SIB health psychology in Brazil: The challenges for working in public health settings

Introduction

Brazil is a country of continental dimensions: 8,515,767,048 km², 27 federated states and 204 million inhabitants (Instituto Brasileiro de Geografia e Estatística (IBGE), 2015). Size and diversity create immense challenges, especially when dealing with inequalities. Brazil has an extensive network of higher education institutions, federal, state and private, and, consequently, many Psychology Departments. It is difficult to know exactly how many Psychology Courses there are as private universities can create new campus in different parts of the country that, for statistical analysis, count as one. However, all practising psychologists must obtain their professional registration with the Federal Council of Psychology (Conselho Federal de Psicologia (CFP)), the institution responsible for professional accreditation. According to information available on the CFP site, there are, at present, 267,998 registered psychologists in the country.

University psychology degrees, like medicine and dentistry, must comply with the norms set out by both the Ministry of Education (responsible for establishing National Guidelines for university courses) and the National Health Council. Courses have a minimum teaching load of 4000 hours which are usually taught in 5-year undergraduate programmes that include 2 years of internship. The course content is mainly generalist in nature, with subjects spanning all areas of the discipline: neurophysiology, psychobiology, social psychology, clinical psychology, developmental psychology, health psychology and organizational psychology (Hutz et al., 2006). However, they must offer a minimum of two ‘emphases’. Emphases are a set of competencies and abilities that create opportunities for practical work in a specific domain of psychology but that are not at the level of formal specializations. For example, they might focus on processes related to clinical practice, educational practice, diagnostic evaluation, health prevention and promotion, educational processes, research, managerial processes or create new emphasis. Although courses are free to define their emphasis, these must be compatible with the social needs of the region where they are located as well as with the vocation and conditions available at the institution.

Independently of the chosen emphasis, psychology graduates can practice in any area as the basic course is seen as providing a sufficiently general set of skills. Thus, although not all courses may choose the emphasis on health, graduates from all courses can and do work in a variety of health services. As a result, those who opt for working in health settings come from very different theoretical and practical work experience backgrounds.

In 2007, a study was carried out to map out the presence of psychologists in the health establishments that were part of the Brazilian Unified Health System (Sistema Unico de Saude (SUS)) using the Ministry of Health human resource data bank and telephone interviews with a stratified sample of 250 psychologists identified through the Ministry of Health data base (Spink, 2007). One of the questions in the interviews concerned the theoretical and methodological basis of practice. The results (Bernardes, 2007) showed an astounding diversity of approaches including a variety of psychoanalytic theories (32.8%) and behavioural theories (14.8%), but also a number of psychosocial approaches and others stemming from collective health traditions.

Added to this diversity, it should be noted that psychologists also work in settings that are not directly related to the SUS: private practices, academic research and, more recently, in the National Social Services System (Sistema Unico de Assistencia Social (SUAS)). This special number of the Journal of Health Psychology has adopted a focused approach. All four editors are committed to a critical view of health that includes ethical and political issues and takes into account the enormous social inequalities in the country. As a functioning public health system is important in order to address these inequalities, the Call for Papers focused on the potential contributions of psychology for the SUS and has left aside other health related questions and debates.

Papers were selected on the basis of three criteria: compatibility with the call for papers, feedback from the double blind review process and diversity of practices, including the development of health policies, training of health professionals and re-inventing ways of being psychologists in complex interdisciplinary settings.

In order to understand this choice of focus, some background information concerning the processes that led to the creation of SUS in 1990 is necessary.

The long road towards a Unified Health System

In the 1970s, in the midst of the military dictatorship in the country, various organizations got together moved by the need to address the manner in which health care was being delivered, especially in view of the access to public health services, then restricted to workers who contributed to the social security system. A diversity of groups joined in this effort: health professionals, academics, public health sector managers, social movements, such as women’s coalitions, movements for housing and for health care provision. The result was the Sanitary Reform Movement (Santos, 2009).

