Abstract

The Brazilian Psychiatry Reform was consolidated after the creation of various services and devices that came to replace the asylum psychiatry system. However, psychiatric hospitals continue to exist, they have not been completely modified and are still part of the mental health services network. This article analyzes arguments developed by professionals from two psychiatric hospitals in João Pessoa, in the state of Paraíba, to criticize the Brazilian Psychiatric Reform, focusing on the rhetorical resources mobilized to present them as objective and factual. This is a qualitative study, in which 42 interviews were obtained and submitted to discourse analysis, according to the proposal of Discursive Social Psychology. The professionals herein interviewed carry out a semantic and pragmatic movement that consists of affirming the ineffectiveness of the Psychiatric Reform while denying any opposition to the values and principles that support it. The statements about the supposed ineffectiveness of the Reform are presented as solid and objective with the use of different resources to produce factuality. Through this process, they present themselves as enlightened, tolerant people guided by the values of the Enlightenment, people who produce a credible account of the Brazilian Psychiatric Reform when they criticize its way of functioning.

Keywords:
Psychiatric Reform; Psychiatric Hospitals; Discursive Social Psychology; Rhetoric; Discourse Analysis

Introduction

In Brazil, psychiatric hospitals emerged in the mid-19th century, influenced by French psychiatry and moral treatment. These institutions began to be opposed in the West in the second half of the 20th century through the anti-psychiatric movement, which began in England, France, the United States, and Italy. Prior to this period, there were other experiences in Brazil that sought to deconstruct the asylum model, among them the work developed by Nise da Silveira, which today is embodied in the Museu de Imagens do Incosciente in Rio de Janeiro. Criticism and the fight against mental institutions in the country grew stronger in the late 1970s with the mobilization of groups linked to the professional sectors of health services, users and their families, who demanded better working conditions and care (Lüchmann; Rodrigues, 2007LÜCHMANN, L. H. H.; RODRIGUES, J. O movimento antimanicomial no Brasil. Ciência & Saúde Coletiva , Rio de Janeiro, v. 12, n. 2, p. 399-407, 2007. DOI: 10.1590/S1413-81232007000200016.
https://doi.org/10.1590/S1413-8123200700... ; Amarante; Nunes, 2018AMARANTE, P.; NUNES, M. D. O. A reforma psiquiátrica no SUS e a luta por uma sociedade sem manicômios. Ciência & Saúde Coletiva, Rio de Janeiro, v. 23, n. 6, p. 2067-2074, 2018. DOI: 10.1590/1413-81232018236.07082018.
https://doi.org/10.1590/1413-81232018236... ).

The public health proposals drawn up by the movement to transform national public health, the so-called Sanitary Reform, combined with the indignation of mental health workers, due to reports of mistreatment and poor working conditions in psychiatric hospitals (Amarante, 1995AMARANTE, P. (Org.). Loucos pela vida: a trajetória da Reforma Psiquiátrica no Brasil. Rio de Janeiro: Fiocruz, 1995.), led to the emergence of the Brazilian Anti-Psychiatric Movement inspired by Italian Democratic Psychiatry. However, it was not until 2001, after 12 years pending in the Federal Congress, that Law No. 10.216, of April 6, 2001, known as the Psychiatric Reform Law, was passed, finally regulating a model of mental health care in Brazil, an integral part of the Brazilian Unified Health System (SUS), based on a psychosocial perspective, offering treatment in the user’s own community and establishing rights for people with mental disorders (Brasil, 2001BRASIL. Lei n. 10.216, de 6 de abril de 2001. Dispõe sobre a proteção e os direitos das pessoas portadoras de transtornos mentais e redireciona o modelo assistencial em saúde mental. Brasília, DF: Ministério da Saúde, 2001. Disponível em: Disponível em: http://www.planalto.gov.br/ccivil_03/leis/leis_2001/l10216.htm . Acesso em: 13 jul. 2023.
http://www.planalto.gov.br/ccivil_03/lei... ).

As a result of historical struggles and a favorable political climate, the reformist proposal was consolidated in the country through a progressive and internationally recognized mental health policy, creating a set of substitute services-among which the Centros de Atenção Psicossocial (CAPS - Psychosocial Care Centers) and therapeutic residences stand out-and devices that counteract asylum practices. It is a complex process, since it involves not only the adoption of and investment in public policies but also the deconstruction and reconstruction of practices and concepts, as well as changes in the meanings and reactions related to psychological suffering by professionals and society (Cavada et al., 2012CAVADA, C. T. et al. O campo teórico conceitual da reforma psiquiátrica no discurso de profissionais de um centro de atenção psicossocial. Revista de Pesquisa: Cuidado é fundamental online, Rio de Janeiro, v. 4, n. 2, p. 2318-2326, 2012. Disponível em: Disponível em: http://www.redalyc.org/articulo.oa?id=505750893023 . Acesso em: 13 jul. 2023.
http://www.redalyc.org/articulo.oa?id=50... ; Nunes et al., 2019NUNES, M. D. O. et al. Reforma e contrarreforma psiquiátrica: análise de uma crise sociopolítica e sanitária a nível nacional e regional. Ciência & Saúde Coletiva , Rio de Janeiro, v. 24, n. 12, p. 4489-4498, 2019. DOI: 10.1590/1413-812320182412.25252019.
https://doi.org/10.1590/1413-81232018241... ).

