Desinstitute: Why and for whom are we pursuing this work?

For more than 200 years, Brazilian public policies in the area of mental health were guided by and operated in favor of hospitalization and the exclusion of people labeled as “crazy” and “diagnosed,” who suffered from a psychological or mental disorder. In many cases, those hospitalized who used alcohol and other drugs, had disabilities, experienced homelessness, and were socially and politically vulnerable — until the 20th century — were known as “outcasts” and “unproductives” in society.

While the model of forced hospitalization was widely defended as an effective treatment by private interest groups with political and economic intervention in Brazil, the service provided in psychiatric hospitals and judicial mental hospitals resulted in mistreatment, neglect, punishment, excessive medicalization, fracturing of social ties and, in many cases, in the death and disappearance of patients.

Brazilian Psychiatric Reform

More than 30 years ago, however, the national mental health policies underwent transformations guided by a process of psychiatric reform initiated during the late-1970s, in part because of the emergence of social movements formed mostly by health workers, family associations, unions, and people with a long history of psychiatric hospitalization.

In the following decades, during the re-democratization of the country and the creation of the United Health System (Sistema Único de Saúde; SUS), by the Constitution of 1988, the first practical and effective demonstrations arose that were proposed by psychiatric reform advocates. During that period, in the cities of São Paulo and Santos, the first Psychosocial Care and Support Centers (Centros e Núcleos de Atenção Psicossocial; CAPS e NAPS) were created, which made it possible to leave the system of institutionalization for integrated social services, returning to the promotion of care in freedom and the social reinsertion of patients.

The first highly successful regional experiences with community-based psychosocial treatment further inspired, during the late-1980s, the formulation—and subsequent approval—of Law 10.216, known nationally as the “Law of Psychiatric Reform.” Enacted in 2001, the legislation established new guidelines for mental health policies, in favor of respecting citizenship and the rights of people with mental illnesses.

With the approval of the law came the progressive extinction of mental hospitals in the country, which were substituted in subsequent years by a complex network of community services, which better understood care in freedom as a fundamental therapeutic element. In that way, the law also guaranteed other rights, that a person with a mental illness, “without any form of discrimination regarding race, color, sex, sexual orientation, religion, political choice, nationality, age, family, economic resources, and the severity or duration of his/her illness (…)”, should be “treated with humanity and respect and in the exclusive interest of benefiting his/her health, aiming to reach restoration of his/her insertion in his/her family, in employment, and in the community [art. 2nd, § II].”

Materialized in the law, the psychiatric reform sought, therefore, to orient the executive powers to invest in processes of deinstitutionalization of people hospitalized for long periods of permanence—in large part without remaining ties with society. In other words, it was looking to influence discourse, knowledge, and secular psychiatric practices that, in the past and even today, sustain the stigma of “insanity” by the diagnosis of “mental illness” and, in many cases, of chemical dependency, in order to defend clinical hospitalization, absenteeism, and social segregation as basic principals of treatment in mental health.

It is worth mentioning that the paradigm shift in the national mental health policies, as well as the construction of new community-based services in rural areas, led the World Health Organization (WHO) to recognize, in 2003, the global relevance of Brazilian public policy. It also was under that new context that the Inter-American Commission on Human Rights (IACHR), the principal, autonomous organ of the Organization of American States (OAS), condemned Brazil, in 2006, for what was known as the “Damião Ximenes Lopes Case”—a young Brazilian who was beaten and died in a psychiatric hospital in the city of Sobral, Ceará, in that same year.

Other achievements in the normative field accompanied by a strong international mobilization were approved, by the Brazilian Congress, including the Convention on the Rights of Persons with Disabilities (CRPD; with status of Constitutional Amendment) in 2009, and the creation of Law 13.146/2015, known as the Brazilian Law of Inclusion of People with Disabilities, which encompassed the rights of people with mental illnesses or arising from alcohol and other drug use.

In the last decades, therefore, the popular pressure of anti-asylum movements, adding to the monitoring of national and international control bodies, contributed to the strengthening and amplification of laws, policies, and community public services related to psychosocial attention within Brazil. A relatively recent process, it resulted in the closing of thousands of psychiatric hospital beds throughout the country.

Dismantling National Policy

Despite the significant achievements reached with the implementation of the Unified Health System and by the gradual process of psychiatric reform in Brazil, policies, public health services, and social assistance have been dismantled and controlled by private interest groups since the end of 2016. For lack of monitoring and transparency of the development of mental health policies in the country, some companies initiated that change.

During the interim federal management of Michel Temer and, during the most recent years, under the current administration of President Jair Bolsonaro, federal resources, before returning to the amplification of community-based services inserted in the SUS, were halted, while representatives of private entities, that included psychiatric associations and businesses called asylum institutions, began to be concerned more and more about the public agenda.

In 2017, for example, the Ministry of Health, in the absence of any discussion with the populace, the civil society, similar bodies aimed at social control, such as the National Health Council (Conselho Nacional  d Saúde; CNS), included psychiatric hospitals in the center of the Psychosocial Attention Network (Rede de Atenção Psicossocial; RAPS), structuring Brazilian mental health policies by altering ministerial decrees. In 2019, therapeutic communities that based their services on labor therapy (work without pay), prayer, and abstinence — were regulated by Law 13.840, known as the “New Law of Drugs,” and protected in the National Drug Policy (PNAD), which since then was expected “to stimulate and support, including financially, the improvement, the development, and the physical and functional organization of the Therapeutic Communities (…)”.

