being limited to the SRT; 3) the association between SRT and the PVC shows the emphasis on the functional dominance pole in the technical-assistance dimension.

Final considerations

Deinstitutionalization involves a deconstruction of the legal, administrative, and medical apparatus that constrains the experience of madness as a symptom of mental illness⁵5 Rotelli F, Leonardis O, Mauri D. Desinstitucionalização, uma outra via. In: Nicácio F, organizador. Desinstitucionalização. São Paulo: Editora HUCITEC; 2001 [1990].. Therefore, the PVC contributes to this process, as its users subvert the assumption of disability and chronicity found in the social imaginary of madness. Deinstitutionalization can be reduced to one of its meanings, namely, de-hospitalization, much like the PVC can be limited to one of its components, the SRT.

Although it is considered the main component of the PVC in some government documents searched, the financial aid is not mentioned in most of the scientific documents gathered on PVC. Moreover, debates about the Program at mental health events attended gave greater visibility to another component: the SRT.

Law 10.708/2003 establishes the psychosocial rehabilitation aid. Like the Law mentioned above, the Ministry of Health’s website also highlights pecuniary aid as a synonym for the PVC. The PVC booklet also positions the aid in this prominent place. In this sense, it is astonishing to find little or no data about the aid in scientific publications about PVC; moreover, not to hear almost anything about the “main component” of the program when it is discussed in scientific congresses. However, we have not investigated all the dimensions of the Brazilian Psychiatric Reform process, such as the sociocultural one. We did not go through the theses, monographs, and dissertations about the PVC, not even the book chapters and collections about the program, so that these study limitations may have contributed to such concealment of the aid.

The technical-assistance dimension of the Brazilian Psychiatric Reform process ends up overlapping the sociocultural one¹1 Amarante P. Teoria e crítica em saúde mental: textos selecionados. São Paulo: Zagodoni; 2015. even when the subject is the PVC, as the program ends up being associated with actions developed in the SRT, rather than with the potential of assistance to change the social place of madness and thus locate the beneficiaries as capable of managing their assets. Suppose the Brazilian Psychiatric Reform process often becomes synonymous with the implementation of CAPS¹1 Amarante P. Teoria e crítica em saúde mental: textos selecionados. São Paulo: Zagodoni; 2015.; in that case, the PVC comes to mean mainly the expansion of the SRTs, the part being taken by the whole, concealing relevant components to understand the social inclusion strategies, which can even not go through the daily routine of mental health services. Most studies with the PVC beneficiaries establish a dialogue with those in the SRTs, making those who rent properties, for example, and the financial aid’s role, invisible in these cases. Instead of the symbolic, the functional dominance pole referred to by Furtado et al.¹²12 Furtado J, Oda W, Borysow I, Kapp S. A concepção de território na Saúde Mental. Cad Saude Publica 2016; 32(9):1-15. reveals itself when records and debates about the PVC hide the financial aid and bring the SRT to the fore.

References

Publication Dates

History