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Stakeholder Involvement in Forensic Psychiatry: the Brazilian Experience

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Stakeholder Involvement in Forensic Psychiatry: the Brazilian Experience EDITORIAL Stakeholder Involvement in Forensic Psychiatry: The Brazilian Experience Mark Costa, MD, MPH J Am Acad Psychiatry Law 44:2–8, 2016 The Brazilian psychiatric reform process has been ian psychiatric reform first hand, it is my intent in going on for 28 years. This complex shift in the this editorial to consider whether such a debate government-sponsored model of mental health care might still be needed in the United States, even has its origins in the anti-institutional thinking of though the U.S. deinstitutionalization movement Franco Basaglia. It involved replacing psychiatric began much earlier than the Brazilian one (more than hospitals, which were the major option for dealing a half century ago). with people with serious mental illnesses in need of care, with systems of community-based services. Be- The Model Before Psychiatric Reform yond the advantages of being more comprehensive and humane, more respectful of human rights, and Until the 1960s, most psychiatric beds in Brazil more hopeful for patients and their loved ones, the were in public state psychiatric hospitals. By this major strength of this approach as it evolved in Brazil time, as was the case in the United States and came from its grassroots construction, as it was dis- elsewhere, the conditions inside these hospitals cussed and constituted through democratic debates.1 had deteriorated. After the coup of 1964, a mili- Having public debates with all stakeholders, includ- tary dictatorship took over command of Brazil. ing health consumers, health workers, and health Under its rule, there was an impressive surge in the care providers, as required by the new regulations, number of privately owned psychiatric hospitals. has been paramount in the success of Brazilian psy- At the end of the 1970s, roughly 80 percent of the chiatric reform. psychiatric hospitals were for-profit, privately The gradual implementation of this new model of owned institutions. The government paid these care has resulted in a significant reduction in the institutions per service, using money from the so- number of psychiatric beds funded by the federal cial security fund of workers (meaning that only government and in the implementation of a complex workers contributing to social security had access network of mental health services based in the com- to these hospitals). Around 15 percent of the fed- munity.2 Initial opposition from different medical eral health budget, through these funds, was des- organizations, such as the Brazilian Psychiatric Asso- ignated to pay psychiatric hospitals, which also ciation and the Brazilian Hospital Association, was made up 99.8 percent of all government expendi- unsuccessful in halting this process, much less in re- tures in mental health. The privately owned psy- versing it.3 Having witnessed the successes of Brazil- chiatric hospitals failed to respect basic human rights, but the government psychiatric hospitals, Dr. Costa is a Postdoctoral Associate, Yale Program for Recovery and which did not receive money from the social secu- Community Health, Department of Psychiatry, Yale School of Med- rity fund, were, in all aspects, even worse.4 icine, New Haven, CT. Address correspondence to: Mark Costa, MD, MPH, 319 Peck Street, Building 1, New Haven, CT 06513. E-mail: The end of the military coup in the beginning of [email protected] the 1980s offered an opportunity for more open and Disclosures of financial or other potential conflicts of interest: None. structured discussions about the health of the popu- 2 The Journal of the American Academy of Psychiatry and the Law Costa lation and the scope of the government’s responsibil- ferences and 50 percent of the members of all health ity. It also created the possibility for discussions councils must be and represent lay persons who have among mental health workers. They pointed out, not no connection with health care. The other half would only the insufficiencies of the mental health model represent health workers (25%) and health care pro- centered on the psychiatric hospital, but also, its op- viders and researchers (25%).6,8,9 pressiveness and how it segregated those with a men- tal illness. It was in 1987 that the Basaglia-inspired slogan of “For a society without asylum” was created, Difficult First Steps marking the beginning of Brazilian psychiatric 4,5 It was clear in the report from the first National reform. Mental Health Conference that government should concentrate its efforts on nonhospital mental health The Democratic Foundation practices and services, even though the image of Bra- The Brazilian Constitution of 1988 stated that all zilian psychiatric hospitals among the general public citizens had the right to health care, and it was the in 1987 was not a positive one.10 On the other hand, responsibility of the government to provide it. This it is known that, in 1987, psychiatric hospitals and legislation had been the result of several years of or- their