According to information from the Ministry of Citizenship, the transfer of public resources to entities that administer therapeutic communities in the country increased from R$157 million, in 2019, to R$300 million, in 2020. In light of the amplification of investment that occurred, bodies and national public mechanisms denounced the lack of oversight, transparency, practical guidelines, and technical criteria that guaranteed the legal function of those institutions in the country.

Despite the “Law of Psychiatric Reform” that prohibited the “hospitalization of patients with mental illnesses in institutions with asylum characteristics,” therapeutic communities and Brazilian psychiatric hospitals continued receiving large public investments and functioning as places of deprivation of freedom and grave violations of human rights, as revealed in reports from the latest national inspections in Therapeutic Communities (2018) and Psychiatric Hospitals (2018/2019).

Coordinated by public bodies and councils, such as the National Mechanism for the Prevention of Torture, Federal Psychology Council, and National Council of the Public Ministry, Brazilian inspections, since 2015, warned of the alarming situation regarding the lack of assistance in the attention to health in psychiatric hospitals and therapeutic communities throughout the country, where there were verified, grave and multiple daily violations of human rights against people in suffering or with a mental illness, including those with needs stemming from the use of alcohol and other drugs. Among the illegalities, there were unsanitary conditions, lacking infrastructure and technical equipment, torture practices, excessive medicalization, forced labor, and crimes of false imprisonment that date back to the past violations in insane asylums and judiciary mental hospitals.

Additionally, the insufficiency of current public data limits the possibility of analyzing the evolution of federal spending in the most recent years with policies regarding mental health, alcohol, and other drugs. However, access to the budget of the Ministry of Health intended for hospitalization procedures in Brazilian psychiatric hospitals, in 2017 and 2018, permits determining an expressive growth in the public financing in psychiatric hospitals to the detriment of the resources invested in the external public network, composed by services like the Psychosocial Care and Support Centers, Reception Units (Unidades de Acolhimento; UAs) and the Community and Culture Centers.

“War on Drugs”

Adding to the interference of those and other private interest groups in the legislative and executive spheres, the resurgence of Criminal Justice that, supported by prohibitionist policy of the “war on drugs” has resulted in the uncontrolled increase of police repression against marginalized population and imprisonment in jails, correctional institutions, and custodial hospitals, principally as of the approval of the “Law of Drugs” (nº11.343), in 2006.

According to the last report of Infopen of the National Penitentiary Department (Depen), within 10 years, the prison population almost doubled. In 2006, the imprisoned population totaled a little more than 400,000; in 2017, it was already around 727,000, with 32% being temporary prisoners (i.e., without conviction). The report points out that drug trafficking was responsible for more than 60% of female prisoners and 26% of the incarceration of men.

Thus, in the name of the “war against drugs”, millions of people are restricted of freedom and deaths every year in Brazil, especially Black people, young people with low education and residents of underserved areas (“regiões periféricas”) although the largest records of possession and consumption of drugs in the country are, respectively, between people who are white people and have higher education, according to the 3rd National Survey on Drug Use by the Brazilian Population.

The same structural process of racism and criminalization of poverty, which elevated Brazil to the third major carceral population of the world, strengthened policies of hospitalization and the imprisonment of people using and/or trafficking drugs, in detriment to the network of community attention based in the care of freedom and the approach of harm reduction. That is, guided by practices of citizenship and social inclusion, that consider the role of users in their respective decisions, as well as their individuality, story, culture, and daily lives.

Pandemic Context

Adding to the public setbacks of recent years is the current situation in lies Brazil and the world with the COVID-19 pandemic. In relation to the people restricted of freedom, in 2020, there were approximately 800,000 people maintained in the prison system, according to the Monitoring Bank of Prisons, of CNJ (Conselho Nacional de Justiça), and other thousands hospitalized in therapeutic communities, psychiatric hospitals, and Hospitals of Custody and Psychiatric Treatment (Hospitais de Custódia e Tratamento Psiquiátrico; HCTPs) in the country.

At a time when the guidance is social distancing, that part of society, formed mostly by people in poverty, Black people, and those without access to basic health services, assistance, and social justice, is confined in unhealthy spaces, overcrowded, and, via the law, without any medical assistance in conditions following minimal guidelines of personal and preventative care or even being tested and monitored to verify possible infection cases.

Lastly, observe that governments and national institutions, as well as representatives of other Latin American states, have minimized the importance of social factors in physical and mental health of their populations, to prioritize predominant clinical focuses and segregations that, historically, neglected the importance of familial and community ties, social interaction, access to qualified and structured primary care services, freedom, and equal opportunity for all people. That context precisely makes scarce the visibility and attention that SUS and mental health policy have received in Brazil and in other Latin American countries — where the lack of transparency and provision of social accounts perpetuate grave and constant violation of rights in the area of health, mental health, and social justice.

It is in the face of that structural reality and framework, underpinned by the stigmatization of people that disagree with a supposed civilization normality, by the institutional violence, and by the dismantling of social advancements, that the Desinstitute is created and organizes its work. With the focus on Brazil and Latin America, its principal mission is to influence and support technically the formulation and the development of policies and public actions that are evidence-based and oriented for principles that guarantee the human rights of all people.

Translation by:  Elizabeth Ruth Wilson, from Euth Foundation