In defense of public mental health policy

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By JULIAN RODRIGUES*

The Bolsonaro government operates the return of asylums and the dismantling of the national public network of psychosocial care

In early December 2020, corporate media outlets published reports reporting the intention of the Ministry of Health to revoke, in a single stroke, almost a hundred ordinances and regulations that structure, from the 1990s to National Mental Health Policy.

A one-time dismantling. A throwback of decades, as if we were going back, in the blink of an eye, to the first half of the XNUMXth century. It is true that it has never been easy to institute a policy of “de-internment of the insane”. Or treat “addicts” like people, creating a humanized CAPS (Psychosocial Care Center) network. And programs like Back home (de-institutionalization), the Therapeutic Residences and os Street offices.

Conservatives, authoritarians, moralists, religious fundamentalists and health mercantilists have always acted against the construction of a public mental health system based on the principle of harm reduction. Backed by the recognition of rights, autonomy, freedom and diversity. Part of the medical community (psychiatrists) and reactionary academics also always militated against the principles of psychiatric reform.

But, by leaps and bounds, we had been advancing building the RAPS (psychosocial care network). The assumptions of this mental health policy are social emancipation and non-incarceration. The focus is on respect for the individual's autonomy, care, networking, social inclusion. Hence the diversity of therapeutic resources (removing the central role of the doctor and the hospital). For example, instead of compulsory hospitalization, comprehensive, interdisciplinary care.

The Temer government, an expression of the democratic rupture that occurred in 2016, launched a first major offensive against the democratic mental health policy. The coup leader appointed Quirino Cordeiro, one of the oldest in the country and in the process of closing, the conservative psychiatrist who directed the asylum in Juqueri, one of the oldest in the country, as coordinator.

Cordeiro worked intensely to expand psychiatric beds and hospitals, disqualifying the principle of prioritizing outpatient care and questioning the effectiveness of CAPS. He edited, between 2016 and 2019, fifteen normative documents pointing to a “new mental health policy”. Expanding the number of units and filling therapeutic communities with resources, encouraging hospitalizations, has become the center of public policy for alcohol and drugs.

However, registration is required. The lack of debate, programmatic-pragmatic concessions, ideological setbacks and alliances with religious fundamentalists already came from the governments led by the PT, especially during the period of President Dilma Rousseff. There was a battle between technicians, managers and historical militants to preserve achievements and shield mental health, alcohol and drug policy from conservative religious influence. An example of a setback was the financial incentive and the loosening of supervision over therapeutic communities and the “Crack is possible to win” program (wrong from beginning to end, encouraging the police apparatus, hostage to moral panic and common sense, anti-scientific ).

In addition to the wrong approach (based on abstinence, moralism, forced hospitalizations), these policies promote and finance right-wing Christian groups/leaders, with strong electoral ties to conservative parties and candidates. They attack science, the secular state, human rights and democracy. Most of them supported the 2016 coup, made possible the election of the neo-fascist Bolsonaro and are, today, one of his main bases of support.

Ensuring civilizational advances

The Unified Health System (universal, free, participatory, promoting equity) is the greatest social achievement of the Brazilian people. The result of a decades-long struggle – driven by activists, sanitarians and (left-wing) thinkers. The Brazilian elites never agreed with the assumptions of the SUS – they have always acted to scrap and privatize the System.

Among the numerous areas and policies of excellence included in the SUS (vaccination, transplants, family health, fighting HIV/AIDS), psychiatric reform and the construction of the national mental health policy are one of the most beautiful and important gains. Bolsonarists' hatred is not gratuitous.

It was in the midst of the movement for redemocratization, at the end of the 1970s, that the struggle for psychiatric reform gained strength, which denounces the violence of asylums, the commodification-instrumentalization of “madness” and the “hospital-centric” model of care for people with mental disorders. mental. Fighting for the Unified Health System, the anti-asylum movement was fundamental in the fight against the true concentration camps that were the great Brazilian asylums, a repository for poor, black, “misfit” people for decades on end.

A paradigmatic example: the Hospital Colônia de Barbacena, founded in 1903, imprisoned, tortured and killed thousands of people. With patients from different regions, it became a veritable extermination camp for the oppressed – those who did not fit the standards. Alcoholics, prostitutes, LGBTI people, political enemies of the elites, all kinds of “unwanted” people. It is estimated that 60 people died in the eight decades of existence of this asylum/prison/concentration camp.

1987: with the growth of the anti-asylum struggle, it was possible to hold, in the city of Bauru, the II National Congress of Mental Health Workers, a key moment that summarizes the objective of the movement: “for a society without asylums”. And the fight went further.

The PT's administrations in Santos, with Telma de Souza and David Capistrano (1989-1996), established the foundations of new public mental health policies, putting the psychiatric reform into practice.

