The rise of the Psychiatric Counter-Reform in Brazil

Rossano Cabral Lima About the author

Since its release in 1991, Physis, whose first editor was the psychoanalyst Joel Birman, has been a witness and agent of the Brazilian Psychiatric Reform process (RPB), through the publication of theoretical articles and qualitative research in the psychosocial care network, among others. As a recent example, at the end of 2014, as part of the celebrations of the 40th anniversary of the Postgraduate Programme in Collective Health, the journal launched a special thematic issue on the Brazilian Mental Health and Psychiatry scenario - including an interview with Jurandir Freire Costa, by Benilton Bezerra (BEZERRA JR.; COSTA, 2014BEZERRA JR, B.; COSTA, J. F. Entrevista: Jurandir Freire Costa. Physis: Revista de Saúde Coletiva. Rio de janeiro, v. 24, n. 4, p. 1023-1033, 2014.), both relevant figures of the RPB trajectory and IMS professors, as well as Birman (all retired now).

Born as a Mental Health Worker's Movement in the late 1970s, and expanded as the Anti-Manicomial Movement in the second half of the 1980s, the Psychiatric Reform gradually ceased to refer only to a social movement, to become the official policy of the Brazilian state. From 1991, through governments of different political and ideological shades, the Mental Health Coordination of the Ministry of Health was successively occupied by RPB members. However, in tune with the changes in the correlation of forces in Brazilian political life, the picture began to change at the end of 2015. It is from this time the editorial by Kenneth Camargo Jr, "Mental Health, Citizenship and Scientific Field", on the crisis that emerged with the appointment of a coordinator of Mental Health, Alcohol and other Drugs with a professional background linked to the manicomial model (CAMARGO JR, 2015CAMARGO JR., K. R. Saúde mental, cidadania e o campo científico. Physis: Revista de Saúde Coletiva. Rio de Janeiro, v. 25, n. 4, p. 1057-1058, 2015.) by the minister of Health. The appointment unleashed significant protests in several cities of Brazil, leading to the occupation of the room of that Coordination in Brasília during 121 days. After the departure of the minister of Health, the coordinator was dismissed on May 9, 2016.

After a nine-month gap, the counter-reformist tide gained momentum on February 10, 2017, with the appointment of a member of the Brazilian Association of Psychiatry, which, since the early 2000s, became a fierce opponent of the Psychiatric Reform. In December 2017, the new coordinator approved, with some changes, the proposal of "new guidelines" for the mental health policies in Brazil in the Tripartite Inter-agency Committee (CIT). These guidelines were strengthened on February 4, 2019, with the disclosure of Technical Note 11/2019, entitled "Clarifications on the changes in the National Mental Health Policy and the Guidelines on National Drug Policy." Removed from the site after the flood of criticisms received, not being fully supported by the current minister of Health, the document announces "changes" that represent, in fact, the setback to a scenario that the country has been struggling to overcome.

The Technical Note has as main motto the inclusion of the psychiatric hospital in the Psychosocial Attention Network, with adjustment of the value of the AIHs. In support of this decision, it states that "there is no longer any need to speak of a 'substitute network', since no service replaces another." Added to this is the possibility that resources from hospital discharge or hospital closure are reapplied within the psychiatric hospital network, rather than being intended for community services, as was done up to 2016. In this way, the document seems to ignore that it was the emphasis on substitutive services to psychiatric hospitals that allowed for the creation of a range of devices - notably the Psychosocial Care Centers (CAPS) and the Residential Therapeutic Services (SRT) - ensuring access to treatment in freedom and near the place of users' homes, with priority for those with severe mental disorders and / or who have been discharged from long hospital stays. In 2002, 75.24% of federal mental health resources went to hospital services, a percentage that in 2013 had fallen to just over 20%, with 79.39% of resources went to the "substitutive" community and territorial attention (BRAZIL, 2015). If the objective is to increase access to hospital admission in cases of crisis and / or life risks, the method should be the expansion of beds in general hospitals, as supported by international experiences (THORNICROFT; TANSELLA, 2002THORNICROFT G.; TANSELLA, M. Balancing community-based and hospital-based mental health care. World psychiatry, v. 1, n. 2, p. 84-90, 2002.), and in CAPS III, which have beds for overnight accommodation, avoiding the rupture of care, since the user stays overnight in the same service that is treated during the day.

Alongside the return of the insane asylum, the other star of the Technical Note are the therapeutic communities, a closed and long-term care model, often religiously based and based on the requirement of total abstinence (IPEA, 2017) for the treatment of people with harmful use alcohol and other drugs, which have been subject of allegations of human rights violations (CFP; MNPCT; MPF, 2018). Thus, harm reduction strategies which entail continuous and free care, even if drug use has not been discontinued, with a focus on prevention and mitigation of health problems, used by dozens of countries around the world, area discarded (BEG; STRATHDEE; KAZATCHKINE, 2015BEG, M.; STRATHDEE, S. A.; KAZATCHKINE, M. State of the art science addressing injecting drug use, HIV and harm reduction. International Journal of Drug Policy, v. 26, suppl. 1, p. S1-S4, 2015.). In fact, this issue is encompassed by a bigger problem, which is the decoupling of the management of mental health policy from that related to alcohol and other drugs, as of this year allocated to the National Secretariat for Care and Prevention of Drugs (SENAPRED), in the Ministry of Citizenship.

There are other problematic points in the Note, such as the emphasis on the creation of specialized outpatient clinics for the treatment of less severe conditions, to the detriment of the matrix support of the family health teams and encouragement to the Nuclei of Attention to the Family Health (NASF), which allow that such cases are attended, for the most part, in Primary Care, which has high potential for resolution and great territorial capillarity in much of the country. Attention is also drawn to the fact that the only topic in which child and adolescent mental health is specifically addressed is the hospitalization of children and adolescents in psychiatric hospitals. Finally, there is the issue of the financing of electroconvulsive therapy (ECT) equipment, a point not to be underestimated, due to its history of abusive use in Brazilian asylums, but it should not be at the center of the debate either. Rehabilitated by the psychiatric literature in the last decades, ECT is still involved in controversies regarding its efficacy and side effects (REISNER, 2003REISNER, A. D. The electroconvulsive therapy controversy: evidence and ethics. Neuropsychology review, v. 13, n. 4, p. 199-219, 2003.), being an exceptional resource to be considered in severe depressions mainly, after other psychosocial and pharmacological measures have not been effective. There is no justification for stimulating their widespread acquisition in Brazil as a strategy favored by mental health policy-makers.

It is not surprising that the Note has provoked an intense reaction from social movements, associations, professional councils, health councils and the academic community, all of them committed to the principles of the RPB (ABRASCO, 2019; COREN-SP, 2019; CFP, 2019; SciELO, 2019; CES-PE, 2019; GULJOR et al., 2019). Until the closing of this editorial, Technical Note 11/2019 was still missing - but our vigilance is still present.

At a time when the rise to the federal government's ultraconservative political project puts at risk the survival of the Unified Health System (SUS), as well as that of the whole fragile Welfare State built in recent years, and in the limit of democracy itself, all care is little. The ghost of the return of asylums is only the tip of the iceberg of a whole manicomial culture that still resists in the Brazilian society, and whose deconstruction is work for a few more generations. Let ours do our part.


IMS-UERJ RJ - Brazil