Although the Brazilian Psychiatric Reform was organized on the basis of criticism and reform of the hospital-centric model, with the aim of deconstructing asylum spaces and creating alternative care models, this did not result in the extinction of psychiatric hospitals or their total reinvention. Psychiatric hospitals were evaluated and restructured both by reducing beds and the number of admissions and by migrating beds from smaller hospitals to larger ones, expanding “community-based out-of-hospital services” (Pessoa Júnior et al., 2016PESSOA JÚNIOR, J. M. et al. A política de saúde mental no contexto do hospital psiquiátrico: Desafios e perspectivas. Escola Anna Nery, Rio de Janeiro, v. 20, n. 1, p. 83-89, 2016. DOI: 10.5935/1414-8145.20160012.
https://doi.org/10.5935/1414-8145.201600... , p. 84, free translation). In the process, some hospitals were shut down. According to these authors, the recommendation is that the most serious cases should be referred to CAPS III (24-hour service), and emergencies to CAPS III or general hospitals. However, because of the challenges faced, the fragility or non-existence of crisis and emergency care services, psychiatric hospital beds are generally used. This corroborates the existence of two models of mental health care in Brazil: the asylum model and the psychosocial model (Pessoa Júnior et al., 2016PESSOA JÚNIOR, J. M. et al. A política de saúde mental no contexto do hospital psiquiátrico: Desafios e perspectivas. Escola Anna Nery, Rio de Janeiro, v. 20, n. 1, p. 83-89, 2016. DOI: 10.5935/1414-8145.20160012.
https://doi.org/10.5935/1414-8145.201600... ; Peres et al., 2018PERES, G. M. et al. Limites e desafios da rede de atenção psicossocial na perspectiva dos trabalhadores de saúde mental. Cadernos Brasileiros de Saúde Mental , Florianópolis, v. 10, n. 27, p. 34-52, 2018. DOI: 10.5007/cbsm.v10i27.69033.
https://doi.org/10.5007/cbsm.v10i27.6903... ).

Brazil’s psychiatric hospitals “were not just passive organizations”, but also institutions where various “debates, clashes and initiatives took place that informed the direction and contradictions of the process of building Brazilian mental health policy” (Goulart; Durães, 2010GOULART, M. S. B.; DURÃES, F. A reforma e os hospitais psiquiátricos: histórias da desinstitucionalização. Psicologia & Sociedade, Recife, v. 22, n. 1, p. 112-120, 2010. DOI: 10.1590/S0102-71822010000100014.
https://doi.org/10.1590/S0102-7182201000... , p. 113, free translation). They are home to a large number of professionals who sometimes work in substitute services and take their practices and representations from the hospital-centered environment to the substitute services and vice versa (Maciel et al., 2008MACIEL, S. C. et al. Exclusão social do doente mental: discursos e representações no contexto da reforma psiquiátrica. Psico-USF, Campinas, v. 13, n. 1, p. 115-124, 2008. DOI: 10.1590/S1413-82712008000100014.
https://doi.org/10.1590/S1413-8271200800... ). These professionals, as Pessoa Júnior et al. (2016PESSOA JÚNIOR, J. M. et al. A política de saúde mental no contexto do hospital psiquiátrico: Desafios e perspectivas. Escola Anna Nery, Rio de Janeiro, v. 20, n. 1, p. 83-89, 2016. DOI: 10.5935/1414-8145.20160012.
https://doi.org/10.5935/1414-8145.201600... ) attest, live with these structural, paradigmatic, operational, and doctrinal changes and with the alterations caused by the existence of other mental health services that call into question the psychiatric hospital and the importance of these professionals.

This study analyzes arguments critical of the Brazilian Psychiatric Reform in reports by professionals from psychiatric hospitals in a city in the Northeast of Brazil, focusing on the rhetorical resources used to construct them as objective and factual.

This is an analysis conducted under the guidance of the discourse analysis method developed by discursive social psychologists (Billig et al., 1988BILLIG, M. et al. Ideological dilemmas: A social psychology of everyday thinking. London: Sage Publications, 1988.; Edwards; Potter, 1993EDWARDS, D.; POTTER, J. Discursive psychology. London: Sage, 1993.; Potter, 1998POTTER, J. La representación de la realidad: discurso, retórica y construcción social. Buenos Aires: Ediciones Paidós Ibérica, 1998.; Potter; Wetherell, 1987POTTER, J.; WETHERELL, M. Discourse and Psychology: beyond attitudes and behavior. London: Sage , 1987.; Stokoe, 2015STOKOE, E. Identifying and responding to possible -isms in institutional encounters: alignment, impartiality and the implications for communication training. Journal of Language and Social Psychology, Thousand Oaks, v. 34, n. 4, p. 427-445, 2015. DOI: 10.1177%2F0261927X15586572.
https://doi.org/10.1177%2F0261927X155865... ; Wetherell; Potter, 1992WETHERELL, M.; POTTER, J. Mapping the language of racism: discourse and the legitimation of exploitation. London: Harvester Wheatsheaf, 1992.; Whitehead, 2015WHITEHEAD, K. A. Everyday antiracism in action: Preference organization in responses to racism. Journal of Language and Social Psychology , Thousand Oaks, v. 34, n. 4, p. 374-389, 2015. DOI: 10.1177%2F0261927X15586433.
https://doi.org/10.1177%2F0261927X155864... ), who understand speeches and texts of the most different types as social practices with the most varied consequences, and pay special attention to the use of different rhetorical resources-construction of narratives, syntactic arrangements, manipulation of categories, among others-which negotiate and constitute identities, resolve dilemmas, and construct and make credible, factual and true certain versions of reality.