In the same period, Paulo Delgado, PT federal deputy, placed on the agenda of the National Congress the bill that “provides for the progressive extinction of asylums and their replacement by other assistance resources and regulates compulsory psychiatric hospitalization”.

However, it was only in 2001 that the new institutional framework was approved: Law 10.216 establishes the psychiatric reform and the rights of people with psychological disorders/suffering. It was the beginning of a long process of political advocacy, dialogue and social pressure to establish new paradigms for a national mental health policy.

Psychiatric reform and public mental health policy, which were hard won in recent decades, are therefore a great democratic and civilizing improvement, connected with the best and most modern developments that have been developed and implemented worldwide.

The hate of conservatives

SUS has a very democratic and advanced architecture. Some of its policies particularly bother the reactionaries, such as the prevention and confrontation of STI/HIV/AIDS, which has always been based on the principles of recognition of human rights, harm reduction, individual autonomy, peer education. Type: empower vulnerable populations (prostitutes, transvestites, drug users, hustlers, young gays) and their organizations, promoting social control.

Despite the historical resilience of the AIDS Program – increasingly attacked – it must be noted, again, that since the Dilma government there have been concessions to the Christian fundamentalist agenda, retreating, for example, in prevention policies for young gay men. May this mistake never be repeated. With each step back that progressives take, more space is lost in the political-ideological-cultural struggle. Until we arrived at a neo-fascist government.

Franco Basaglia, in the 1960s and 1970s, was the Italian forerunner-mentor of psychiatric reform, defending the closure of hospitals/prisons. Michel Foucault, in 1972, establishes the philosophical-historical bases for the critique of total institutions; he denounces-describes the repressive and discriminatory essence of the mechanisms of punishment and control of insane bodies, deconstructs the pathologization of “madness”, operates the destabilization of medical knowledge (the majority wing of psychiatry never forgave him for this).

But before all that there was Nise da Silveira, a communist from Alagoas, a psychiatrist-physician, and a friend of Jung's. In the 1940s, Nise already refused to apply electroshock (there are many young psychiatrists trained in good universities defending the return of this torture mechanism). She also repudiated practices such as the lobotomy. Precursor of occupational therapy and art therapy, researcher of the unconscious Nise da Silveira was an avant-garde activist in the fight against the authoritarian and dehumanizing model.

In fact, even before that, the genius Machado de Assis had already published Or Alienist, in 1882, giving literary form to an entire avant-garde philosophical-medical-sociological discussion. Who is “crazy”, who is not? What does it mean to be a doctor-scientist anyway? Who can arrest whom, for what reasons? Science or random guess? We know everything. Or not? Vale, this novel by Machado, for many, many treatises, by the way. (“Crazier is anyone who tells me he is not happy”, in contemporary language).

Reactionaries, sexists, racists, right-wingers, bigots of all kinds, conservatives, religious fundamentalists and, above all, fascists, are truly disgusted with the principles that guide psychiatric reform. Not to mention the principle of harm reduction – respect for the free will of each person in dealing with so-called “drugs” (legal or not).

One of the bases of this conservative thinking involves interdicting the autonomy of subjects, imprisoning bodies and minds to pre-established standards by a bourgeois morality inherent to racist, patriarchal and cis-heteronormative capitalism.

They work to keep the state's repressive apparatus working at full speed. From the military police that daily promote the genocide of black/peripheral youths, passing through overcrowded prisons to the expansion of “rehabilitation” clinics for addicts (!).

Mental health policy in Brazil goes against this set of ideas by recognizing the complexity – and the immense challenges posed when dealing with the human condition itself.

It also discards prejudices, deconstructs practices of normalization and subjugation. It understands – and wants to overcome – the historical process that arbitrarily stigmatizes the so-called “madness” (a mere subjective manifestation of the diversity inherent in each person).

Neo-fascists and religious fundamentalists (or hypocrites-cynics in general) do not support a key idea. They reject plurality. They do not accept a world without so many norms, remedies, rules, gods, holy bibles, religions, possessions, hierarchies. They are afraid to depathologize life – in each and every one of its dimensions – starting with sexuality (so exciting and controlled by conservative morality).

If life is not normative – and when it is trivial and acceptable to be “crazy”, or whore, trans, queer, drugged, drunk, lazy, radical, sad, euphoric, unstable, revolutionary, dreamy, genderless, talkative, depressed, their system will fall.

Class society would tend to lose control of bodies, minds and the possibilities of living, having sex, loving and thinking.

It would become more difficult to prevent every little person from rushing to engage in the making of another world (without the State, classes, genders, religions, properties, borders or oppressions of any kind).

For a society without asylums.

* Julian Rodrigues, professor and journalist, he is an adviser to the National Human Rights Movement.

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