Pressures stemming from the Sanitary Reform Movement as well as from segments of the population that gave it support led to the creation of the National Committee for Sanitary Reform (Comissao Nacional de Reforma Sanitaria), whose main task was to elaborate the proposals that were to be discussed at the National Constituent Assembly (1987–1988). The committee included the three government spheres (federal, state and municipal), private and public health institutions and trade unions. As a grassroots movement, social participation was of utmost importance and the presence of social movements and civil society entities in the plenary (Plenaria Nacional de Saude) guaranteed the inclusion of channels for participation in the process of definition of the new health system (Santos, 2013). These proposals were discussed in a historic gathering that took place in 1986, in Brasília – the VIII Conference on Health – where the basis for the creation of the SUS was established.

The main proposals included a series of premises: (a) that public health care is a state responsibility and a citizen’s right; (b) that health and illness are directly related to living conditions, with the implication that preventive, promotion and curative actions have to be provided in an articulated manner, within an organized system; (c) that management of the system should be decentralized; and (d) that social control would be present at the various levels of the care system, encouraging the participation of the population in the planning, implementation and evaluation of health actions (Mattos, 2009).

The design of the SUS took into account basic propositions which were translated into three tenets: universality, integral care and equity. Universality means that all citizens, independently of their contribution to the welfare system, should have access to health care at all levels of complexity. To ensure integral care, health/illnesses processes must be addressed taking into account their social determination. As for equity, specific needs of different segments of the population must be taken into account. From an organization point of view, SUS is conceived on the basis of four managerial principles: decentralization, regionalization, hierarchical organization and social control (Spink et al., 2014).

The enormous efforts of redirecting health care delivery through broad based discussions carried out within the Sanitary Reform Movement had impact in the elaboration of the 1988 Constitution that recognized health as a citizen right and created the SUS. However, the process of implementation of the SUS has proved to be complex especially because of the prevailing mix of service providers:

The health system has three subsectors: the public subsector (SUS), in which services are financed and provided by the state at the federal, state, and municipal levels, including military health services; the private (for-profit and non-profit) subsector, in which services are financed in various ways with public or private funds; and the private health insurance subsector, with different forms of health plans, varying insurance premiums, and tax subsidies. The public and private components of the system are distinct but interconnected, and people can use services in all three subsectors, depending on ease of access or their ability to pay. (Paim et al., 2011)

Various aspects of the present day system do not correspond to the ideals put forward by the Sanitary Movement, notably because of the freedom given to the private sector that has led to the emergence of a plurality of private health plans throughout the Brazilian territory (Mattos, 2009). Hence the importance of insuring that the SUS continues to be in the political agenda of the country as well as in educational strategies for health professionals that can promote the potential of a health system that is indeed public and universal.

The Psychiatric Reform: towards a psychosocial model of care

In the late 1970s and early 1980s, as part of the democratization process, health professionals and service users rebelled against the violence and disrespect of human rights in psychiatric hospitals as well as against the existing authoritarian hospital-centred approach based on medicalization. The result was the Psychiatric Reform Movement.

In 1987, mental health workers, former interns of psychiatric hospitals and their families, as well as other social movements, articulated the Anti-Asylum Movement that adopted the slogan ‘For a society without asylums’ and proposed a programme that included extinguishing all psychiatric hospitals, creating substitute care services and questioning society, politically, for sustaining a pro-asylum culture (Amarante, 2003). It aimed to construct other approaches to madness based on diversity (Birman, 1992). Some actions undertaken at that time became emblematic, such as closing the Casa de Saude Anchieta in the city of Santos.