The notion of ideological dilemmas is central to this study. Criticizing social psychology’s approach to dilemmas, Billig et al. (1988BILLIG, M. et al. Ideological dilemmas: A social psychology of everyday thinking. London: Sage Publications, 1988.) consider that social psychologists do not investigate dilemmas per se, only the decision-making process. In turn, they propose that social psychology research should focus on the content of dilemmas, which would be the precondition for decision-making. For them, every dilemma includes conflicting values in society, ideological values par excellence. Ideology, for these authors, is not a set of concepts with internal unity; ideologies can produce conformity, but as they contain conflicting themes within them, they make argumentation and reflection possible.

The conflicting values in society are actualized in individual subjectivities (Billig et al., 1988BILLIG, M. et al. Ideological dilemmas: A social psychology of everyday thinking. London: Sage Publications, 1988.), often producing ambiguous, tortuous, and indirect narratives and arguments when people are asked to talk about issues that involve them.

In these narratives and arguments, people often find themselves facing certain problems. One of them, which is present in the speeches of the professionals investigated here, can be formulated like this: how can you attack a certain group, institution, theory, etc. without being accused of reactionaryism, backwardness, intolerance? This is solved through rhetorical resources that seek to inoculate the attacker against this type of accusation, which have been so well studied by authors such as Van Dijk (1987VAN DIJK, T. A. Communicating racism: Ethnic prejudice in thought and talk. London: Sage Publications , 1987.), Billig et al. (1988BILLIG, M. et al. Ideological dilemmas: A social psychology of everyday thinking. London: Sage Publications, 1988.), Edwards and Potter (1993EDWARDS, D.; POTTER, J. Discursive psychology. London: Sage, 1993.), Wetherell and Potter (1992WETHERELL, M.; POTTER, J. Mapping the language of racism: discourse and the legitimation of exploitation. London: Harvester Wheatsheaf, 1992.), and Potter (1998POTTER, J. La representación de la realidad: discurso, retórica y construcción social. Buenos Aires: Ediciones Paidós Ibérica, 1998.). Another problem to be solved in these cases is the following: how can what is claimed about groups, institutions, or movements be constructed as a factual account, and not as a false, illusory, or ideologically motivated account? Social psychologists such as Edwards and Potter (1993EDWARDS, D.; POTTER, J. Discursive psychology. London: Sage, 1993.) and Potter (1998POTTER, J. La representación de la realidad: discurso, retórica y construcción social. Buenos Aires: Ediciones Paidós Ibérica, 1998.) have investigated this type of epistemological action of discourse, and some of the rhetorical resources they highlight to carry out this type of action are mobilized by the participants in this research.

The way in which these professionals from the mental health network define the Reform provides clues as to how they work in the field of mental health and to what extent they position themselves at the service of hospital principles, which reproduce traditional practices for treating mental suffering. The relevance of this study lies, above all, in the possibility of understanding these arguments and their implications and contributing to further reflection on the Brazilian Psychiatric Reform.

Method

Context, participants, and instruments

The research was carried out in João Pessoa, capital of the state of Paraíba, in northeastern Brazil. At the time of the research, there were two psychiatric hospitals in this municipality: the Instituto de Psiquiatria da Paraíba (a private institution) and the Complexo Psiquiátrico Juliano Moreira (a public institution).

An average of 62 professionals worked at the Instituto de Psiquiatria da Paraíba (IPP). This hospital was closed down because it was discovered that the patients were being mistreated and tortured. Around 108 professionals worked at the Complexo Psiquiátrico Juliano Moreira (CPJM).

To carry out the research, we used the qualitative methodology of Oral History, obtaining oral testimony-which aims to “(…) obtain information and testimony from the interviewee about their experience in certain situations or their participation in certain institutions” (Lang; Campos; Demartini, 2010LANG, A. B. S. G.; CAMPOS, M. C. S. S.; DEMARTINI, Z. B. F. História oral, sociologia e pesquisa: a abordagem do CERU. São Paulo: Centro de Estudos Rurais e Urbanos, 2010., p. 45, free translation)-since this study is not looking for realistic accounts of these professionals’ experience in these institutions, but is interested in understanding how they discursively construct these institutions and their participation in them.

A total of 42 professionals were interviewed. Of the 11 interviewees at the IPP, one is a psychiatrist; three are nurses; two are nursing technicians; two are psychologists; two are social workers; and one is a nutritionist. Nine of them have completed higher education, and two have technical training. Participants’ working time at the institution ranged from two months to 40 years. As for gender, six are women and five are men, ranging from 28 to 66 years of age.

At the CPJM, of the 31 professionals interviewed, four are psychologists; seven are nurses; five are nursing technicians; one is an art therapist; one is an acupuncturist and biomagnetist; one is an auriculotherapist; one is a librarian; five are social workers; two are pharmacists; two are nutritionists; and two are psychiatrists. Twenty-three have completed higher education; six have technical training; and two have secondary education. As for gender, 24 are women and seven are men. Participants’ working time at the institution ranged from one year and six months to 49 years.

The number of interviews was determined by the saturation point criterion (Lang; Campos; Demartini, 2010LANG, A. B. S. G.; CAMPOS, M. C. S. S.; DEMARTINI, Z. B. F. História oral, sociologia e pesquisa: a abordagem do CERU. São Paulo: Centro de Estudos Rurais e Urbanos, 2010.). Thus, the analysis was carried out simultaneously with the construction of the corpus and, when it was observed that there was no more formal and content variation, the interviews were terminated. All the interviews were carried out in the institutions in question, in private places, in order to guarantee the right conditions for obtaining the testimonies. The interviews began by asking the participants to give a statement on what they understood by Psychiatric Reform. Questions were then asked to address the research objectives. So the following items were prioritized: substitute services and the professionals who work in them; users; psychiatric hospitals and the professionals who work in them; and psychological suffering. During the course of the interviews, when these items were not raised spontaneously by the interviewees, the interviewers put them on the agenda.

