Much is being said about depression, but there are other equally important issues on psychiatry’s agenda. In the not-so-distant past, persons with mental disorders suffered absurd and obscurantist treatment in Brazil’s psychiatric hospitals. According to the book entitled “(Asylum) - a silent tragedy”, men and women suffered sub-human conditions, lost their basic rights, and were packed into overcrowded hospitals that used violent and often fatal treatments – the cadavers were sold to anatomy laboratories at medical schools. According to official records, at least 60 thousand men, women, and children died in Brazilian psychiatric hospitals.

There were also cases of people without mental disorders being hospitalized simply to remove them from contact with society, for countless reasons. Paulo Amarante, coordinator of the Laboratory for Mental Health Research and Psychosocial Care of the Sergio Arouca National School of Public Health (LAPS/ENSP/FIOCRUZ), spearheaded the fight against such abuses. As a consequence, he and two colleagues were fired from their positions, starting a long story of struggles and triumphs in Brazil’s anti-asylum movement.

In this edition of Conexão FIOTEC-FIOCRUZ, Amarante (one of the organizers of the book “(Asylum): a silent tragday”, the point of departure for other publications on the absurdities of Brazil’s psychiatric hospitals) talks about his life experience in psychiatry and the Brazilian situation in this field.

You participated in Brazil’s anti-asylum reform since the 1970s. What was your part in this movement?

Two colleagues and I were the first to denounce the widespread violence and neglect in the asylums, and this led to our being fired” [Amarante is referring to 1978, when he worked in the National Division of Mental Health, DINSAM). The three mental health professionals had reported the shortage of physicians on shifts, nutritional deficiencies in patients, and outright violence, mostly deaths from stabbings and beatings, which were not investigated and blamed on other patients. They investigated these situations, even exposing the fact that political prisoners were being confined to these hospitals. Their dismissal sparked a petition, which resulted in the firing of 263 more professionals and triggering the so-called “DINSAM crisis”. Source: Revista Radis]. This all launched a chain of solidarity that culminated in the Mental Health Workers’ Movement (MTSM) and later the Movement of the Anti-Asylum Reform.

“The Brazilian psychiatric reform movement began in the 1970s, and I’ve participated since the very beginning. It’s my life’s most important project. I’ve devoted all my time to it, as a teacher, a researcher, and an activist. I’ve dedicated my work exclusively to training professionals in this new scenario, producing research and knowledge. As an activist, I participated in the National Council on Mental Health and other forums, representing the social movement.”

“The first major exposé of the country’s psychiatric hospitals at this media level was the film “Em nome da razão” (“In the Name of Reason”), by Helvécio Ratton, soon after the second visit to Brazil by Franco Basaglia, the renowned Italian psychiatrist who led an important reform in his country’s mental health system. After the film we launched a major exposé in the book “(Asylum): a silent tragedy”, of which I was one of the organizers and editors along with Jairo Toledo Furtado.”

Italian physician Franco Basaglia visited Brazil in 1979, denounced the abuses in the Colony Farm Psychiatric Hospital in Barbacena, Minas Gerais, and compared them to Nazi concentration camps. Basaglia was one of your own work’s influences. Which of his principles and research lines influenced you?

“That was the first time I heard someone compare psychiatric hospitals to concentration camps. I’d never thought of it before: the institutional aim of a concentration camp is not recovery. It’s an extermination camp, and extermination often happened in the asylums.”

“I identified with Basaglia because of the struggle against violence and in defense of human rights for people with mental disorders. Exactly because they’re in a situation of vulnerability and difficulty integrating socially, they must be protected, not isolated and subjected to violence.“

“Basaglia’s greatest innovation was to put brackets around the illness, for us to discover the persons with their characteristics and difficulties. They’re people that need affection, care, love, food, housing, work, and everything else. That’s why Brazil’s psychiatric reform struggles against the asylums (which are places of segregation and violence, not only social, but physical and moral, as places of mortification and death) and also began to build new spaces and other social places. We began to develop cultural projects, work cooperatives, income generation, and treatment settings as spaces for sociability. More than dispensing medications and technical treatment, these spaces are developed for people to socialize and exercise social learning. There is a whole network of devices, equipment, structures, and projects that give our movement recognition as one of the most important reforms in the entire world.”

“For example, this year will feature many Carnival troupes in Brazil. These groups do not stay inside the asylums, putting on a ‘make-believe’ Carnival. They really take to the streets. Some examples are “Suburban Madness”, “Flipping, Flipping, Flipped”, and “The Conspirators”. There are also music groups, theater groups, artists, and many other initiatives. That’s what we’ve succeeded in doing: freeing people from unpleasant asylums, places of isolation and death, to places of life, like homes, cultural projects, and work projects.”

The late 1980s witnessed the first Centers for Psychosocial Care (CAPS), functioning as an “alternative” to the asylums. What was this work like, and what’s the role of the CAPS today?