In the 1980s and 1990s, a series of experiences of deinstitutionalization proved important for the consolidation of strategies regarding assistance to mental health problems. One was the creation of services to substitute psychiatric hospitals. As from 1992, the Ministry of Health authorized and financed the construction of Psychosocial Community Centres (Centros de Atencao Psicossocial (CAPS)) within the SUS. The CAPS are staffed by interdisciplinary teams and function on a territorial basis, aiming at social insertion and care provision in a more libertarian mode, promoting autonomy through co-managerial strategies that include service users and the community (Brazil, 2005). They are also strategic for organizing health care demands, giving support to mental health care providers at primary care health centres and to other programmes geared for mental health.

The other strategy concerned the creation of residential services for people who had long histories of internment in psychiatric hospitals, which also involved carrying out a census of people still living in psychiatric hospitals and the development of programmes for giving support for patients released from these hospitals, such as the Return Home Program (De Volta para Casa, Brazil, 2003).

Based on these pioneering experiences, legislation was approved in 2001 which incorporated the models, directives and norms that were already being experimented (Brazil, 2001) and transformed the agenda of Psychiatric Reform into a national public policy. This policy, referred to as psychosocial care, is based on principles of articulation, user embracement, accountability, establishment of links and relationships, accessibility, territoriality and integral care. In this process, the Mental Health Conferences were important locus of contributions for the debate, criticism and formulation of this public policy, becoming part of the fight for reinforcing social control (Conselho Nacional de Saude, 2010).

In 2011, the Mental Health Policy assumed the format of a Network of Psychosocial Care within the SUS which envisaged actions: (a) in basic health care, including not only Primary Health Units but also possibilities for consultation on the streets (Consultorios de Rua) and Culture and Community Centres (Centros de Convivencia e Cultura); (b) in psychosocial care for severe and persistent mental disorders provided in the Psychosocial Community Centres (CAPS) which also included more focused centres for adults, children and young people, for users of alcohol and other drugs and a special modality for overnight care (CAPS III); (c) in emergency and hospital based care; and (d) for transitory residential care. The network of care also included strategies for social rehabilitation (such as programmes for generating work and income as well as cooperative enterprises) and strategies for people who have been through long periods of psychiatric hospitalization (Brazil, 2011).

With the implementation of the network of psychosocial care, there has been a significant expansion of the CAPS and a reduction in psychiatric hospital beds (World Health Organization (WHO), 2007). According to the Ministry of Health (Brazil, 2015), between 2000 and 2014 the number of CAPS increased from 208 to 2209 and the number of psychiatric beds was reduced from 51,393 to 25,998 in this same period. However, there has been less investment in substitute services such as the CAPS III and residential services.

Despite obvious improvements, which include a different juridical framework that guarantees the rights of people with mental disorders as well as changes in practices and cultural values (Amarante, 2003), there are many challenges to be met especially in this phase of consolidation. As pointed out by Vasconcelos (2010), the focus has moved from the academic and political debate to the evaluation of the results and effectivity of these new systems of care.

The expansion of new services and their territorial spread, with concomitant increase of the number of mental health professionals in a context marked by outsourcing and precarious working conditions, have created a more complex political and institutional scenario. In this context, the last Mental Health Conference, entitled ‘Mental Health, rights and engagement by all: consolidating progresses and facing challenges’, pointed to the need for an intersection of policies in order to consider the real and concrete challenges brought about by the change in the model of care, radicalizing the multidimensional character of this area (Conselho Nacional de Saude, 2010).

An overview of the contributions included in this special number on health psychology in Brazil

Although the SUS has sound ethical–political foundations, it is operationally frail. One reason for this is that it was instituted within a framework of existing private health care systems and initially acquired the connotation of ‘health for the poor’, so those who can afford it opt for private care via health plans. In order for it to be strengthened, much has still to be done. From the point of view of health psychology, one of the urgent tasks is to reorient training at both graduate and post-graduate levels, a challenge that requires critical analysis of the health needs of the population, of the services being provided and of the many possibilities of psychological contributions for health care at all levels. It also requires experimentation of new modes of training. These were the issues that the contributors to this special number of the Journal of Health Psychology addressed.