Before starting the investigation, the research project was submitted to the Ethics and Research Committee of the university to which most of the researchers are affiliated. To keep the interviewees anonymous, pseudonyms were used.

Analysis of the interviews

The interviews were transcribed, read, and reread, necessary steps for the coding process which, in discourse analysis, is a preliminary assessment whose aim is not to find results, but to organize the categories determined by the research questions for further study (Potter; Wetherell, 1987POTTER, J.; WETHERELL, M. Discourse and Psychology: beyond attitudes and behavior. London: Sage , 1987.; Gill, 2003GILL, R. Análise de discurso. In: BAUER, M.; GASKELL, G. (Org.). Pesquisa qualitativa com texto, imagem e som: um manual prático. 2. ed. Rio de Janeiro: Vozes, 2003. p. 244-270.).

The analysis process consists of two associated stages. The first is when we look for differences and similarities in the content and forms of the discourses, common characteristics in the different discourses. The second is when the function and consequences of the discourses are identified, hypotheses are formulated about the effects produced by them and evidence for these hypotheses is sought in the material being analyzed (Potter; Wetherell, 1987POTTER, J.; WETHERELL, M. Discourse and Psychology: beyond attitudes and behavior. London: Sage , 1987.).

Results

The results of the analysis of the professionals’ arguments will be divided into three subsections. The first will explore an argument about Psychiatric Reform that was repeated with slight variations in the participants’ interventions. In the second, the focus will be on the rhetorical resources they use, which aim to present the descriptions they produce as solid and factual. The third examines the identities they construct for themselves in the development of the argumentative line and how they are used to give credibility to what they say.

These three discursive processes will be examined in the excerpts below from the interviews of four research participants.

Look, as I said at the beginning, the Psychiatric Reform, as it stands on paper, is beautiful. It’s perfect. It’s only that, in practice, it doesn’t… it doesn’t happen, okay? What are we seeing today? I’ll tell you for myself. I live… I’m working in the first neighborhood of João Pessoa, which is Cruz das Armas, but I live in the last neighborhood of João Pessoa, which is Bessa. After Bessa, Cabedelo begins. Another municipality. So every day I take the BR [highway] to get to work. Look, I’ve seen lots of mentally ill people on these… on these roadsides, on these… BR… with… with… sticks, carrying their little bundle of clothes, carrying… eh… dirty, begging for food, I can’t believe it. And we know they’re mentally ill. If you go to the handicraft market in João Pessoa, here on the beach, you’ll see another… another… full of patients there… mentally ill people there. If you go to those stalls on the beach, where the… a… the fish market and those stalls where… eh… food is provided, you’ll see another bunch of mentally ill people there. So much so that… I, who usually walked along the beach at five in the morning, stopped. I stopped walking. Why did I stop walking? Because when I went for a walk, they… shouted: “Dr. Fernanda! Dr. Fernanda! Dr. Fernanda!” And the situation… it was… it was so sad, you know? So sad that I stopped walking, I’m not walking anymore. I’m not… so I don’t see that situation (…) So… it seems that… eh… the hospital’s demand has been reduced. Hospital vacancies have been reduced because of the substitute services… substitutes. So what happens… but… what we’re seeing is that the substitute service hasn’t… they haven’t absorbed all these clients. So what happens? It’s full of mentally ill people on the seafront, full of mentally ill people on the highways, full of mentally ill people in prisons. In prisons. I say that because… I work in a judicial asylum, and I know. I have… I have the credentials to say that (…) (Fernanda, Psychiatrist, IPP).

Because if it’ not like that, it doesn’t work, what Paulo Delgado [author of the Brazilian Psychiatric Reform law] did was a very beautiful thing, (…) it’s the Psychiatric Reform law, right? So it talks about therapeutic residences, the De Volta pra Casa program [financial aid for the care and monitoring of people in psychological distress who have left psychiatric hospitals], it talks about family participation in care, it talks about the right to the client, exceptional medication, by law, it talks about the right to hospitalization, the right to a consultation, it talks about the length of time the patient should stay and because it’s in hospital, a long time in the psychiatric hospital… but we know that in practice it doesn’t quite work like that… there are medications that the patient, for example, will take and then go for three months without medication, and then what? The medication costs 1,500 reais, 2,000 reais… so we put a law into practice that has to work, but the services aren’t available. The CAPS, for example, when the patient is in an outbreak, the CAPS doesn’t give support, there are patients there from Guarabira [a municipality in Paraíba], from the CAPS to take an intramuscular medication for an emergency and come back, because the CAPS doesn’t have support for the patient. Because they only have a psychiatrist once a week (Patrícia, Nurse, CPJM).

In theoretical terms, we see that everything… not just psychiatric reform, but many other measures that exist in the SUS itself… The SUS is a very beautiful model, and the reform also has a beautiful objective. But in practice we see something different. So, the part that has the objective of taking the patient into the family, removing this question of the institution, these patients spending their lives in the institution as it used to be, while there is this side to it, which is very interesting, in quotes, I have the reality of some patients who need to be in an institution both because they have a psychiatric family and because they are a patient who is in an institution from a psychiatric point of view, but when they return to their family they become ill again because of that family, because the family is sick, the family isn’t treated (…) it’s interesting, this question of removing this… this stigma of the psychiatric hospital. There’s a good side and there’s a bad side, I think it’s a question of how the whole SUS needs to be refined (Joana, Nutritionist, CPJM).

