Superando a polarização psiquiatria-reforma psiquiátrica brasileira: contribuições winnicottianas e spinozistas para uma ética no cuidado em saúde mental

Abstract

Philippe Pinel, a French physician and founder of alienism, is frequently remembered for removing madness from the domain of mystical-religious speculation and juridical political repression. By inaugurating the first medical specialty—alienism, later termed psychiatry—Pinel introduced a new object for Medicine: madness. No longer would its etiology and symptoms be explained through religion, nor would it be suppressed in the name of public order. Instead of repression, the mentally ill required medical treatment. As a therapeutic method, Pinel devised “moral treatment” and established hospitalization as a condition for its effectiveness. The French alienist’s objective was to reintegrate the mentally ill into society as citizens capable of sociability and productivity. Pinel’s thought provided the epistemological foundation that, over two centuries, linked madness to dangerousness and legitimized the isolation of the mentally ill in hospitals. Over the past forty years, the Brazilian Psychiatric Reform has advanced through the closure of psychiatric beds in asylum-like institutions, the construction of a broad network of community-based mental health services, the consolidation of legislation protecting the rights of mental health service users, and the struggle against the stigmatization of mental illness and of those affected by it. The aim of the Brazilian Reform is to transform society itself so that individuals labeled as mentally ill may participate as citizens, advocating treatment in freedom and with the active involvement of users and their families. This dissertation investigates the common ground between two seemingly antagonistic approaches to the care of the mentally ill: the objective of converting them into citizens. It is based on the hypothesis that both Pinel and Brazilian reformers share the same metaphysical mode of thought, which generates idealizations concerning the social and political performance of the “mad.” Employing Martins’ philosophical-conceptual method of constructing and updating concepts, and drawing upon the theoretical clinical contributions of Martins, Winnicott, and Spinoza, madness is reinterpreted through an immanentist perspective. This approach seeks to refine the achievements of the Brazilian Reform and to strengthen therapeutic strategies ethically oriented toward alleviating the suffering of individuals with severe mental disorders—without resorting to rigid ideological positions that, not infrequently, reduce mental health care to political-ideological militancy. Despite good intentions, such militancy may result in serious neglect of the needs of users and their families.