emergency rooms were the only public places, ganization and mobilization among public health for better or worse, that people facing a mental health care workers and the general population. Social mo- crisis could rely on and go to for care.5,11 Govern- bilization, exemplified in the Eighth National ment in general, at that time, was not willing to put Health Conference, which occurred in 1986, with more money into the health budget, especially into more than 4,000 people debating and voting in its mental health.11 This reticence meant that any effort final plenary, was a main reason for congressional to develop new psychiatric services would have to be approval of the health-related article in the new Con- financed by taking money away from psychiatric stitution.6,7 It made sense that the social mobiliza- hospitals. If we add to this equation the general dis- tion before the Constitution should now become the crimination against people with a mental illness social control of government regarding the develop- (principally against those who were inside psychiatric ment of the now so-called Unique System of hospitals),12 we can understand why there was strong Health.6,7 Therefore, the regulation of this new con- resistance to the development and implementation stitutional right not only created mechanisms to in- of community-based psychiatric services. The per- crease investments in public health, but also guaran- ception was that people inside psychiatric hospitals teed the participation of consumers and all were essentially dangerous and should be kept locked stakeholders involved in health care and in decision- up.12 making about health care. Government at all levels Psychiatrists who owned and worked in psychiatric (federal, state, and municipal) would also submit hospitals were part of those advocating to maintain the health budgets for approval by health councils, be- mental health care system as it was. Dangerousness yond the standard legislative approval.8,9 and inevitable deterioration of those with serious As a result, two forms of cooperative participation mental illness was part of the argument.3–5,11,12 were created: councils that would meet regularly with Again, mobilization of stakeholders (street demon- the executive branch to approve the budget, and con- strations became a standard practice, with May 18 ferences that should happen every four years to de- being chosen in 1987 to be the national day of the fine the health guidelines for the next four years. fight against psychiatric asylums) and debates con- Conferences would be held first at the local level, to vinced some mayors to invest in a new model of debate and approve proposals related to their local mental health care.1 The positive return from these problems. The local conferences would elect dele- first experiences not only inside the so-called antia- gates to present proposals to the state conference sylum movement, but from the population in gen- where decisions about state concerns would also be eral, helped build momentum toward psychiatric re- debated and approved. Finally, state delegates would form. These experiences became a convincing take their propositions to the federal level. Each state argument inside city health councils and health and would then present its proposal in a final national mental health conferences, pushing forward the psy- conference. Fifty percent of the delegates in all con- chiatric reform agenda.1 Volume 44, Number 1, 2016 3 Increasing Stakeholer Involvement in Forensic Psychiatry The Approval of the Brazilian Mental of people in the debates that took place in more Health Law in 2001 than half of all the cities in the country, always In its early stages, the social movement advocating culminating in a final National Conference with for Brazilian psychiatric reform proposed a strategy representatives from all states. In all its stages, and similar to that which had successfully transformed as noted above, it was required that half of the 1 delegates be lay persons representing the general mental health care in Italy. In 1978 in Italy, Law 7,10,18–26 180 (the so-called Basaglia law) proposed by the population. Regarding the Mental Health Democratic Psychiatry Movement, was ap- Conferences, except for the first one in 1987, each proved.13,14 This law mandated that all psychiatric conference involved more than 45,000 people in- hospitals be closed and that a web of community- tensely discussing and debating models of care, needs, and policies related to the mental health based mental health services and psychiatric beds in 10,18–20 general hospitals replace them. field. Again, half of the delegates in all In Brazil, in 1989, a similar law proposed by the stages were lay persons from the population, mental health social movement entered Congress, mostly consumers and their family members. It is but it was halted immediately in its approval process important to note that all health conferences were supportive of Brazilian psychiatric reform, when- because of opposition from medical institutions such 7,21–26 as the Brazilian Hospital Association and the Brazil- ever this topic was discussed.
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