What do you think of the Psychiatric Reform? (Interviewer)

I think it’s a wonderful idea. Now I think the implementation is lacking a lot, right? Because there’s a lot of equipment from the reform, right? That haven’t been implemented. So… it’s leaving a lot to be desired, right? Because there’s a large contingent of… of patients with mental disorders who are not receiving care. There’s even a statistic from the Ministry of Health itself… of… of… 2012-2013 that… there are around fifty thousand… it’s… patients with disorders… mental disorders without assistance. Many of these people are on the streets and… in prisons, jails, right? There has been a very strong… very… comprehensive withdrawal of psychiatric beds from hospitals and… (…) We know that psychiatric hospitals have never offered good treatment, right? And even… to this day they treat in the same way, and perhaps worse because… because those that are still working… are automatically working in the red and the service is getting worse. Why is that? The staff is reduced, right? There’s less staff… things get more difficult… every time… it gets more and more difficult for the hospitality… of the hospital to be good. Yeah… as far as I know… the daily rate… the daily rate for… of the patients here at the hospital, at the moment, I think it’s around a hundred. If I’m not mistaken, it’s still that amount. Then it gets complicated… most… most hospitals have closed their doors because they can’t, right? (Rogério, Psychologist, IPP).

I have nothing against the reform, but…

In the line of argument developed, the professionals do not criticize the existence of the Reform itself, nor the objectives it seeks to achieve. The criticism is aimed at the precarious functioning of the different services that make up the Reform and which would determine its ineffectiveness.

These and several other professionals interviewed in this study reproduced in their statements a semantic and pragmatic movement with the same structure as that described by Van Dijk (1987VAN DIJK, T. A. Communicating racism: Ethnic prejudice in thought and talk. London: Sage Publications , 1987., p. 91) when studying racist discourse, which consists of denying any negative opinion about a specific ethnic group and then expressing a negative opinion about that group. This is a semantic movement with the following form: “I’m not racist, but…”.

In the interventions above and in several others, the format is as follows: “I’m not against the values and principles that underpin the reform, but…”. Fernanda says: “Look, as I said at the beginning, the Psychiatric Reform, as it stands on paper, is beautiful. It’s perfect. It’s only that, in practice, it doesn’t…”. Patrícia, after listing what care should be like in substitute services, says: “but we know that in practice it doesn’t quite work like that”. Joana, after stating that the objective of the Reform is “very beautiful”, says: “But in practice we see something different”. In Patrícia’s and Joana’s formulations [in Portuguese], the contrast present in the semantic movement identified by Van Dijk (1987VAN DIJK, T. A. Communicating racism: Ethnic prejudice in thought and talk. London: Sage Publications , 1987.) is represented by the adversative conjunction “mas” (but) and, in Fernanda’s, by the phrase “só que” (it’s only that), which replaces the conjunction “mas” in informal language.

Rogério, like Fernanda, Patrícia, and Joana, also carries out the semantic and pragmatic movement described by Van Dijk (1987VAN DIJK, T. A. Communicating racism: Ethnic prejudice in thought and talk. London: Sage Publications , 1987.). He begins by saying that the Reform “is a wonderful idea”, but then uses the adverb “agora” (now), which, depending on the context, also functions as the adversative conjunction “but” to mark the transition from praise to attack: “now, I think the implementation is lacking”. And he proceeds to exhaustively describe that which is lacking in the implementation.

His account subtly suggests that hospitals today are not the same as in the past. Today’s psychiatric hospitals are in a worse situation than those of the past due to insufficient funding for these facilities by the Brazilian state.

The importance of a frequent dichotomy in the arguments of these professionals should be emphasized. This is the dichotomy between theory and practice (“But in practice we see…”, “only, in practice, it doesn’t…”, “but we know that in practice…”). In these statements, they create a confrontation between the beautiful ideals of the Reform and the harsh institutional reality, as described by them, and position themselves as people who present a realistic and objective version of the institutional context in which they work.

Construction of facts

In a fundamental study of discursive social psychology on the construction of factuality, Potter (1998POTTER, J. La representación de la realidad: discurso, retórica y construcción social. Buenos Aires: Ediciones Paidós Ibérica, 1998.) examines the epistemological orientation of descriptions, an important concept for analyzing the accounts of the participants in this research. According to Potter, at one end of a continuum that hierarchizes descriptions in terms of the validity of the knowledge they produce about the world, we have descriptions that are seen as solid and definitive, understood as separate and independent from the speakers. At the other extreme, on the other hand, we have descriptions that are considered provisional, uncertain, doubtful, descriptions that are suspected of being affected by the speaker’s interests, values, etc. The author is not positioning himself between the defenders of realism and anti-realism. He is therefore not defending any epistemological position. His interest is in identifying and understanding the discursive strategies used to construct a description as factual and those used to undermine its factuality.

In these professionals’ interventions, different resources were used to produce factuality. They constructed stories, sometimes only sketched out, in small fragments (“there are medications that the patient, for example, will take and then go for three months without medication”, “I have the reality of some patients who need to be…”), to turn the argument that the Reform’s substitute services are ineffective into fact, because “in practice, they don’t work”. In argumentative lines, stories have the function of providing factual evidence for the argument being mobilized (Van Dijk, 1987VAN DIJK, T. A. Communicating racism: Ethnic prejudice in thought and talk. London: Sage Publications , 1987.).