The first four articles focus on aspects concerning the preparation of psychologists for work within the context of public health. The first, Psychologists in public health: Historical aspects and current challenges, provides a historical account of the presence of psychology in health policies in Brazil as a way of discussing the main challenges for psychological practice. Among these, three are considered particularly relevant: working in contexts of high social vulnerability, working in multi-professional settings, and the need to broaden research agendas. The next one, A good training based on insufficiency: Work in health care as an ethics, presents an experience in training of health professionals that was conducted at the São Paulo Federal University in their Santos municipality campus. It addresses the changing scenario of training for health professionals that have at their core both the specific needs of the Brazilian Unified Health System as well as the challenges of the Psychiatric Reform. Their pedagogical proposal is based on three issues: a clinic that is common to all professions, the ethics of working in health settings and ‘insufficiency’ as a challenge in educational programmes.

Training is then put to test through experiences with internships in the network of psychosocial services in the Northeast, such as the CAPS, Experiences in the health services network and in the street: Captures and detours in psychology training for public health services. Experiences in and outside of these services were analysed through the theoretical lenses of Institutional Analysis and Schizoanalysis. The authors conclude that the health area creates tensions between instituted practices and psychological training and practice.

In order to overcome the traditional individual and analytic clinic model that is much associated with psychological practice in Brazil, the authors of Group work in the public health context: A proposal for training in psychology, propose that training in group work is fundamental. As a contribution, they present a proposal for training in group processes that span all levels of undergraduate training: from initial internships through to professional internship.

The next set of articles concern the challenges of working in complex multi-professional settings. The issues addressed in the previous articles, concerning traditional clinical practice and working in multi-professional settings are discussed in the article entitled Care in movement: Health psychology in the Sofia Feldman Maternity Hospital in Belo Horizonte, Brazil. This article looks at the way in which psychologists in a maternity hospital located in a working class district of a large Brazilian city adapted their practices to meet the challenges of an integral approach to health care, and in doing so helped other professionals to break down a number of hospital barriers. Through analysis of the activities in this specific hospital, the authors aim to show that, in addition to their patient centred focus, psychologists also have skills that enable them to work with multiple interactions as social phenomena and to act strategically within them.

Multi-professional practice is also the focus of the next two articles. The matrix approach to mental health care: Experiences in Florianopolis, Brazil reports on experiences with a matrix approach to mental health care in Florianopolis – Brazil, carried out through the Family Health Support Nuclei – Nucleo de Apoio a Saude da Familia (NASF). The research carried out at the NASF showed that, for these professionals, care involves many challenges in the everyday provision of mental health care at the primary care level.

The matrix approach is also the focus of the article Matrix support in mental health: The experience in Vitoria, Espirito Santo. Using public documents and semi-structured interviews, the authors tell the history of the inclusion of a matrix approach in Vitoria, Espirito Santo. The results indicate that there have been reorientations of care, with the integration of mental health issues at the primary care level and appropriation of primary care issues by the psychosocial services, CAPS.

Specific care issues were the focus of four articles. The first one entitled Effectiveness of a multidimensional web-based intervention program to change Brazilian health practitioners’ attitudes toward the LGBT population discusses the Brazilian LGBT (Lesbian, Gay, Bisexual and Transgender) related health policy that emerged with the governmental response for the AIDS epidemics in the early 1980s. At that time, the Brazilian HIV/AIDS national policy assisted the organization of the contemporary LGBT movement by funding non-governmental organizations and promoting health actions through communities. One of the guidelines of the LGBT National Health policy is the creation of state- and municipal-level strategies to ensure non-discriminatory health care access through the training of the providers. The study was aimed at assessing the effectiveness of a multidimensional (educational, affective and behavioural) web-based intervention programme to change Brazilian health care practitioners’ attitudes towards the LGBT population.