“The Centers for Psychosocial Care (CAPS), Nuclei for Psychosocial Care (NAPS), and Mental Health Referral Centers (CERSAM) marked a turning point from the 1980s to the 1990s, when we were criticizing the asylum-centered model but lacked alternative practices in mental health care. Based on these new alternatives, we were able to demonstrate that patients with severe mental disorders could be treated outside the asylums, in an open system, connected to the family and work and involved in other activities.”

“The CAPS were revolutionary here in Brazil. They were a new service that began to provide intensive care for people with major needs. But unlike the asylums, they did not isolate or ignore patients, and unlike the outpatient clinics, they did not simply dispense a regular medical prescription. The Centers provided daily care, with beds in case of emergencies. Contrary to what many may think, the anti-asylum struggle is not against psychiatric admission; it’s against institutionalization in models that segregate people permanently.”

“Brazil now has some 2,500 CAPS. Most have changed the mental health care scenario, helped free many people from psychiatric institutions or keep many people from being admitted to these institutions in the first place. They are open projects, in homes, with care by shifts, multidisciplinary, connected to the family and the community’s resources.”

Do you believe society still shows prejudice towards people with mental disorders? If so, what is the cause of such prejudice?

“Prejudice towards mental illness is historically constructed. Mental disorders, referred to generically as madness, have always been a mystery in human history. All societies have persons with bizarre, strange, exotic, unfamiliar, and inexplicable behaviors, which can be seen as either demonic possession or divine gifts. To this day there are many explanations for mental disorders. Psychiatry seized this issue of strange and bizarre behavior, transformed it, and gave it a medical and scientific interpretation, especially when Philippe Pinel, known as the father of psychiatry, wrote his medical and philosophical treatise on mental alienation.”

“What does it mean to ‘alienated’? According to Pinel, to be alienated person is be out of one’s mind, incapable of reason, judgment, or discernment. René Descartes, often considered the father of modern philosophy, said that a human being has the exclusive capacity to reason; all other beings are inanimate or irrational. Thus, to be alienated is to be an animal, nearly a beast, that which is not of human nature. In this sense, from the moment this concept emerged, to be alienated was viewed as being incapable – incapable of citizenship, of collective exercise, dispossessed of judgment and rational discernment, thus nearly an animal.”

“From the beginning, alienation was always associated with the idea of danger. Hence the issue of institutionalization, isolation, cells, correction by force, moral treatment, coercive treatment. All this created in the community the notion that an insane person is dangerous, incapable, irresponsible, and unfit for life in society. It is this historical legacy that we are trying to change, building another social place for these subjects, freeing them from the asylums and integrating them into group work, income-generating work cooperatives, cultural projects, and homes. We see them building life projects, citizenship, and rights.”

“The cultural transformation is very challenging. Like every change related to culture, it’s slow, but it exists. Films like “Bicho de 7 cabeças” (Seven-Headed Beast), “Nise: coração da loucura” (Nise da Silveira: Heart of Madness), and “Estamira” are signs that something is changing in society. Insane persons were society’s greatest fear in early 19th-century Europe and early 20th-century Brazil. Today this fear is shifting to other social prejudices: the sexuality issue, the immigrant issue, refugees, other cultures, different cultures.”

People are talking a lot about the “scourge of the 21st century”, which is supposedly depression. According to recent WHO estimates, more than 300 million people are now living with depression, an increase of more than 18% from 2005 to 2015. Do you believe that depression is really one of the main health villains today? And how do you explain such an increase?

“The issue of depression illustrates the debate on what we call the ‘pathologization of daily life’, or ‘medicalization’. Mental disorders display great elasticity and lack of diagnostic precision. A life crisis situation, like a person who has lost their job or just went through a divorce, or grief, for example, can easily be seen as an illness. But it’s not necessarily. Depression, sadness, loss, and mourning are common processes in life and must be confronted. It’s very important for the person to ‘work through the grief’, and that’s what we usually do, working through grief or overcoming a crisis in order to move on.”

“Psychiatry now turns everything into a disease and thus also conveys the notion that mental illness is a neurochemical disorder and that treatment should focus on correcting this disorder. Treatment is usually based on techniques and uses of psychotropic medications and sometimes psychotherapies and other therapies. In such cases, the person is robbed of the broader view that he or she is undergoing a crisis, of analyzing the situations they’re experiencing, turning them into depression. In this sense, these experiences of distress, suffering, and difficulty coping with these demands end up being individualized, since they’re considered individual disorders. It’s necessary to understand that diseases are biochemical alterations in the individual and not a process which is often collective in large cities, as in catastrophes, economic crises, and political crises. In such cases it’s not only a matter of recovering the individual, but of understanding that as processes, they’re linked to collective health, transcending the field of health and involving issues of an economic and political order, something more general.”