According to Potter (1998POTTER, J. La representación de la realidad: discurso, retórica y construcción social. Buenos Aires: Ediciones Paidós Ibérica, 1998.), in this process of constructing factuality through stories, the narrators often present themselves as a witness, an effective position when it comes to transforming what is being narrated into fact. This is because the one who places themselves in this position describes the scene as it would have been perceived with their own eyes. In Fernanda’s story, she presents herself as a credible witness in a very effective way. The detailed and expressive description and the use of direct speech (“Dr. Fernanda! Dr. Fernanda! Dr. Fernanda!”) contribute to giving the story being told a character of factuality. These resources are, as Potter (1998POTTER, J. La representación de la realidad: discurso, retórica y construcción social. Buenos Aires: Ediciones Paidós Ibérica, 1998.) reminds us, producers of externalization, they divert attention away from the interests of the narrator and, in empiricist fashion, present what is narrated as something impersonal and objective, using direct quotations and detailed, expressive, and intense descriptions.

The rhetoric of quantification, another resource for constructing factuality (Potter; Wetherell; Chitty, 1991POTTER, J.; WETHERELL, M.; CHITTY, A. Quantification rhetoric - cancer on television. Discourse & Society, Thousand Oaks, v. 2, n. 3, p. 333-365, 1991. DOI: 10.1177/0957926591002003005.
https://doi.org/10.1177/0957926591002003... ; Potter, 1998POTTER, J. La representación de la realidad: discurso, retórica y construcción social. Buenos Aires: Ediciones Paidós Ibérica, 1998.), is used by Rogério when he states that: “There’s even a statistic from the Ministry of Health itself… of… of… 2012-2013 that… there are around fifty thousand… it’s… patients with disorders… mental disorders without assistance”. Rogério mentions these statistics from the Ministry of Health at a time when he suggests that this number of unassisted people is related to “a very strong withdrawal” of “psychiatric beds from hospitals”.

Identity management

The identity of the participants in this research has been managed in different ways to present as solid, definitive and factual the claim that the Reform does not work “in practice”.

Resources used to construct factual accounts can be centered on the identity of the speakers (their interests, knowledge, etc.) or they can highlight the independence between the speaker and their account (Potter, 1998POTTER, J. La representación de la realidad: discurso, retórica y construcción social. Buenos Aires: Ediciones Paidós Ibérica, 1998.). But also in the latter case, the identity of the speaker must be managed, because they must be carefully presented as a person whose interests, desires, etc. do not affect the objectivity of their account.

Fernanda’s statement about there being “mentally ill people in prisons” is preceded by the statement that she works in a judicial asylum and therefore has “the credentials to say that”. In this case, an attribute of Fernanda’s identity, her “credentials”, i.e., her knowledge, her training, is mobilized to give solidity to the statement.

The identity of witness, on the other hand, used very intensely when Fernanda describes her contact with “mentally ill people” on the streets of João Pessoa, seeks to highlight the independence between the speaker and her account. In this testimony, she presents herself as someone who has no interest, someone who describes the scene in such detail and vividly because she witnessed it and can reproduce it objectively and faithfully.

There is yet another strategy used to highlight the independence between the speaker and their account in the speeches of these professionals that should be emphasized. By affirming their agreement with the Reform’s values at various points, the participants are formulating an identity for themselves that inoculates them against the accusation of being sympathetic to oppressive and reactionary practices, a likely accusation if one takes into account that they are criticizing the functioning of a Psychiatric Reform whose raison d’être is to combat these practices in the field of mental health. They are therefore implicitly saying that what they say is an objective description of reality and not a distorted description determined by adherence to some political ideology.

Discussion

The accounts analyzed above can only be understood by considering the relationship between the psychiatric hospitals where the interviewees work and the Brazilian health system. The Brazilian Psychiatric Reform law determines the gradual reduction of psychiatric beds and their replacement by other mental health services, especially CAPS. This reduction is taking place, despite resistance from sectors of traditional psychiatry, in both public and private hospitals that have agreements with the SUS (Duarte; Garcia, 2013DUARTE, S. L.; GARCIA, M. L. T. Reforma psiquiátrica: trajetória de redução dos leitos psiquiátricos no Brasil. Emancipação, Ponta Grossa, v. 13, n. 1, p. 39-54, 2013. DOI: 10.5212/Emancipacao.v.13i1.0003.
https://doi.org/10.5212/Emancipacao.v.13... ) and depend on public funds controlled and distributed by this health system to operate.

The direct and indirect criticisms of the Reform in the professionals’ accounts, which state not only its ineffectiveness, but also the stigmatization of psychiatric hospitals by the Brazilian state, are part of an ongoing struggle for resources that are distributed in Brazil, both to substitute services and to public and private psychiatric hospitals. It should also be considered that in the discourse that drove the Brazilian Psychiatric Reform, psychiatric hospitals should cease to exist. As Luzio and Yasui (2010LUZIO, C. A.; YASUI, S. Além das portarias: desafios da política de saúde mental. Psicologia em estudo, Maringá, v. 15, n. 1, p. 17-26, 2010. Diponível em: Diponível em: https://www.scielo.br/j/pe/a/kMBL9LPfptHsJZCs5H5Vhpr/?lang=pt . Acesso em: 13 jul. 2023.
https://www.scielo.br/j/pe/a/kMBL9LPfptH... , p. 21) argue, the text of the reform that was approved was far removed from the “healthy radicalism of the original project”, in which it was proposed that mental institutions should be phased out.