Public policy aimed at enhancing care was also the focus of the article Health care provision in Brazil: A dialogue between health professionals and lesbian, gay, bisexual and transgender (LGBT) service users. With an innovative methodology, based on a dialogical approach, the authors present the results of research carried out with health professionals and LGBT service users of a primary care unit.

The next article, Counselling in STD/HIV/aids in the context of rapid test: Perception of service users and health professionals at a testing and counselling centre (CTA) in Porto Alegre, presents the results of research concerning the use of rapid tests at an HIV/AIDS Testing and Counselling Centre in Porto Alegre, Rio Grande do Sul. Perceptions about the use of rapid tests as well as of the counselling procedures were explored through interviews with professionals and service users. Despite some ambivalence, the introduction of rapid tests was seen as an opportunity to rethink practices, especially with regard to how information can best be conveyed to clients.

Health issues associated with work settings have long been a focus of health services in Brazil, but mental health issues related to work conditions have only been recognized in the late 1990s. The article Work-related mental disorders and their inclusion in health policies in the Brazilian Unified Health System (SUS) explores the diversity of reasons that have led to the inclusion of mental health as a work related issue.

Matters concerning the Psychiatric Reform were addressed in four articles. From manicomial logic to territorial logic: Impasses and challenges of psychosocial care is focused on the problems of inclusion of psychosocial care in the context of Psychiatric Reform. Focusing on the organization of care as a territorial bound network, it calls attention to the need to take into account social and cultural diversity as an essential element in care giving strategies. It also points to the need to identify logics of exclusion that have recently assumed conservative connotations.

The authors of A critical view of the ‘social reinsertion’ concept and its implications for psychologists’ practices in the mental health field at the Brazilian Unified Health System (SUS) propose that a critical analysis of central concepts, such as social reinsertion, is essential for the enhancement of psychological practice in the field of mental health. Based on the dialectic of exclusion/inclusion, the authors suggest that the concept of social reinsertion, as propounded by the Psychiatric Reform, is impregnated with the adaptation paradigm and an asylum view that create obstacles for its implementation.

This next article, The construction of autonomy for professionals who work with drug users: An analysis of two intervention projects in the largest asylum centre in Brazil, is focused on experiences of deinstitutionalization in Sorocaba, São Paulo. The authors discuss the many possibilities for a promotional health approach in the field of mental health, and more specifically with regard to the use of drugs. Two experiences with professionals who work with these issues are discussed; one concerning continued education and the other related to strengthening the network of services for drug users.

Temporary housing as a mental health intervention for the needs of children and adolescents users of alcohol and other drugs: Hybridity between care and protection presents the results of research on the temporary housing of children and adolescents as a modality of health care. Using the theoretical approach of French Institutional Analysis, and based on participant observation, interviews and analysis of records, the trajectories of these children and adolescents are discussed. The temporary home is described through the lenses of hybridity, which brings to the fore the problems of continued stigmatization in the assistance directed to infancy and adolescence in Brazil.

Last but not least, The Forum for Defence of the Brazilian Unified Health System (SUS) and its role in building community participation in the fight against the privatization of health deals with the important role of public participation in defence of the SUS in view of the increasing presence of the private sector in health care. The analysis is focused on the creation of a Forum for the Defence of the SUS in Rio Grande do Sul as a social movement that attempts not to be co-opted by the institutionalized powers.

The preparation of this special issue was not an easy task. Besides the usual editorial decisions, facilitated by the strenuous work of many reviewers, we faced the added difficulty of working in the framework of two languages: most of the first versions were submitted in Portuguese and, when approved by reviewers, were translated into English. Some expressions were particularly hard to translate as they derive from ethical–political decisions. For example, usuarios is a term used in Brazil to counteract the effect of naming those who use health services as ‘patients’ or ‘clients’. Following McLaughlin’s (2009) discussion of the implication of naming in the UK social work arena, the option was to translate the expression as ‘service users’.

We hope that the selected texts might provide bridges for communications and, perchance, joint research across the world.