The mental health and psychosocial care policies developed in the context of the Brazilian Psychiatric Reform began to be implemented at the beginning of a historical period, the New Republic, which marked Brazil’s departure from the dictatorial regime that began in 1964. Mental health workers were inspired by the Italian anti-psychiatric movement and other anti-psychiatric movements in other Western countries to build the reform process in Brazil (Amarante; Nunes, 2018AMARANTE, P.; NUNES, M. D. O. A reforma psiquiátrica no SUS e a luta por uma sociedade sem manicômios. Ciência & Saúde Coletiva, Rio de Janeiro, v. 23, n. 6, p. 2067-2074, 2018. DOI: 10.1590/1413-81232018236.07082018.
https://doi.org/10.1590/1413-81232018236... ).

The slogan “A society without asylums”, under the influence of intellectuals from the international anti-psychiatric movement, such as Franco Rotelli, Franca Basaglia, Félix Guatarri, among others, became central to the discourse of those who criticized psychiatric care in Brazil in the 1980s. From that moment on, they began to fight explicitly for the extinction of the asylum and not just for its reform (Amarante; Nunes, 2018AMARANTE, P.; NUNES, M. D. O. A reforma psiquiátrica no SUS e a luta por uma sociedade sem manicômios. Ciência & Saúde Coletiva, Rio de Janeiro, v. 23, n. 6, p. 2067-2074, 2018. DOI: 10.1590/1413-81232018236.07082018.
https://doi.org/10.1590/1413-81232018236... ).

The hospitals have not been abolished, but they have started to operate under the guidelines established by the Psychiatric Reform, which determine, for example, a reduction in the number of hospital beds and the construction of smaller hospitals (Duarte; Garcia, 2013DUARTE, S. L.; GARCIA, M. L. T. Reforma psiquiátrica: trajetória de redução dos leitos psiquiátricos no Brasil. Emancipação, Ponta Grossa, v. 13, n. 1, p. 39-54, 2013. DOI: 10.5212/Emancipacao.v.13i1.0003.
https://doi.org/10.5212/Emancipacao.v.13... ). This situation helps to understand the ambiguous rhetoric of the subjects interviewed for this study, salaried professionals in mental health facilities that are funded by the SUS. This system implements a public mental health policy that was created to combat the obscurantist, oppressive, and violent practices that characterized the history of psychiatric hospitals in Brazil and other parts of the world, and whose principles guide everything that is planned in mental health in Brazil.

In such a context, it was to be expected that the criticisms of the Reform formulated by the professionals would be carefully organized in a process of identity management so as to avoid the accusation of reactionism, backwardness, and authoritarianism. The arguments analyzed here expressed total or partial adherence to some of the Reform’s principles, which are part of a certain liberal humanism: psychosocial rehabilitation, the reintegration of people with psychological disorders into the family, the world of work, culture, and leisure, humanized treatment, etc.

Therefore, to say that they are managing their identity by trying not to come across as reactionary does not mean that they are hiding their representations of the Reform. The organization of their narratives indicates that they are negotiating with conflicting values, trying to resolve ideological dilemmas (Billig et al., 1988BILLIG, M. et al. Ideological dilemmas: A social psychology of everyday thinking. London: Sage Publications, 1988.). One of these dilemmas is made up, on the one hand, of the economic interests of professionals in psychiatric hospitals and, on the other, of the values of Western liberalism which they share to a greater or lesser extent. Adherence to these values and the recognition that they are important to other people in our society is what organizes these discourses that seek to present them as people who do not hold irrational prejudices against people with psychological disorders. By affirming the values of liberalism and enlightenment and constructing an identity characterized by tolerance and rationality, they make a common movement of individuals in Western societies, as shown by Billig et al. (1988BILLIG, M. et al. Ideological dilemmas: A social psychology of everyday thinking. London: Sage Publications, 1988.).

Nor can we disqualify these criticisms of the implementation of the Reform by simply classifying them as absurd or fanciful, motivated solely by the pure economic interest of these professionals who are salaried employees of psychiatric hospitals. Weaknesses in the implementation of the Reform have been identified in the literature. In fact, the proposal has faced and is facing various problems and challenges in putting into practice the principles that underpin it, as evidenced by the work of Hirdes (2009HIRDES, A. A reforma psiquiátrica no Brasil: uma (re) visão. Ciência & Saúde Coletiva , Rio de Janeiro, v. 14, n. 1, p. 297-305, 2009. DOI: 10.1590/S1413-81232009000100036.
https://doi.org/10.1590/S1413-8123200900... ), Amancio and Elia (2017AMANCIO, V. R.; ELIA, L. Panorama histórico-político da luta antimanicomial no Brasil: as instabilidades do momento atual. Cadernos Brasileiros de Saúde Mental, Florianópolis, v. 9, n. 24, p. 22-49, 2017. DOI: 10.5007/cbsm.v9i24.69616.
https://doi.org/10.5007/cbsm.v9i24.69616... ), Amarante and Nunes (2018AMARANTE, P.; NUNES, M. D. O. A reforma psiquiátrica no SUS e a luta por uma sociedade sem manicômios. Ciência & Saúde Coletiva, Rio de Janeiro, v. 23, n. 6, p. 2067-2074, 2018. DOI: 10.1590/1413-81232018236.07082018.
https://doi.org/10.1590/1413-81232018236... ), Peres et al. (2018PERES, G. M. et al. Limites e desafios da rede de atenção psicossocial na perspectiva dos trabalhadores de saúde mental. Cadernos Brasileiros de Saúde Mental , Florianópolis, v. 10, n. 27, p. 34-52, 2018. DOI: 10.5007/cbsm.v10i27.69033.
https://doi.org/10.5007/cbsm.v10i27.6903... ), Nunes et al. (2019NUNES, M. D. O. et al. Reforma e contrarreforma psiquiátrica: análise de uma crise sociopolítica e sanitária a nível nacional e regional. Ciência & Saúde Coletiva , Rio de Janeiro, v. 24, n. 12, p. 4489-4498, 2019. DOI: 10.1590/1413-812320182412.25252019.
https://doi.org/10.1590/1413-81232018241... ), and Chagas and Brutti (2019CHAGAS, G. D.; BRUTTI, T. A. As recentes mudanças na Política Nacional de Saúde Mental frente à Constituição de 1988. Revista Caribeña de Ciencias Sociales, outubro 2019, paginação irregular, 2019. Disponível em: Disponível em: https://www.eumed.net/rev/caribe/2019/10/recentes-mudancas-politica.html . Acesso em: 29 maio 2020.
https://www.eumed.net/rev/caribe/2019/10... ).

There is still a “discrepancy” between what the reformist proposal advocates and the concrete reality, especially with regard to changing “an aspect that is so ingrained in the national culture”, which is to conceive of the mental health user “as an obstacle to the full development of social dynamics”, considering “‘justifiable’ their exclusion to the intra-hospital environment” (Chagas; Brutti, 2019CHAGAS, G. D.; BRUTTI, T. A. As recentes mudanças na Política Nacional de Saúde Mental frente à Constituição de 1988. Revista Caribeña de Ciencias Sociales, outubro 2019, paginação irregular, 2019. Disponível em: Disponível em: https://www.eumed.net/rev/caribe/2019/10/recentes-mudancas-politica.html . Acesso em: 29 maio 2020.
https://www.eumed.net/rev/caribe/2019/10... , p. 4, emphasis added, free translation).

As Nunes et al. (2019NUNES, M. D. O. et al. Reforma e contrarreforma psiquiátrica: análise de uma crise sociopolítica e sanitária a nível nacional e regional. Ciência & Saúde Coletiva , Rio de Janeiro, v. 24, n. 12, p. 4489-4498, 2019. DOI: 10.1590/1413-812320182412.25252019.
https://doi.org/10.1590/1413-81232018241... ) warn, the Reform’s advances-procedural and unfinished-distributed unevenly across the country, have made a significant contribution to the implementation of psychosocial care and the process of deinstitutionalization. However, no Psychiatric Reform movement has ever been a definitive historical achievement, as the movement is constantly the target of rejections and attacks and is at the mercy of sociohistorical, cultural, and political factors, which is no different in Brazil. In this sense, since 2017, a policy of dismantling the National Mental Health Policy has been in place in the country, orchestrated by the federal government since 2015, which has reinforced the hospital-centric and neoliberal model and directly affected the reformist proposal with the advancement of a Psychiatric Counter-Reform project (Chagas; Brutti, 2019CHAGAS, G. D.; BRUTTI, T. A. As recentes mudanças na Política Nacional de Saúde Mental frente à Constituição de 1988. Revista Caribeña de Ciencias Sociales, outubro 2019, paginação irregular, 2019. Disponível em: Disponível em: https://www.eumed.net/rev/caribe/2019/10/recentes-mudancas-politica.html . Acesso em: 29 maio 2020.
https://www.eumed.net/rev/caribe/2019/10... ; Lima, 2019LIMA, R. C. O avanço da Contrarreforma Psiquiátrica no Brasil. Physis: Revista de Saúde Coletiva, Rio de Janeiro, v. 29, n. 1, e290101, 2019. DOI: 10.1590/S0103-73312019290101.
https://doi.org/10.1590/S0103-7331201929... ; Nunes et al., 2019NUNES, M. D. O. et al. Reforma e contrarreforma psiquiátrica: análise de uma crise sociopolítica e sanitária a nível nacional e regional. Ciência & Saúde Coletiva , Rio de Janeiro, v. 24, n. 12, p. 4489-4498, 2019. DOI: 10.1590/1413-812320182412.25252019.
https://doi.org/10.1590/1413-81232018241... ). The accounts of the professionals analyzed here were constructed in this context and can only be fully understood if the regressive nature of this historical moment is taken into account.

Final considerations

This article analyzed the arguments developed by professionals from psychiatric hospitals to criticize the Brazilian Psychiatric Reform, paying attention to the rhetorical resources used to present the accounts as factual.

These professionals do not formulate criticisms that question the principles of the Psychiatric Reform, but rather focus on the effectiveness of the Reform. They mobilize rhetorical resources that construct them as enlightened, tolerant, and reasonable people, people who produce an objective and factual account of the Brazilian Psychiatric Reform when they criticize the way it works.

This is not to say that these professionals cynically manage the construction of their identities, hiding their aversion to the values of the Reform and their predilection for the hospital-centered model. Nothing in their statements indicates that the discourse and values of the Brazilian Psychiatric Reform are not important to them and affect them in some way. Their comings and goings and the care they take in formulating their statements show that they are people crossed by conflicting values and interests. However, we cannot disregard the consequences that these positions may have for the reform movement and the deinstitutionalization process, especially in a context where the counter-reform movement is gaining ground and supporters.

It is estimated that this research, although limited to the city of João Pessoa, can contribute to evaluating the impact of the process of implementing the Psychiatric Reform in the country, offering a basis for interventions in the area of mental health and public policies in line with reformist principles.

References

Publication Dates

History